Aims

Paediatric triplane fractures and adult trimalleolar ankle fractures both arise from a supination external rotation injury. By relating the experience of adult to paediatric fractures, clarification has been sought on the sequence of injury, ligament involvement, and fracture pattern of triplane fractures. This study explores the similarities between triplane and trimalleolar fractures for each stage of the Lauge-Hansen classification, with the aim of aiding reduction and fixation techniques.

Aims

Proximal humeral fractures are the third most common fracture among the elderly. Complications associated with fixation include screw perforation, varus collapse, and avascular necrosis of the humeral head. To address these challenges, various augmentation techniques to increase medial column support have been developed. There are currently no recent studies that definitively establish the superiority of augmented fixation over non-augmented implants in the surgical treatment of proximal humeral fractures. The aim of this systematic review and meta-analysis was to compare the outcomes of patients who underwent locking-plate fixation with cement augmentation or bone-graft augmentation versus those who underwent locking-plate fixation without augmentation for proximal humeral fractures.

Titanium Elastic Nails have been around for the last 40 years, but it has never been introduced properly in the Pacific especially in Samoa in the management of femoral & in severely displaced forearm fractures in the paediatric age group & also Adult upper limb Trauma. This paper looks at the cases treated in TTM Hospital (Apia, Samoa) from June 2019- June 2023, looking at common injury patterns, indications for fixation and the cost benefit to the family and hospital, in terms of early rehabilitation and improving the length of stay in hospital pre-Tens nail era from 6–8 weeks to 1–2 weeks in hospital. 29 cases were treated with TENs concept during this period, 17 femoral fractures, 10 forearm fractures & 1 humerus fracture. Lastly this is very useful skill and tool to have in every hospital in the Pacific Islands, through proper training to prevent long term complications

Aims

Fractures of the humeral shaft represent 3% to 5% of all fractures. The most common treatment for isolated humeral diaphysis fractures in the UK is non-operative using functional bracing, which carries a low risk of complications, but is associated with a longer healing time and a greater risk of nonunion than surgery. There is an increasing trend to surgical treatment, which may lead to quicker functional recovery and lower rates of fracture nonunion than functional bracing. However, surgery carries inherent risk, including infection, bleeding, and nerve damage. The aim of this trial is to evaluate the clinical and cost-effectiveness of functional bracing compared to surgical fixation for the treatment of humeral shaft fractures.

Introduction. We aim to assess whether radiographic characteristics of the greater tuberosity fragment can predict rotator cuff tears inpatients with anterior shoulder dislocations combined with an isolated fracture of the greater tuberosity. Methods. A retrospective single-centre case series of 61 consecutive patients that presented with anterior shoulder dislocations combined with an isolated fracture of the greater tuberosity between January 2018 and July 2022. Inclusion criteria: patients with atraumatic anterior shoulder dislocation associated with an isolated fracture of the greater tuberosity with a minimum follow-up of 3-months. Exclusion criteria: patients with other fractures of the proximal humerus or glenoid. Rotator cuff tears were diagnosed using magnetic resonance or ultrasound imaging. Greater tuberosity fragment size and displacement was calculated on plain radiographs using validated methods. Results. The case series was composed of 22 men and 39 women with a mean age of 65 years (29 - 91 years). The mean follow-up was 15months and median follow up 8.5 months (3 – 60 months). A rotator cuff tear was diagnosed in 14 patients (16%) and involved the supraspinatus (13), infraspinatus (4) and subscapularis (2). Full-thickness tears occurred in 6 patients and partial-thickness tears in 8patients. The mean time from initial injury to rotator cuff tear diagnosis was 5 months (2 – 22 months). The mean greater tuberosity fragment length was 23.4 mm in rotator cuff tear patients versus 32.6 mm in those without a tear (p = 0.006, CI: -15 - -2). The mean greater tuberosity. fragment width was 11.1 mm in rotator cuff tear patients versus 17.8 mm in those without a tear (p = 0.0004, CI: -10 - -2). There was no significant difference in the super inferior and anteroposterior fragment displacement between the two groups. Conclusion. In patients with shoulder dislocations combined with an isolated fracture of the greater tuberosity, rotator cuff tears are associated with a smaller sized greater tuberosity fragment

Abstract. Introduction. Intra-articular distal humerus OTA type C fractures are challenging to treat. When osteosynthesis is not feasible one can choose to do a primary arthroplasty of elbow or manage non-operatively. The indications for treatment of this fracture pattern are evolving. Objectives. We present our outcomes and complications when this cohort of patients was managed with either open reduction internal fixator (ORIF), elbow arthroplasty or non-operatively. Methods. Retrospective study to include OTA type C2 and C3 fracture distal humerus of 36 patients over the age of 50 years managed with all the three modalities. Patient's clinical notes and radiographs were reviewed. Results. Between 2016 and 2022, 21 patients underwent ORIF – group 1, 10 patients were treated with arthroplasty – group 2 and 5 were managed conservatively- group 3. The mean age of patients was 62 years in group 1, 70 years in group 2 and 76 years in group 3. The mean range of movement (ROM) arc achieved in the group 1 & 2 was 103 while group 3 was 68. At least follow up was 6 months. 5 patients in group 1 underwent metalwork removal and 2 patients in group 3 under arthroplasty. Conclusion. The outcomes of arthroplasty and ORIF are comparable, but reoperation rates and stiffness were higher in ORIF and conservative group. Surgeon choice and patient factors play important role in decision towards choosing treatment modality. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Aims

The aim of this study was to describe the incidence of refractures among children, following fractures of all long bones, and to identify when the risk of refracture decreases.

The June 2023 Shoulder & Elbow Roundup³⁶⁰ looks at: Proximal humerus fractures: what does the literature say now?; Infection risk of steroid injections and subsequent reverse shoulder arthroplasty; Surgical versus non-surgical management of humeral shaft fractures; Core outcome set needed for elbow arthroplasty; Minimally invasive approaches to locating radial nerve in the posterior humeral approach; Predictors of bone loss in anterior glenohumeral instability; Does the addition of motor control or strengthening exercises improve rotator cuff-related shoulder pain?; Terminology and diagnostic criteria used in patients with subacromial pain syndrome.

Standard fixation for intra-articular distal humerus fracture is open reduction and internal fixation (ORIF). However, high energy fractures of the distal humerus are often accompanied with soft tissue injuries and or vascular injuries which limits the use of internal fixation. In our report, we describe a highly complex distal humerus fracture that showed promising healing via a ring external fixator. A 26-year-old man sustained a Gustillo Anderson Grade IIIB intra-articular distal humerus fracture of the non-dominant limb with bone loss at the lateral column. The injury was managed with aggressive wound debridement and cross elbow stabilization via a hinged ring external fixator. Post operative wound managed with foam dressing. Post-operatively, early controlled mobilization of elbow commenced. Fracture union achieved by 9 weeks and frame removed once fracture united. No surgical site infection or non-union observed throughout follow up. At 2 years follow up, flexion - extension of elbow is 20°- 100°, forearm supination 65°, forearm pronation 60° with no significant valgus or varus deformity. The extent of normal anatomic restoration in elbow fracture fixation determines the quality of elbow function with most common complication being elbow stiffness. Ring fixator is a non-invasive external device which provides firm stabilization of fracture while allowing for adequate soft tissue management. It provides continuous axial micro-movements in the frame which promotes callus formation while avoiding translation or angulation between the fragments. In appropriate frame design, they allow for early rehabilitation of joint where normal range of motion can be allowed in controlled manner immediately post-fixation. Functional outcome of elbow fracture from ring external fixation is comparable to ORIF due to better rehabilitation and lower complications. Ring external fixator in our patient achieved acceptable functional outcome and fracture alignment meanwhile the fracture was not complicated with common complications seen in ORIF. In conclusion, ring external fixator is as effective as ORIF in treating complex distal humeral fractures and should be considered for definitive fixation in such fractures

The April 2023 Shoulder & Elbow Roundup. 360. looks at: Arthroscopic Bankart repair in athletes: in it for the long run?; Functional outcomes and the Wrightington classification of elbow fracture-dislocations; Hemiarthroplasty or ORIF intra-articular distal humerus fractures in older patients; Return to sport after total shoulder arthroplasty and hemiarthroplasty; Readmissions after shoulder arthroplasty; Arthroscopic Bankart repair in the longer term; Bankart repair with(out) remplissage or the Latarjet procedure? A systematic review and meta-analysis; Regaining motion among patients with shoulder pathology: are all exercises equal?

Aims. The ‘pink, pulseless hand’ is often used to describe the clinical situation in which a child with a supracondylar fracture of the humerus has normal distal perfusion in the absence of a palpable peripheral pulse. The management guidelines are based on the assessment of perfusion, which is difficult to undertake and poorly evaluated objectively. The aim of this study was to review the available literature in order to explore the techniques available for the preoperative clinical assessment of perfusion in these patients and to evaluate the clinical implications. Methods. A systematic literature review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered prospectively with the International Prospective Register of Systematic Reviews. Databases were explored in June 2022 with the search terms (pulseless OR dysvascular OR ischaemic OR perfused OR vascular injury) AND supracondylar AND (fracture OR fractures). Results. A total of 573 papers were identified as being suitable for further study, and 25 met the inclusion criteria for detailed analysis. These studies included a total of 504 patients with a perfused, pulseless limb associated with a supracondylar humeral fracture. Clinical examination included skin colour (23 studies (92%)), temperature (16 studies (64%)), and capillary refill time (13 studies (52%)). Other investigations included peripheral oxygen saturation (SaO2) (six studies (24%)), ultrasound (US) (14 (56%)), and CT angiogram (two studies (8.0%)). The parameters of ‘normal perfusion’ were often not objectively defined. The time to surgery ranged from 1.5 to 12 hours. A total of 412 patients (82%) were definitively treated with closed or open reduction and fixation, and 92 (18%) required vascular intervention, ranging from simple release of entrapped vessels to vascular grafts. Conclusion. The description of the vascular assessment of the patient with a supracondylar humeral fracture and a pulseless limb in the literature is variable, with few objective criteria being used to define perfusion. The evidence base for decision-making is limited, and further research is required. We were able, however, to make some recommendations about objective criteria for the assessment of these patients, and we suggest that these are performed frequently to allow the detection of any deterioration of perfusion. Cite this article: Bone Joint J 2023;105-B(3):231–238

Aims. Early large treatment effects can arise in small studies, which lessen as more data accumulate. This study aimed to retrospectively examine whether early treatment effects occurred for two multicentre orthopaedic randomized controlled trials (RCTs) and explore biases related to this. Methods. Included RCTs were ProFHER (PROximal Fracture of the Humerus: Evaluation by Randomisation), a two-arm study of surgery versus non-surgical treatment for proximal humerus fractures, and UK FROST (United Kingdom Frozen Shoulder Trial), a three-arm study of two surgical and one non-surgical treatment for frozen shoulder. To determine whether early treatment effects were present, the primary outcome of Oxford Shoulder Score (OSS) was compared on forest plots for: the chief investigator’s (CI) site to the remaining sites, the first five sites opened to the other sites, and patients grouped in quintiles by randomization date. Potential for bias was assessed by comparing mean age and proportion of patients with indicators of poor outcome between included and excluded/non-consenting participants. Results. No bias in treatment effect was observed overall for the CI site, or the first five sites, compared with the remaining sites in either trial. An early treatment effect on the OSS was observed for the first quintile of participants recruited to ProFHER only (clinically relevant difference of seven points). Selection bias for age was observed in the ProFHER trial only, with slightly younger patients being recruited into the study. Both trials showed some selection bias for markers of poor prognosis, although these did not appear to change over time. Conclusion. No bias in treatment effects overall were found at the CI or early sites set-up. An early treatment effect was found in one of the two trials, which was likely a chance effect as this did not continue during the study. Selection bias was observed in both RCTs, however this was minimal and did not impact on outcome. Cite this article: Bone Jt Open 2023;4(2):96–103

Aims

The optimal choice of management for proximal humerus fractures (PHFs) has been increasingly discussed in the literature, and this work aimed to answer the following questions: 1) what are the incidence rates of PHF in the geriatric population in the USA; 2) what is the mortality rate after PHF in the elderly population, specifically for distinct treatment procedures; and 3) what factors influence the mortality rate?

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Management of displaced paediatric supracondylar elbow fractures remains widely debated and actual practice is unclear. This national trainee collaboration aimed to evaluate surgical and postoperative management of these injuries across the UK.

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The aim of this systematic review and meta-analysis was to gather epidemiological information on selected musculoskeletal injuries and to provide pooled injury-specific incidence rates.

Abstract. Background. Fractures Proximal humerus account for nearly 10 % of geriatric fractures. The treatment options varies. There is no consensus regarding the optimal treatment, with almost all modalities giving functionally poor outcomes. Hence literature recommends conservative management over surgical options. MULTILOC nail with its design seems to be a promising tool in treating these fractures. We hereby report our early experience in the treatment of 37 elderly patients. Objectives. To evaluate the radiological outcome with regards to union, collapse, screw back out/cut through, implant failures, Greater tuberosity migration. To evaluate the functional outcome at the end of 6 months using Constant score. Study Design & Methods. All patients aged >65 years who underwent surgery for 3,4-part fracture proximal humerus using the MULTILOC nail were included in the study after consent. Pre – existing rotator cuff disease were excluded. Within the time frame, a total of 39 patients underwent the said surgery. 2 patients were lost to follow up. All the measurements were taken at the end of 6 months and results tabulated and analysed. Results. Union was achieved in all the 37 patients. There were no varus collapse or screw backout/cut through seen in any of the patients. There was Greater tuberosity migration in 1 patient who underwent revision surgery at 6 weeks. All the patients got a minimum of 70 degrees of abduction and forward flexion. We had 29 excellent, 6 good, 2 fair and none poor results as per Constant scoring system. Study done in Tejasvini Hospital & SSIOT Mangaluru India

Abstract. Reverse shoulder arthroplasty (RSA) is being increasingly used for complex, displaced fractures of the proximal humerus. The main goal of the current study was to evaluate the functional and radiographic results after primary RSA of three or four-part fractures of the proximal humerus in elderly patients. Between 2012 and 2020, 70 consecutive patients with a recent three- or four-part fracture of the proximal humerus were treated with an RSA. There were 41 women and 29 men, with a mean age of 76 years. The dominant arm was involved in 42 patients (60%). All surgeries were carried out within 21 days. Displaced three-part fracture sustained in 16 patients, 24 had fracture dislocation and 30 sustained a four-part fracture of the proximal humerus. Patients were followed up for a mean of 26 months. The mean postoperative OSS at the end of the follow-up period was 32.4. The mean DASH score was 44.3. Tuberosity non-union occurred in 18 patients (12.6%), malunion in 7 patients (4.9%), heterotopic ossification in 4 patients (2.8%) and scapular notching in one patient. Anatomical reconstruction was achieved in 25 patients (17.5%), the influence of greater tuberosity healing on shoulder function could not be demonstrated. Heterotopic ossification seems to affect OSS and QDASH, we found statistically significant relation between HO and clinical outcomes. Patients with heterotopic ossification had significantly lower postoperative scores on DASH and OSS (P = .0527). Despite expecting good functional outcome with low complication rate after RSA, the functional outcome was irrespective of healing of the tuberosities

Aims

To describe outcome reporting variation and trends in non-pharmacological randomized clinical trials (RCTs) of distal tibia and/or ankle fractures.

Aim. A significant number of patients undergoing shoulder arthroplasty surgery have C acnes contamination at the end of the primary surgery. The objective of this study is to determine whether patients with C acnes contamination at the end of their primary shoulder surgery have a worse prognosis than those who end up without C. acnes contamination. Method. Prospective study including all patients who underwent a reverse shoulder prosthesis from January 2015 to December 2018. In all of them, 5 to 12 cultures were performed during primary surgery. The patients underwent surgery for shoulder arthritis secondary to rotator cuff tears, acute fracture of the proximal humerus, and sequelae of fracture of the proximal humerus. Exclusion criteria included the existence of previous surgeries on the affected shoulder, the presence of signs of infection, having received infiltrations and / or complementary invasive examinations (Arthro-MRI and Arthro-CT). Follow-up from 2 to 5 years. Functional assessment according to the Constant Functional Scale. All complications were also recorded. Results. 162 patients were included. Of these, 25 had positive cultures for C. acnes at the end of primary shoulder surgery. Average age of 74.8 years. 136 women and 26 men. 75.9% Shoulder arthritis secondary to rotator cuff tears, 13.6% acute fractures and 10.5% sequelae of fractures. There were no differences between patients with C. acnes and those without C. acnes regarding age and indication for surgery. Predominance of men in the group with positive C. acnes (p <0.001). No differences at 2 and 5 years in the Constant functional scale between the two groups (2 years, 59.6 vs 59.2 p 0.870) (5 years, 62.4 vs 59.5 p 0.360). Significant differences regarding the number of complications (p 0.001). Patients without C. acnes had 1 aseptic loosening of the metaglene and patients with C. acnes had 2 infections, 1 dislocation, and 1 revision surgery. Patients with contamination by C. acnes had more comorbidities (p 0.035) than patients without contamination. Conclusions. Patients with C acnes contamination at the end of primary surgery do not have functional differences when compared with patients without contamination at 2 and 5 years, but they have a higher number of complications in the medium term