Aims. The primary aim of this study was to develop a reliable, effective radiological score to assess the healing of humeral shaft fractures, the Radiographic Union Score for HUmeral fractures (RUSHU). The secondary aim was to assess whether the six-week RUSHU was predictive of nonunion at six months after the injury. Patients and Methods. Initially, 20 patients with radiographs six weeks following a humeral shaft fracture were selected at random from a trauma database and scored by three observers, based on the Radiographic Union Scale for Tibial fractures system. After refinement of the RUSHU criteria, a second group of 60 patients with radiographs six weeks after injury, 40 with fractures that united and 20 with fractures that developed nonunion, were scored by two blinded observers. Results. After refinement, the interobserver intraclass correlation coefficient (ICC) was 0.79 (95% confidence interval (CI) 0.67 to 0.87), indicating substantial agreement. At six weeks after injury, patients whose fractures united had a significantly higher median score than those who developed nonunion (10 vs 7; p < 0.001). A receiver operating characteristic curve determined that a RUSHU cut-off of < 8 was predictive of nonunion (area under the curve = 0.84, 95% CI 0.74 to 0.94). The sensitivity was 75% and specificity 80% with a positive predictive value (PPV) of 65% and a negative predictive value of 86%. Patients with a RUSHU < 8 (n = 23) were more likely to develop nonunion than those with a RUSHU ≥ 8 (n = 37, odds ratio 12.0, 95% CI 3.4 to 42.9). Based on a PPV of 65%, if all patients with a RUSHU < 8 underwent fixation, the number of procedures needed to avoid one nonunion would be 1.5. Conclusion. The RUSHU is reliable and effective in identifying patients at risk of nonunion of a humeral shaft fracture at six weeks after injury. This tool requires external validation but could potentially reduce the morbidity associated with delayed treatment of an established nonunion. Cite this article: Bone Joint J 2019;101-B:1300–1306

Aims. Arthroplasty is being increasingly used for the management of distal humeral fractures (DHFs) in elderly patients. Arthroplasty options include total elbow arthroplasty (TEA) and hemiarthroplasty (HA); both have unique complications and there is not yet a consensus on which implant is superior. This systematic review asked: in patients aged over 65 years with unreconstructable DHFs, what differences are there in outcomes, as measured by patient-reported outcome measures (PROMs), range of motion (ROM), and complications, between distal humeral HA and TEA?. Methods. A systematic review of the literature was performed via a search of MEDLINE and Embase. Two reviewers extracted data on PROMs, ROM, and complications. PROMs and ROM results were reported descriptively and a meta-analysis of complications was conducted. Quality of methodology was assessed using Wylde’s non-summative four-point system. The study was registered with PROSPERO (CRD42021228329). Results. A total of 29 studies met the inclusion and exclusion criteria. The mean Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) score was 19.6 (SD 7.5) for HA and 38 (SD 11.9) for TEA and the mean abbreviated version of DASH was 17.2 (SD 13.2) for HA and 24.9 (SD 4.8) for TEA. The Mayo Elbow Performance Score was the most commonly reported PROM across included studies, with a mean of 87 (SD 5.3) in HA and 88.3 (SD 5) in TEA. High complication rates were seen in both HA (22% (95% confidence interval (CI) 5 to 44)) and TEA (21% (95% CI 13 to 30), but no statistically significant difference identified. Conclusion. This systematic review has indicated PROMs and ROM mostly favouring HA, but with a similarly high complication rate in the two procedures. However, due to the small sample size and heterogeneity between studies, strength of evidence for these findings is low. We propose further research in the form of a national randomized controlled trial. Cite this article: Bone Joint J 2022;104-B(5):559–566

This study reviews the early results of Distal Humeral Hemiarthroplasty(DHH) for distal humeral fracture and proposed a treatment algorithm incorporating the use of this technique in the overall management of distal humeral fractures. DHH was performed on 30 patients (mean 65 years; 29-91) for unreconstructable fractures of the distal humerus or salvage of failed internal fixation. A triceps on approach was used in six and an olecranon osteotomy in 24. A Sorbie Questor prosthesis (Wright Medical Technology) was used in 14 patients and a Latitude (Tornier) in 16. Clinical review at a mean of 25 months (3–88) included the American Shoulder and Elbow Surgeons elbow outcomes instrument (ASES), Mayo Elbow Performance Index (MEPI) and radiological assessment. At follow up of 28 patients mean flexion deformity was 25 degrees, flexion 128 degrees, range of pronosupination 165 degrees, mean ASES 83, MEPI 77 and satisfaction 8/10. Acute cases scored better than salvage cases. Re- operation was required in 16 patients (53%); two revisions to a linked prosthesis for periprosthetic fracture and aseptic loosening at 53 and 16 months, 12 metalwork removals and four ulnar nerve procedures. Posterolateral rotatory instability was present in one elbow, four had laxity and mild pain on loading (two with prosthesis or pin loosening), four had laxity associated with column fractures (two symptomatic) and 10 had asymptomatic mild laxity only. The triceps on approach had worse instability and clinical scores. Uncomplicated union occurred in all olecranon osteotomies and 86% of column fractures. One elbow had an incomplete cement mantle and seven had lucencies >1 mm; one was loose but acceptable. Five prostheses were in slight varus. Two elbows had early degenerative changes and 15 developed a medial spur on the trochlea. This is the largest reported experience of DHH. Early results of DHH show good outcomes after complex distal humeral fractures, despite a technically demanding procedure. Better results are obtained for treatment in the acute setting and with use of an olecranon osteotomy. As a result of this experience anatomical and clinical pre-requisites and advise on technique are outlined. An algorithm for use of DHH in relation to total elbow arthroplasty and ORIF for the treatment of complex intra-articular distal humeral fractures with or without column fractures is proposed

Introduction. Humeral non-union may present a challenging problem. The instability from the un-united fracture leads to pain, disability and significant morbidity. The incidence of humeral shaft non-union as a complication of both operative and non-operative treatment is approximately 8% to 12%. This retrospective study reviews the results of surgical treatment of humeral fracture non-union performed by a single surgeon with a consistent surgical protocol. Material and Method. We present a retrospective analysis of a series of 51 consecutive cases of humeral fracture non-union treated in our limb reconstruction centre. Data were collected on mechanism of injury, associated co-morbidities, smoking, use of NSAIDs and treatment before referral. Patients were followed up to clinical and radiological union. Results. From 1994-2008, 48 patients with established humeral non-union were referred to our unit following initial management locally. Three patients were managed in our unit from the outset. There were 20 male and 28 female patients with a mean age of 53 years (range 15-86 years). There were 34 (68%) diaphyseal, nine (17%) proximal and eight (15%) distal humeral non-unions. The treatment in our unit involved plate fixation in 44 (86%) cases, intramedullary nailing in three (6%) and external fixation in three (6%) patients. Iliac crest bone graft, bone morphogenetic protein or a combination of these were utilised in 44 (86%) cases. Thirty-six patients required at least one surgical intervention to achieve union. Twelve patients had more than one operation. The average follow-up was 19.6 months. Union was achieved in all but one case at an average time of 9.8 months (range 3-24 months); one case developed a functionally inconsequential pseudoarthrosis. Conclusion. Union of ununited humeral fractures can be achieved consistently by providing appropriate mechanical stability and biological environment at the fracture site

Objective: The primary aim was to describe the epidemiology of the Holstein-Lewis humeral shaft fracture, its association with radial nerve palsy and the outcome regarding recovery from the radial nerve palsy and fracture healing. The secondary aim was to analyze the long-term functional outcome. Setting: Six major hospitals in Stockholm County. Design: Descriptive study. Retrospective assessment of radial nerve recovery and fracture healing. Prospective assessment of functional outcome. Patients: All 27 patients with a 12A1.3 humeral shaft fracture according to the OTA classification satisfying the criteria of a Holstein-Lewis fracture in a population of 358 consecutive patients with 361 traumatic humeral shaft fractures. Intervention: Nonoperative or operative treatment according to the decision of the attending orthopedic surgeon. Main Outcome Measurements: Recovery of the radial nerve, fracture healing and functional outcome according to the Short Musculoskeletal Function Assessment (SMFA). Results: The Holstein-Lewis humeral shaft fracture constituted 7.5% of all humeral shaft fractures and was associated with an increased risk of acute radial nerve palsy compared to other types of humeral shaft fractures, 22% versus 8% (p< 0.05). The fractures of six of the seven operatively treated patients healed after the primary surgical procedure while one fracture healed after revision surgery. The fractures of all patients treated nonoperatively healed without any further intervention. All six radial nerve palsies (two patients treated nonoperatively and four operatively) recovered. The functional outcome according to the SMFA was good with no differences between the nonoperatively and operatively treated patients: SMFA dysfunction index 7.6 and 9.7, respectively, and SMFA bother index 6.1 and 6.8, respectively. Conclusion: The Holstein-Lewis humeral shaft fracture was associated with a significantly increased risk of acute radial nerve palsy. The overall outcome regarding fracture healing, radial nerve recovery, and function is excellent regardless of the primary treatment modality, i.e. operative or nonoperative treatment. The indication for primary operative intervention in this fracture type appears to be relative

Aims. The primary aim was to estimate the cost-effectiveness of routine operative fixation for all patients with humeral shaft fractures. The secondary aim was to estimate the health economic implications of using a Radiographic Union Score for HUmeral fractures (RUSHU) of < 8 to facilitate selective fixation for patients at risk of nonunion. Methods. From 2008 to 2017, 215 patients (mean age 57 yrs (17 to 18), 61% female (n = 130/215)) with a nonoperatively managed humeral diaphyseal fracture were retrospectively identified. Union was achieved in 77% (n = 165/215) after initial nonoperative management, with 23% (n = 50/215) uniting after surgery for nonunion. The EuroQol five-dimension three-level health index (EQ-5D-3L) was obtained via postal survey. Multiple regression was used to determine the independent influence of patient, injury, and management factors upon the EQ-5D-3L. An incremental cost-effectiveness ratio (ICER) of < £20,000 per quality-adjusted life-year (QALY) gained was considered cost-effective. Results. At a mean of 5.4 yrs (1.2 to 11.0), the mean EQ-5D-3L was 0.736 (95% confidence interval (CI) 0.697 to 0.775). Adjusted analysis demonstrated the EQ-5D-3L was inferior among patients who united after nonunion surgery (β = 0.103; p = 0.032). Offering routine fixation to all patients to reduce the rate of nonunion would be associated with increased treatment costs of £1,542/patient, but would confer a potential EQ-5D-3L benefit of 0.120/patient over the study period. The ICER of routine fixation was £12,850/QALY gained. Selective fixation based on a RUSHU < 8 at six weeks post-injury would be associated with reduced treatment costs (£415/patient), and would confer a potential EQ-5D-3L benefit of 0.335 per ‘at-risk patient’. Conclusion. Routine fixation for patients with humeral shaft fractures to reduce the rate of nonunion observed after nonoperative management appears to be a cost-effective intervention at five years post-injury. Selective fixation for patients at risk of nonunion based on their RUSHU may confer even greater cost-effectiveness, given the potential savings and improvement in health-related quality of life. Cite this article: Bone Jt Open 2022;3(7):566–572

This paper reports our experience of revision open reduction, internal fixation and bone grafting of distal humeral fracture non-unions and in addition looks specifically at factors that may predispose to the development of non-union. Between 1993 and 2003 18 patients with distal humeral fracture non-unions underwent revision surgery with bone grafting and rigid internal fixation. Two patients were lost to follow-up leaving a study group of 16 patients. The patients’ age, sex, mechanism of injury, AO classification of the initial fracture and the primary treatment method were analysed with respect to possible factors predisposing to non-union. All revision procedures were performed by the senior author. The non-union site was debrided, bone grafted and rigidly internally fixed. Clinical assessment was performed using the Mayo Elbow Performance Score and radiographs were reviewed for evidence of bony union. The Mayo elbow performance scores were excellent in 11, good in 2, fair in 2 and poor in 1. Our results indicate that age, sex and mechanism of injury are not important in the development of non-union. Twelve patients (75%) however were considered to have undergone inadequate management of the original fracture. Our experience would suggest that to reduce the risk of non-union following distal humeral fractures appropriate consideration must be given to the established and well proven surgical techniques. If adequate fixation is considered beyond the experience of the treating surgeon we would strongly advise referral to a specialist unit

This study reviews the early results of elbow hemiarthroplasty for distal humeral fracture. Elbow hemiarthroplasty was performed on 30 patients (mean 65 years; 29–91) for unreconstructable fractures of the distal humerus or salvage of failed internal fixation. A ‘triceps on’ approach was used in 6 and an olecranon osteotomy in 24. A Sorbie Questor prosthesis (Wright Medical Technology) was used in 14 patients and a Lattitude (Tornier) in 16. Clinical review at a mean of 25 months (3 – 88) included the American Shoulder and Elbow Surgeons elbow outcomes instrument (ASES), Mayo Elbow Performance Index (MEPI) and radiological assessment. At follow up of 28 patients, mean flexion deformity was 25 degrees, flexion 128 degrees, range of pronosupination 165 degrees, mean ASES 83, MEPI 77 and satisfaction 8/10. Acute cases scored better than salvage cases. Re-operation was required in 16 patients (53%); 2 revisions to a linked prosthesis for periprosthetic fracture and aseptic loosening at 53 and 16 months, 12 metalwork removals and 4 ulnar nerve procedures. Posterolateral rotatory instability was present in one elbow, 4 had laxity and pain on loading (2 with prosthesis or pin loosening), 4 had laxity associated with column fractures (2 symptomatic) and 10 had asymptomatic laxity only. The triceps on approach had worse laxity and clinical scores. Uncomplicated union occurred in all olecranon osteotomies and 86% of column fractures. One elbow had an incomplete cement mantle and 7 had lucencies > 1 mm; one was loose but acceptable. 5 prostheses were in slight varus and 2 were flexed. 2 elbows had early degenerative changes and 15 an osteophytic lip on the medial trochlea. Elbow hemiarthroplasty has good early results after complex distal humeral fractures, despite a demanding procedure, metalware removal in 40%, symptomatic laxity in 12% and column non-union in 8%. Better results are obtained for treatment in the acute setting and with use of an olecranon osteotomy

Pathological fractures of the humerus are associated with pain, morbidity, loss of function and a diminished quality of life. We report our experience of stabilising these fractures using polymethylmethacrylate and non-locking plates. We undertook a retrospective review over 20 years of patients treated at a tertiary musculoskeletal oncology centre. Those who had undergone surgery for an impending or completed pathological humeral fracture with a diagnosis of metastatic disease or myeloma were identified from our database. There were 63 patients (43 men, 20 women) in the series with a mean age of 63 years (39 to 87). All had undergone intralesional curettage of the tumour followed by fixation with intramedullary polymethylmethacrylate and plating. Complications occurred in 14 patients (22.2%) and seven (11.1%) required re-operation. At the latest follow-up, 47 patients (74.6%) were deceased and 16 (25.4%) were living with a mean follow-up of 75 months (1 to 184). A total of 54 (86%) patients had no or mild pain and 50 (80%) required no or minimal assistance with activities of daily living. Of the 16 living patients none had pain and all could perform activities of daily living without assistance. Intralesional resection of the tumour, filling of the cavity with cement, and plate stabilisation of the pathological fracture gives immediate rigidity and allows an early return of function without the need for bony union. The patient’s local disease burden is reduced, which may alleviate tumour-related pain and slow the progression of the disease. The cemented-plate technique provides a reliable option for the treatment of pathological fractures of the humerus

Introduction. Although the majority of adult distal humeral fractures are successfully treated with ORIF, the management in frail patients, often elderly with multiple co-morbidities and osteoporotic bone, remains controversial. Elbow replacement is frequently recommended if stable internal fixation cannot be achieved, especially in low, displaced, comminuted fractures. The “bag-of-bones” method ie early movement with fragments accepted in their displaced position, is rarely considered as there has been little in the literature since 10 successful cases were reported by Brown & Morgan in 1971 (JBJS 53-B(3):425–428). We present the experience of three units in which conservative management has been actively adopted in selected cases. Methods. 44 distal humeral fractures were initially treated conservatively - 2004–2010. Mean age 73.9 yrs (40–91) and 34 F: 10 M. Clinical and radiological review at a mean follow-up of 2 years (1–6). Results. There were 18 AO Type A, 7 B and 19 C fractures. The range of elbow movement was extension/flexion 38/124, and pronation/supination 75/76 at their last follow-up. Using the Oxford elbow score (0 = worst/4 best result), the mean pain score was 2.44 (range 1–4), 2.26 (0–4) for function, and 2.04 (0–4) for psycho-social, although several patients had early dementia. Only 5 subsequently underwent replacement out of 44 patients whose residual symptoms have not been sufficient to require surgery. Discussion. We believe that there is a role for initial conservative treatment in selected higher-risk patients, as initial early mobilisation within the limits of discomfort can give good functional results. There is a significant complication rate after fixation or replacement in elderly, frail patients, which includes infection, stiffness and loosening. Unnecessary operations can be avoided in the majority of cases, with replacement of a virgin joint at a later date only if required

Since its approval by the FDA two decades ago, Negative Pressure Wound Therapy (NPWT) has become a valuable asset in the management of open fractures with significant soft tissue damage as those seen in high velocity gunshot injuries. These lesions are often associated with grossly contaminated wounds and require a prompt and effective approach. Wound dehiscence and surgical site infection are two of the most common post-operative complications, with poor results when treated with standard gauze dresses. NPTW comes as a legitimate resource promoting secondary intention healing through increased granulation and improved tissue perfusion, as well as continuous local wound drainage preventing bacterial growth and further infection. Recent evidence-based guidelines are still limited for use of NPWT in the treatment of Gustilo-Anderson type IIIB open fractures and there are few cases in literature reporting the management of upper extremity injuries. We present and discuss a successful case of a type IIIB open humeral fracture wound treated with NPWT. A 38-years-old male was admitted to the Emergency Room with a type IIIB open humeral fracture as a result of a gunshot with extensive soft tissue damage. IV antibiotic therapy was promptly started followed by surgical stabilization by intramedullary nailing with primary wound closure. The patient presented an early surgical site infection with wound dehiscence requiring secondary debridement with poor subsequent healing and deficient soft tissue coverage. After ineffective 28 days of standard gauze dresses we started NPWT. NPTW was applied using foam coverage over the dehiscence area with visible results after 13 days and complete granulation of the skin defect by the 28th day. The wound healed completely after 14 weeks of NPWT. The fracture evolved into a painless pseudarthrosis revealing an excellent functional recovery and an acceptable aesthetic result. NPTW is a valuable, effective, and well tolerated resource in the treatment of open fractures with extensive soft tissue damage such as Gustilo-Anderson type IIIB fractures. It should be considered not just as a salvage procedure but as well as a primary option especially in grossly contaminated wounds. No benefits in any form have been received from a commercial party

Purpose: Distal humeral fractures are often difficult injuries to treat. We hypothesise that more complex distal humeral fractures have unacceptable functional outcomes due to multi-factorial reasons. Methods: 42 patients with AO/ASIF type B and C fractures of the distal humerus who were treated with open reduction and internal fixation over a six year period were included in the study. All patients were from a single district general hospital. 37 (88%) were clinically, radiologically, and functionally assessed for this study, with the remainder either lost to follow-up or expired. Results: There were 21 type B and 16 type C fractures, all managed by open reduction and internal fixation. Various fixation techniques were utilised. These were performed by consultant surgeons in 14 cases and by surgeons in training in 23 cases. Average follow up was 38 months (range 22–54 months). The arc of elbow motion was 94 degrees (range 58–130), with an average extension deficit of 28 degrees (range 20–55) and an average flexion deficit of 32 degrees (range 15–45). The average arc of forearm rotation was 136 degrees (range 45–140), with an average supination of 68 (range 35–85) and an average pronation of 72 (range 45–90). The complications (n=20/37) included superficial skin infection (n=4), ulnar nerve neurapraxia (n=3), non-union of the humerus fracture (n=2), non-union of olecranon osteotomy site (n=1), intra-articular screw placement (n=1), loosened plate (n=1), loose/backed out screw (n=2), fixed flexion deformity (n=4) and mild elbow instability (n=2). Second surgery was performed in 24% (n=9/37), revision of metal work (n=2), bone grafting (n=2), anterior capsulectomy (n=4), and removal of screw (n=1). Conclusions: Fractures of the distal humerus are often more complex than appreciated, and challenging to treat, with respect to fracture union and functional outcome. A generalist practice appears adequate for achieving bony union, but inadequate for obtaining low complication rates and functional outcomes. Our data suggest that such injuries may constitute a fracture group requiring the acute intervention by centres that have specific sub-specialisation and adequate rehabilitation facilities

We treated 49 patients at an average age of 80 years (75 to 90) with distal mostly intraarticular humeral fractures by open reduction. There were 8 class A, 13 class B and 28 class C fractures on Muller's classification. The patients were reviewed at a postoperative average of 18 months. The patients' assessment of the result was very good in 31%, good in 49%, fair in 15% and poor in 5%. The flexion-extension range was very good in 41%, good in 44% and fair in 15%. The incidence of implant failure, pseudarthrosis of the olecranon osteotomy and ulnar nerve lesion was no higher in these elderly patients than in younger patients. Old age is not a contraindication to open reduction and internal fixation; it is important to restore full function

Aims. The primary aim of this study was to determine the rates of return to work (RTW) and sport (RTS) following a humeral shaft fracture. The secondary aim was to identify factors independently associated with failure to RTW or RTS. Methods. From 2008 to 2017, all patients with a humeral diaphyseal fracture were retrospectively identified. Patient demographics and injury characteristics were recorded. Details of pre-injury employment, sporting participation, and levels of return post-injury were obtained via postal questionnaire. The University of California, Los Angeles (UCLA) Activity Scale was used to quantify physical activity among active patients. Regression was used to determine factors independently associated with failure to RTW or RTS. Results. The Work Group comprised 177 patients in employment prior to injury (mean age 47 years (17 to 78); 51% female (n = 90)). Mean follow-up was 5.8 years (1.3 to 11). Overall, 85% (n = 151) returned to work at a mean of 14 weeks post-injury (0 to 104), but only 60% (n = 106) returned full-time to their previous employment. Proximal-third fractures (adjusted odds ratio (aOR) 4.0 (95% confidence interval (CI) 1.2 to 14.2); p = 0.029) were independently associated with failure to RTW. The Sport Group comprised 182 patients involved in sport prior to injury (mean age 52 years (18 to 85); 57% female (n = 104)). Mean follow-up was 5.4 years (1.3 to 11). The mean UCLA score reduced from 6.9 (95% CI 6.6 to 7.2) before injury to 6.1 (95% CI 5.8 to 6.4) post-injury (p < 0.001). There were 89% (n = 162) who returned to sport: 8% (n = 14) within three months, 34% (n = 62) within six months, and 70% (n = 127) within one year. Age ≥ 60 years was independently associated with failure to RTS (aOR 3.0 (95% CI 1.1 to 8.2); p = 0.036). No other factors were independently associated with failure to RTW or RTS. Conclusion. Most patients successfully return to work and sport following a humeral shaft fracture, albeit at a lower level of physical activity. Patients aged ≥ 60 yrs and those with proximal-third diaphyseal fractures are at increased risk of failing to return to activity. Cite this article: Bone Jt Open 2022;3(3):236–244

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. Methods. The HUmeral SHaft (HUSH) fracture study is a multicentre, prospective randomized superiority trial of surgical versus non-surgical interventions for humeral shaft fractures in adult patients. Participants will be randomized to receive either functional bracing or surgery. With 334 participants, the trial will have 90% power to detect a clinically important difference for the Disabilities of the Arm, Shoulder and Hand questionnaire score, assuming 20% loss to follow-up. Secondary outcomes will include function, pain, quality of life, complications, cost-effectiveness, time off work, and ability to drive. Discussion. The results of this trial will provide evidence regarding clinical and cost-effectiveness between surgical and non-surgical treatment of humeral shaft fractures. Ethical approval has been obtained from East of England – Cambridge Central Research Ethics Committee. Publication is anticipated to occur in 2024. Cite this article: Bone Jt Open 2024;5(4):343–349

Aims: The purposes of this study were to design a more useful fracture classiþcation system for distal humeral fractures and to validate it by exactly reproducing methodology from a previous study. Methods: We designed a new fracture classiþcation system based upon our experience of managing these fractures. We tested its validity by reproducing methodology from a study performed in Oxford. Using the same radiographs, we asked 9 independent assessors to classify the fractures, on two separate occasions, according to the Riseborough and Radin, Jupiter and Mehne and AO classiþcation systems as well as our own Ð The Shefþeld Classiþcation. The assessors were unaware that the new system was produced for the purposes of the study. Using the Kappa statistic, the level of interobserver and intraobserver agreement was determined. Results: Amongst all observers, The Shefþeld Classiþcation is a moderately reliable (k=0.603) but substantially reproducible (k=0.713) classiþcation system. The system improves to become substantially reliable (k=0.643) amongst orthopaedic surgeons. The proportion of fractures unclassiþable by the new system is similar to the AO classiþcation (3.7%). Conclusions: By reproducing previous methodology, we have a unique study that validates The Shefþeld Classiþcation. We believe that it can be used in a management algorithm for these complex fractures

The primary aim was to assess the reliability of ultrasound in the assessment of humeral shaft fracture healing. The secondary aim was to estimate the accuracy of ultrasound assessment in predicting humeral shaft nonunion. Twelve patients (mean age 54yrs [20–81], 58% [n=7/12] female) with a non-operatively managed humeral diaphyseal fracture were prospectively recruited and underwent ultrasound scanning at six and 12wks post-injury. Scans were reviewed by seven blinded observers to evaluate the presence of sonographic callus. Intra- and inter-observer reliability were determined using the weighted kappa and intraclass correlation coefficient (ICC). Accuracy of ultrasound assessment in nonunion prediction was estimated by comparing scans for patients that united (n=10/12) with those that developed a nonunion (n=2/12). At both six and 12wks, sonographic callus was present in 11 patients (10 united, one developed a nonunion) and sonographic bridging callus (SBC) was present in seven patients (all united). Ultrasound assessment demonstrated substantial intra- (6wk kappa 0.75, 95% CI 0.47-1.03; 12wk kappa 0.75, 95% CI 0.46-1.04) and inter-observer reliability (6wk ICC 0.60, 95% CI 0.38-0.83; 12wk ICC 0.76, 95% CI 0.58-0.91). Absence of sonographic callus demonstrated a sensitivity of 50%, specificity 100%, positive predictive value (PPV) 100% and negative predictive value (NPV) 91% in nonunion prediction (accuracy 92%). Absence of SBC demonstrated a sensitivity of 100%, specificity 70%, PPV 40% and NPV 100% (accuracy 75%). Of three patients at risk of nonunion based on reduced radiographic callus formation (Radiographic Union Score for HUmeral fractures <8), one had SBC on 6wk ultrasound (and united) and the other two had non-bridging or absent sonographic callus (both developed a nonunion). Ultrasound assessment of humeral shaft fracture healing was reliable and predictive of nonunion, and may be a useful tool in defining the risk of nonunion among patients with reduced radiographic callus formation

We retrospectively reviewed 89 consecutive patients (45 men and 44 women) with a mean age at the time of injury of 58 years (18 to 97) who had undergone external fixation after sustaining a unilateral fracture of the distal humerus. Our objectives were to determine the incidence of heterotopic ossification (HO); identify risk factors associated with the development of HO; and characterise the location, severity and resultant functional impairment attributable to the presence of HO.

HO was identified in 37 elbows (42%), mostly around the humerus and along the course of the medial collateral ligament. HO was hazy immature in five elbows (13.5%), mature discrete in 20 (54%), extensive mature in 10 (27%), and complete bone bridges were present in two elbows (5.5%). Mild functional impairment occurred in eight patients, moderate in 27 and severe in two. HO was associated with less extension (p = 0.032) and less overall flexion-to-extension movement (p = 0.022); the flexion-to-extension arc was < 100º in 21 elbows (57%) with HO compared with 18 elbows (35%) without HO (p = 0.03). HO was removed surgically in seven elbows.

The development of HO was significantly associated with sustaining a head injury (p = 0.015), delayed internal fixation (p = 0.027), the method of fracture fixation (p = 0.039) and the use of bone graft or substitute (p = 0.02).HO continues to be a substantial complication after internal fixation for distal humerus fractures.

Cite this article: Bone Joint J 2014;96-B:1681–7.

Aims. Medial humeral epicondyle fractures (MHEFs) are common elbow fractures in children. Open reduction should be performed in patients with MHEF who have entrapped intra-articular fragments as well as displacement. However, following open reduction, transposition of the ulnar nerve is disputed. The aim of this study is to evaluate the need for ulnar nerve exploration and transposition. Methods. This was a retrospective cohort study. The clinical data of patients who underwent surgical treatment of MHEF in our hospital from January 2015 to January 2022 were collected. The patients were allocated to either transposition or non-transposition groups. Data for sex, age, cause of fracture, duration of follow-up, Papavasiliou and Crawford classification, injury-to-surgery time, preoperative ulnar nerve symptoms, intraoperative exploration of ulnar nerve injury, surgical incision length, intraoperative blood loss, postoperative ulnar nerve symptoms, complications, persistent ulnar neuropathy, and elbow joint function were analyzed. Binary logistic regression analysis was used for statistical analysis. Results. A total of 124 patients were followed up, 50 in the ulnar nerve transposition group and 74 in the non-transposition group. There were significant differences in ulnar nerve injury (p = 0.009), incision length (p < 0.001), and blood loss (p = 0.003) between the two groups. Binary logistic regression analysis revealed that preoperative ulnar nerve symptoms (p = 0.012) were risk factors for postoperative ulnar nerve symptoms. In addition, ulnar nerve transposition did not affect the occurrence of postoperative ulnar nerve symptoms (p = 0.468). Conclusion. Ulnar nerve transposition did not improve clinical outcomes. It is recommended that the ulnar nerve should not be transposed when treating MHEF operatively. Cite this article: Bone Joint J 2024;106-B(2):212–218

We analysed the outcome of the Coonrad-Morrey total elbow replacement used for fracture of the distal humerus in elderly patients with no evidence of inflammatory arthritis and compared the results for early versus delayed treatment. We studied a total of 32 patients with 15 in the early treatment group and 17 in the delayed treatment group. The mean follow-up was 56.1 months (18 to 88). The percentage of excellent to good results based on the Mayo elbow performance score was not significantly different, 84% in the early group and 79% in the delayed group. Subjective satisfaction was 92% in both the groups.

One patient in the early group developed chronic regional pain syndrome and another type 4 aseptic loosening. Two elbows in the early group also showed type 1 radiological loosening.

Two patients in the delayed group had an infection, two an ulnar nerve palsy, one developed heterotopic ossification and one type 4 aseptic loosening. Two elbows in this group also showed type 1 radiological loosening. The Kaplan-Meier survivorship analysis for the early and delayed treatment groups was 93% at 88 months and 76% at 84 months, respectively.

No significant difference was found between the two groups.

Background

Humerus fracture non-union is a challenge for which a wide range of treatments exist. We present our experience of managing these by hybrid Ilizarov frame fixation, without bone graft or debridement of the non-union site.

The problem of retained drain fragments is a well known but under reported complication in the literature.

The authors present the case of a 66 years old male, who suffered a right distal humerus fracture luxation six years ago that was treated conservatively. He went to the emergency service with fever and right elbow purulent drainage.

Physical examination showed deformity, swelling and fluctuation of the right elbow with purulent drainage through cutaneous fistula. The x-ray showed instable inveterate pseudarthrosis of the distal humerus. Leucocytosis and neutrophylia with increased CRP were presente in the blood tests and the patient started empiric treatment with Ceftiaxone IV. A MRSA was isolated in cultural exam of the exsudate, and a six weeks treatment with Vancomycin IV was iniciated.

Exhaustive surgical cleaning was performed and two plastic foreing bodies (fragmented drains) were removed.

At the time of discharge the patient was afebrile, with normal analytical parameters and negative culture tests.

The orthopaedic surgeon should considerate the presence of a foreign body in patients with infected abcess and traumatic or surgery previous history.

Helical plates are preferably used for proximal humeral shaft fracture fixation and potentially avoid radial nerve irritation as compared to straight plates. Aims:(1) to investigate the safety of applying different long plate designs (straight, 45°-, 90°-helical and ALPS) in MIPO-technique to the humerus. (2) to assess and compare their distances to adjacent anatomical structures at risk. MIPO was performed in 16 human cadaveric humeri using either a straight plate (group1), a 45°-helical (group2), a 90°-helical (group3) or an ALPS (group4). Using CT-angiography, distances between brachial arteries and plates were evaluated. Following, all specimens were dissected, and distances to the axillary, radial and musculocutaneous nerve were evaluated. None of the specimens demonstrated injuries of the anatomical structures at risk after MIPO with all investigated plate designs. Closest overall distance (mm(range)) between each plate and the radial nerve was 1(1-3) in group1, 7(2-11) in group2, 14(7-25) in group3 and 6(3-8) in group4. It was significantly longer in group3 and significantly shorter in group1 as compared to all other groups, p<0.001. Closest overall distance (mm(range)) between each plate and the musculocutaneous nerve was 16(8-28) in group1, 11(7-18) in group2, 3(2-4) in group3 and 6(3-8) in group4. It was significantly longer in group1 and significantly shorter in group3 as compared to all other groups, p<0.001. Closest overall distance (mm(range)) between each plate and the brachial artery was 21(18-23) in group1, 7(6-7) in group2, 4(3-5) in group3 and 7(6-7) in group4. It was significantly longer in group1 and significantly shorter in group3 as compared to all other groups, p<0.021. MIPO with 45°- and 90°-helical plates as well as ALPS is safely feasible and showed a significant greater distance to the radial nerve compared to straight plates. However, distances remain low, and attention must be paid to the musculocutaneous nerve and the brachial artery when MIPO is used with ALPS, 45°- and 90°-helical implants. Anterior parts of the deltoid insertion will be detached using 90°-helical and ALPS implants in MIPO-technique

This single-centre prospective randomised trial aimed to assess the superiority of operative fixation compared with non-operative management for adults with an isolated, closed humeral shaft fracture. 70 patients were randomly allocated to either open reduction and internal fixation (51%, n=36/70) or functional bracing (49%, n=34/70). 7 patients did not receive their assigned treatment (operative n=5/32, non-operative n=2/32); results were analysed based upon intention-to-treat. The primary outcome measure was the DASH score at 3 months. Secondary outcomes included treatment complications, union/nonunion, shoulder/elbow range of motion, pain and health-related quality of life (HRQoL). At 3 months, 66 patients (94%) were available for follow-up; the mean DASH favoured surgery (operative 24.5, non-operative 39.4; p=0.006) and the difference (14.9 points) exceeded the MCID. Surgery was also associated with a superior DASH at 6wks (operative 38.4, non-operative 53.1; p=0.005) but not at 6 months or 1yr. Brace-related dermatitis affected 7 patients (operative 3%, non-operative 18%; OR 7.8, p=0.049) but there were no differences in other complications. 8 patients (11%) developed a nonunion (operative 6%, non-operative 18%; OR 3.8, p=0.140). Surgery was associated with superior early shoulder/elbow range of motion, and pain, EuroQol and SF-12 Mental Component Summary scores. There were no other differences in outcomes between groups. Surgery confers early advantages over bracing, in terms of upper limb function, shoulder/elbow range of motion, pain and HRQoL. However, these benefits should be considered in the context of potential operative risks and the absence of any difference in patient-reported outcomes at 1yr

We treated three patients with malunion after comminuted intercondylar fractures of the humerus by intra-articular derotational opening-wedge osteotomy and the insertion of a tricortical iliac bone graft. Two patients required additional operations, including interposition arthroplasty and hardware removal. A mean arc of increased motion of 65 degrees was achieved in flexion and extension in two patients and a more functional arc in the third. Although this is viewed as a salvage procedure in patients who are thought to be too young for elbow arthroplasty, none of the three patients has significant pain and none has required total elbow arthroplasty after an average follow-up of 7.6 years.

The purpose of this study is to describe the use of the PHILOS plate (Synthes) in reverse configuration to treat complex distal humeral non-unions. Non-union is a frequent complication of distal humeral fracture. It is a challenging problem due to the complex anatomy of the distal humerus, small distal fragment heavily loaded by the forearm acting as a long lever arm with powerful forces increasing the chances of displacement. Rigid fixation and stability with a device of high “pull-out” strength is required. The PHILOS plate has been used in reverse configuration to achieve good fixation while allowing central posterior placement of the implant. 11 patients with established non-union of distal humeral fractures were included in this study. No patient in whom this implant was used has been excluded. Initial fixation was revised using the PHILOS plate in reverse configuration and good fixation was achieved. Bone graft substitutes were used in all cases. Patients were followed to bony union, and functional recovery. All fractures united. One required revision of plate due to fatigue failure. Average time to union was 8 months with excellent restoration of elbow function. A reversed PHILOS plate provides an excellent method of fixation in distal humeral non-union, often complicated by distorted anatomy and previous surgical intervention. It has a high “pull-out” strength and may be placed in the centre of the posterior humerus, allowing proximal extension of the fixation as far as is required. It provides secure distal fixation without impinging on the olecranon fossa. It is more versatile and easier to use than available pre contoured plating systems

The primary aim was to assess patient-reported outcomes following a humeral diaphyseal fracture. The secondary aim was to compare the outcomes of patients who achieved union after initial management (operative or non-operative) with those that achieved union after nonunion surgery. From 2008–2017, 291 patients (mean age 55yrs [17–86], 58% [n=168/291] female) were retrospectively identified and available to complete a survey. Sixty-four (22%) were managed with primary surgery and 227 (78%) non-operatively. Outcomes (QuickDASH, EQ-5D, EQ-VAS, SF-12) were obtained at a mean of 5.5yrs (1.2–11.0). After initial management, 229 patients (79%) united (n=62 operative, n=167 non-operative) and 62 (21%) developed a nonunion (n=2 operative, n=60 non-operative; p<0.001). Fifty-two of 56 patients (93%) achieved union after nonunion surgery. The overall mean QuickDASH was 20.8, EQ-5D 0.730, EQ-VAS 74, SF-12 PCS 44.8 and MCS 50.2. Patients who united after nonunion surgery reported a worse functional outcome (mean QuickDASH 27.9 vs. 17.6, p=0.003) and health-related quality of life (HRQoL; mean EQ-5D 0.639 vs. 0.766, p=0.008; EQ-VAS 66 vs. 76, p=0.036; SF-12 PCS 41.8 vs. 46.1, p=0.036) than those who united primarily. When adjusting for confounders, union after nonunion surgery was independently associated with poorer function (difference in QuickDASH 8.1, p=0.019) and HRQoL (difference in EQ-5D -0.102, p=0.028). Humeral diaphyseal union after nonunion surgery was associated with poorer function and HRQoL compared to patients who united primarily. Targeting early operative intervention to patients at risk of nonunion may have an important role, given the potential impact of nonunion on longer-term outcome

The treatment for Humeral Supracondylar fractures in children is percutaneous fixation with Kirschner wires using a unilateral or crossed wire configuration. Capitellar entry point with divergent wires is thought crucial in the lateral entry approach. Crossed wire configuration carries a risk of Ulnar nerve injury. Our department had recorded a number of failures and this required review. A search was conducted for children with this injury and surgical fixation. A two year time frame was allocated to allow for adequate numbers. The hospitals radiography viewing system and patient notes were utilized to gather required information. 30 patients from 2–14 years all underwent surgery on the day of admission or the following day. 18 had sustained Gartland grade 3 or 4 injuries. Unilateral configuration was used in 10 cases; a loss of reduction was noted in 5 of these with one case requiring reoperation. Crossed wires were used in 20 cases with a loss of reduction in 1. Crossed wire configuration provides a more reliable fixation with a lower chance or re-operation. Our DGH policy now advises the use of this configuration. A small “mini-open” ulnar approach is utilized with visualization and protection of the nerve

Acute fractures of the humeral shaft are usually managed conservatively. The rate of union is high, whereas that of nonunion ranges from 1 – 6%. Various risk factors for nonunion have been identified, including the following: open fracture, mid shaft fracture, transverse or short-oblique fracture, comminuted fracture, unstable fixation, fracture gap. This paper evaluates the results of treatment of humeral shaft fracture by open reduction and internal fixation with DCP, supplemented with cancelous bone graft but not in all cases. One hundred and five cases of nonunion of a humeral shaft fracture between 1988 and 2006 were analyzed retrospectively. The study population comprised 66 males and 39 females with an average of 46.2 years (range, 17 – 81 years). Sixty seven fractures were defined as atrophic nonunion, and 20 as hypertrophic nonunion, whereas 18 could not be defined clearly. All the fractures were managed by open reduction and internal fixaztion with DCP and cancelous bone graft. The mean follow up period was 20 months (range, 14 – 28 months). All nonunion fractures united within an average of 16 weeks (range 10–26 weeks). Complications included 4 patients with temporary radial nerve palsies, and 3 patients with wound infections. At the final follow-up shoulder and elbow functions of the operated limbs were all satisfactory. Fixation by DCP with supplemental cancellous bone graft is a reliable and effective treatment for nonunion of a humeral shaft fracture

Excellent results can be achieved by plating fractures of the shaft of the humerus in patients with multiple injuries. This helps in nursing care and in the management of other injuries. In 38 patients admitted to a regional trauma centre, 39 humeral shaft fractures were plated. There were 27 men and 11 women, with an average age of 31.5 years. Fourteen of the humeral fractures were compound and 20 had significant comminution; 23 were fixed by a plate on the day of admission and all 39 by the twentieth day. Follow-up of 34 fractures showed that all had united, 33 primarily. All patients but one had a fully functional shoulder and no patient with a fractured humerus alone had lost any elbow movement. Complications were rare--one case each of non-union, fixation failure and infection. No permanent nerve injuries were produced at operation. The plating of fractures of the humerus in these circumstances has been shown to produce excellent results and has a place in the management of the patient with multiple injuries

Background. Although minimally invasive plate osteosynthesis (MIPO) has become popular option for humeral shaft fractures, indirect reduction and its maintenance are technically challenging. The purpose of this study is to describe a reproducible technique utilizing an external fixator during MIPO and to assess its outcomes. Methods. Twenty-nine cases with a mean age of 37.1 years were included. There were 7 simple (type A) and 22 comminuted (type B or C) fractures. Indirect reduction was achieved and maintained by a monolateral external fixator on the lateral aspect of humeral shaft, and MIPO was performed on the anterior surface. Union, alignment, complications, and functional results of the shoulder and elbow were assessed. Results. Twenty-eight of 29 fractures were united with a mean of 19.1 weeks including 3 delayed unions. The mean follow-up period was 20.8 months. There was one hypertrophic nonunion, which was healed after fixing two additional screws. None had angulation greater than 10 degrees in the coronal and sagittal planes. Mean constant shoulder score and mean Mayo elbow performance score were 89.1 and 95.5, respectively. There was no direct damage to nerves related to the pin of external fixator, while two cases of radial neuropraxia developed, which recovered within 2 months after operation. Conclusion. Assisted by the preliminary external fixation, MIPO may achieve successful outcomes for humeral shaft fractures

We compared the outcome of peri-operative humeral condylar fractures in patients undergoing a Coonrad-Morrey semiconstrained total elbow replacement with that of patients with rheumatoid arthritis undergoing the same procedure without fractures. In a consecutive series of 40 elbows in 33 patients, 13 elbows had a fracture in either condyle peri-operatively, and 27 elbows were intact. The fractured condyle was either fixed internally or excised. We found no statistical difference in the patients’ background, such as age, length of follow-up, immobilisation period, Larsen’s radiological grade, or Steinbrocker’s stage and functional class. There was also no statistical difference between the groups in relation to the Mayo Elbow Performance Score, muscle strength, range of movement, or radiolucency around the implants at a mean of 4.8 years (1.1 to 8.0) follow-up. We conclude that fractured condyles can be successfully treated with either internal fixation or excision, and cause no harmful effect

Ten patients with humeral shaft fractures and no clinical or radiographic signs of healing after at least six weeks' immobilisation were treated by flexible intramedullary nailing using a closed retrograde technique. Bone grafting was not performed, and active movement was encouraged after operation. Nine fractures healed; the mean time to union was 10.5 weeks (range 6 to 22 weeks). One patient needed compression plating and bone grafting at 22 weeks, and another required re-operation for distal migration of the rods. There were no infections, nerve palsies or other complications. Stiffness of the shoulder which had developed during early treatment improved after operation

Objectives: To evaluate and compare the results of interlocking nailing (ILN) and plating (PL) in fresh humeral shaft fractures (HSF). Material and Methods: During 7 years period 145 patients with HSF (84 males and 61 females) were operated and followed up for 8 – 60 months (mean 18 months). According to AO there were 64 Type A, 53 Type B and 28 Type C fractures. Of 18 open injuries there were 10 grades I, 5 grades II and 3 grades IIIA. There were 33 patients with polytrauma, 11 cases with associated limb injuries, 9 cases with floating elbow and 22 patients with primary neurological deficit. In 75 fractures ILN was performed and PL in rest 70. Results: The mean operative time was 85 min for ILN vs./117 min for PL and the mean blood loss 100ml vs./250 ml. Healing occurred in 139(95.6%) fractures with mean healing time 75 days vs./85 days. Functional results according to Rommens score were as follows. Shoulder: excellent 62(82.6%) vs./55(78.5%), good 11(14.6%) vs./11(15.7%), poor 2(2.8%) vs./4(5.8%). Elbow: excellent 69(92%) vs./52(74.3%), good 6(8%) vs./16(22.8%), poor 0 vs./2(2.9%). Complications noted were iatrogenic nerve palsy 1(1.3%) vs./12(17%), delayed union 5(7%) vs./2(3%), non union 1(1.3%) vs./5(7%), infection 0 vs./1(1.4%), fixation failure 1(1.3%) vs./5(7%) and reosteosynthesis 1(1.3%) vs./1(1.4%), shoulder impingement 8(11%) vs./2(3%). Conclusions: Interlockimg nailing reduces risk of nerve injury and infection, provides more stability in segmental, complex and osteoporotic HSF. No significant differences in the term of healing in the both methods. Plating should be preferred in open Fx with incidental nerve palsy or vascular injury and juxtaarticular Fx, especially distally located. The method provides anatomical reduction, but requires extended approach and increases risk of iatrogenic nerve palsy

The incidence of nerve injuries in primary shoulder dislocation and humeral neck fracture is uncertain. We made a prospective study of 101 patients, using clinical examination and extensive electrophysiological assessment when there was suspicion of nerve damage. We found electrophysiological evidence of nerve injury in 45%, most involving the axillary, suprascapular, radial and musculocutaneous nerves. There were significantly more nerve injuries in older patients and those with a haematoma. Most patients recovered partially or completely in less than four months, and only eight had persistent motor loss. Early diagnosis and physiotherapy are recommended

We have analysed 249 consecutive fractures of the humeral shaft treated over a three-year period. The fractures were defined by their AO morphology, position, the age and gender of the patient and the mechanism of injury. Open fractures were classified using the Gustilo system and soft-tissue injury, and closed fractures using the Tscherne system.

The fractures were classified as AO type A in 63.3%, type B in 26.2% and type C in 10.4%. Most (60%) occurred in the middle third of the diaphysis with 30% in the proximal and 10% in the distal third. The severity of the fracture and soft-tissue injury was greater with increasing injury severity. Less than 10% of the fractures were open. There was a bimodal age distribution with a peak in the third decade as a result of moderate to severe injury in men and a larger peak in the seventh decade after a simple fall in women.

The management of proximal humeral fractures is determined by fragment displacement. Intra-operative and radiological classification systems have been proposed, namely AO and the Neer classifications to assess therapeutic options.

This study evaluates the usefulness of these classification systems by the creation of physical 3D models using a rapid prototyping technique avoiding the problems associated with 3D illusions on a 2D screen.

Seven consecutive patients with complex fractures of the proximal humerus were investigated using the data from multi-sliced spiral CT scans. Fractures associated with dislocation were excluded. The data from these CTs was segmented to reveal the anatomy of interest and converted to a stereolithographic format from which the physical models could be made of the proximal humerus via a laser guided filament deposition process. Further manipulation with software allowed angulation and displacements of fragments to be measured.

Inter-observer agreement: All models were assessed by three surgeons. A consultant with a special interest in shoulder surgery, a fellowship trained surgeon and a senior house officer in basic surgical training. Independent assessment of the fractures from the models was made using the Neer and AO classifications. In only 1 incidence did all 3 observers agree on the classification, in 5 incidences only two observers agreed and on 8 occasions none of the observers agreed. Indeed there were 9 occasions that at least one observer thought the fracture pattern could not be applied to a classification.

Fracture Patterns: Observation of the individual models together with measurements of angulation and displacement by further software analysis, demonstrated major subtypes namely valgus and varus angulation with minimal displacement of the greater tuberosity. Appreciation of the integrity of the medial hinge and buckling could be made in relation to the different fracture patterns.

This study highlights concerns on the validity of current classification systems. It also questions whether the existing systems reflect the pathophysiological subtypes of these fractures allowing comparison of surgical results in order to evaluate treatment options.

Aims. The aim of this study was to characterize the influence of social deprivation on the rate of complications, readmissions, and revisions following primary total shoulder arthroplasty (TSA), using the Social Deprivation Index (SDI). The SDI is a composite measurement, in percentages, of seven demographic characteristics: living in poverty, with < 12 years of education, single-parent households, living in rented or overcrowded housing, households without a car, and unemployed adults aged < 65 years. Methods. Patients aged ≥ 40 years, who underwent primary TSA between 2011 and 2017, were identified using International Classification of Diseases (ICD)-9 Clinical Modification and ICD-10 procedure codes for TSA in the New York Statewide Planning and Research Cooperative System database. Readmission, reoperation, and other complications were analyzed using multivariable Cox proportional hazards regression controlling for SDI, age, ethnicity, insurance status, and Charlson Comorbidity Index. Results. A total of 17,698 patients with a mean age of 69 years (SD 9.6), of whom 57.7% were female, underwent TSA during this time and 4,020 (22.7%) had at least one complication. A total of 8,113 patients (45.8%) had at least one comorbidity, and the median SDI in those who developed complications 12 months postoperatively was significantly greater than in those without a complication (33 vs 38; p < 0.001). Patients from areas with higher deprivation had increased one-, three-, and 12-month rates of readmission, dislocation, humeral fracture, urinary tract infection, deep vein thrombosis, and wound complications, as well as a higher three-month rate of pulmonary embolism (all p < 0.05). Conclusion. Beyond medical complications, we found that patients with increased social deprivation had higher rates of humeral fracture and dislocation following primary TSA. The large sample size of this study, and the outcomes that were measured, add to the literature greatly in comparison with other large database studies involving TSA. These findings allow orthopaedic surgeons practising in under-served or low-volume areas to identify patients who may be at greater risk of developing complications. Cite this article: Bone Joint J 2024;106-B(2):174–181

We treated 39 patients with fractures of the humeral shaft by closed retrograde locked intramedullary nailing, using Russell-Taylor humeral nails. The mean healing time of all fractures was 13.7 weeks. After consolidation, shoulder function was excellent in 92.3% and elbow function excellent in 87.2%. Functional end-results were excellent in 84.6% of patients, moderate in 10.3% and bad in 5.1%. One patient had a postoperative radial nerve palsy, which recovered within three months. There was additional comminution at the fracture site in three patients (7.7%) which did not affect healing, and slight nail migration in two older patients (5.1%). Two patients (5.1%) needed a second procedure because of disturbed fracture healing. One screw breakage was seen in a patient with delayed union. Retrograde locked humeral nailing appears to be a better solution for the stabilisation of fractures of the humeral shaft than anterograde nailing or plate and screw fixation. We found the complication rate to be acceptable and shoulder and elbow function to recover rapidly in most cases.

We report the results of locked Seidel nailing for 30 fractures of the humerus. There were frequent technical difficulties at operation especially with the locking mechanisms. Protrusion of the nail above the greater tuberosity occurred in 12 cases, usually due to inadequate locking, and resulted in shoulder pain and poor function. Poor shoulder function was also seen in five patients with no nail protrusion, presumably because of local rotator cuff damage during insertion. Our results suggest that considerable modifications are required to the nail, and possibly to its site of insertion, before its use can be advocated.

The primary aim was to estimate the cost-effectiveness of routine operative fixation for all patients with humeral shaft fractures. The secondary aim was to estimate the cost-effectiveness of using a Radiographic Union Score for HUmeral fractures (RUSHU)<8 to facilitate selective fixation for patients at risk of nonunion. From 2008-2017, 215 patients (mean age 57yrs [17–81], 61% female) with a non-operatively managed humeral diaphyseal fracture were retrospectively identified. Union was achieved in 77% (n=165/215) after non-operative management, with 23% (n=50/215) uniting after nonunion surgery. The EuroQol Five-Dimension (EQ-5D) Health Index was obtained via postal survey. An incremental cost-effectiveness ratio (ICER) <£20,000 per quality-adjusted life-year (QALY) gained was considered cost-effective. At a mean of 5.4yrs (1.2–11.0), the mean EQ-5D was 0.736. Multiple regression demonstrated that uniting after nonunion surgery was independently associated with an inferior EQ-5D (beta=0.103, p=0.032). Routine fixation for all patients to reduce the nonunion rate would be associated with increased treatment costs (£1,542/patient) but confer a potential EQ-5D benefit of 0.120/patient. The ICER of routine fixation was £12,850/QALY gained. Selective fixation, based upon a RUSHU<8 at 6wks post-injury, would be associated with reduced treatment costs (£415/patient) and confer a potential EQ-5D benefit of 0.335 per ‘at-risk patient’. Routine fixation for patients with humeral shaft fractures, to reduce the nonunion rate observed after non-operative management, appears to be cost-effective at 5yrs post-injury. Selective fixation for patients at risk of nonunion based upon the RUSHU may confer greater cost-effectiveness, given the potential savings and improvement in EQ-5D

We report our experience with a modified implant and a new technique for locked intramedullary nailing of the humerus in 41 patients. Locking was by cross-screws placed from lateral to medial in the proximal humerus, and anteroposteriorly in the distal humerus. Early in the series, 11 nails were inserted at the shoulder, but we found that rehabilitation was faster after retrograde nailing through the olecranon fossa, which was used for the other 30. We used a closed technique for 29 of the nailings. Of the 41 patients treated, 21 had acute fractures, five had nonunion, and 15 had pathological fractures. Secure fixation was obtained for comminuted and osteoporotic fractures in any part of the humeral shaft, which allowed the early use of crutches and walking frames. Two nails were locked at only one end, and one of these became the only failure of union after an acute fracture.

Proximal humeral shaft fractures are commonly treated with long straight plates or intramedullary nails. Helical plates might overcome the downsides of these techniques as they are able to avoid the radial nerve distally. The aim of this study was to investigate in an artificial bone model: (1) the biomechanical competence of different plate designs and (2) to compare them against the alternative treatment option of intramedullary nails. Twenty-four artificial humeri were assigned in 4 groups and instrumented as follows: group1 (straight 10-hole-PHILOS), group2 (MULTILOCK-nail), group3 (45°-helical-PHILOS) and group4 (90°-helical-PHILOS). An unstable proximal humeral shaft fracture was simulated. Specimens were tested under quasi-static loading in axial compression, internal/external rotation and bending in 4 directions monitored by optical motion tracking. Axial displacement (mm) was significantly lower in group2 (0.1±0.1) compared to all other groups (1: 3.7±0.6; 3: 3.8±0.8; 4: 3.5±0.4), p<0.001. Varus stiffness in group2 (0.8±0.1) was significantly higher compared to groups1+3, p≤0.013 (1: 0.7±0.1; 3: 0.7±0.1; 4: 0.8±0.1). Varus bending (°) was significantly lower in group2 compared to all other groups (p<0.001) and group4 to group1, p=0.022. Flexion stiffness in group1 was significantly higher compared to groups2+4 (p≤0,03) and group4 to group1, p≤0,029 (1: 0.8±0.1; 2: 0.7±0.1; 3: 0.7±0.1; 4: 0.6±0.1). Flexion bending (°) in group4 was higher compared to all other groups (p≤0.024) and lower in group2 compared to groups1+4, p≤0.024. Torsional stiffness remained non significantly different, p≥0.086. Torsional deformation in group2 was significantly higher compared to all other groups, p≤0.017. Shear displacement remained non significantly different, p≥0.112. From a biomechanical perspective, helical plating with 45° and 90° may be considered as a valid alternative fixation technique to standard straight plating of proximal third humeral fractures. Intramedullary nails demonstrated higher axial and bending stiffness as well as lower fracture gap movements during axial loading compared to all plate designs. However, despite similar torsional stiffness they were associated with higher torsional movements during internal/external rotation as compared to all investigated plate designs

The April 2024 Children’s orthopaedics Roundup. 360. looks at: Ultrasonography or radiography for suspected paediatric distal forearm fractures?; Implant density in scoliosis: an important variable?; Gait after paediatric femoral shaft fracture treated with intramedullary nail fixation: a longitudinal prospective study; The opioid dilemma: navigating pain management for children’s bone fractures; 12- to 20-year follow-up of Dega acetabuloplasty in patients with developmental dysplasia of the hip; Physeal fractures of the distal ulna: incidence and risk factors for premature growth arrest; Analysis of growth after transphyseal anterior cruciate ligament reconstruction in children; Management of lateral condyle humeral fracture associated with elbow dislocation in children: a retrospective international multicentre cohort study

Fractures of the humeral diaphysis occur in a bimodal distribution and represent 3-5% of all fractures. Presently, the standard treatment of isolated humeral diaphyseal fractures is nonoperative care using splints, braces, and slings. Recent data has questioned the effectiveness of this strategy in ensuring fracture healing and optimal patient function. The primary objective of this randomized controlled trial (RCT) was to assess whether operative treatment of humeral shaft fractures with a plate and screw construct provides a better functional outcome than nonoperative treatment. Secondary objectives compared union rates and both clinical and patient-reported outcomes. Eligible patients with an isolated, closed humeral diaphyseal fracture were randomized to either nonoperative care (initial sugar-tong splint, followed by functional coaptation brace) or open reduction and internal fixation (ORIF; plate and screw construct). The primary outcome measure was the Disability Shoulder, Arm, Hand (DASH) score assessed at 2-, 6-, 16-, 24-, and 52-weeks. Secondary outcomes included the Short Musculoskeletal Functional Assessment (SMFA), the Constant Shoulder Score, range of motion (ROM), and radiographic parameters. Independent samples t-tests and Chi-squared analyses were used to compare treatment groups. The DASH, SMFA, and Constant Score were modelled over time using a multiple variable mixed effects model. A total of 180 patients were randomized, with 168 included in the final analysis. There were 84 patients treated nonoperatively and 84 treated with ORIF. There was no significant difference between the two treatment groups for age (mean = 45.4 years, SD 16.5 for nonoperative group and 41.7, SD 17.2 years for ORIF group; p=0.16), sex (38.1% female in nonoperative group and 39.3% female in ORIF group; p=0.87), body mass index (mean = 27.8, SD 8.7 for nonoperative group and 27.2, SD 6.2 for ORIF group; p=0.64), or smoking status (p=0.74). There was a significant improvement in the DASH scores at 6 weeks in the ORIF group compared to the nonoperative group (mean=33.8, SD 21.2 in the ORIF group vs. mean=56.5, SD=21.1 in the nonoperative group; p < 0 .0001). At 4 months, the DASH scores were also significantly better in the ORIF group (mean=21.6, SD=19.7 in the ORIF group vs. mean=31.6, SD=24.6 in the nonoperative group; p=0.009. However, there was no difference in DASH scores at 12-month follow-up between the groups (mean=8.8,SD=10.9 vs. mean=11.0, SD=16.9 in the nonoperative group; p=0.39). Males had improved DASH scores at all timepoints compared with females. There was significantly quicker time to union (p=0.016) and improved position (p < 0 .001) in the ORIF group. There were 13 (15.5%) nonunions in the nonoperative group and four (4.7%) combined superficial and deep infections in the ORIF group. There were seven radial nerve palsies in the nonoperative group and five (a single iatrogenic) radial nerve palsies in the ORIF group. This large RCT comparing operative and nonoperative treatment of humeral diaphyseal fractures found significantly improved functional outcome scores in patients treated surgically at 6 weeks and 4 months. However, the early functional improvement did not persist at the 12-month follow-up. There was a 15.5% nonunion rate, which required surgical intervention, in the nonoperative group and a similar radial nerve palsy rate between groups

Fractures of the humeral diaphysis occur in a bimodal distribution and represent 3-5% of all fractures. Presently, the standard treatment of isolated humeral diaphyseal fractures is nonoperative care using splints, braces, and slings. Recent data has questioned the effectiveness of this strategy in ensuring fracture healing and optimal patient function. The primary objective of this randomized controlled trial (RCT) was to assess whether operative treatment of humeral shaft fractures with a plate and screw construct provides a better functional outcome than nonoperative treatment. Secondary objectives compared union rates and both clinical and patient-reported outcomes. Eligible patients with an isolated, closed humeral diaphyseal fracture were randomized to either nonoperative care (initial sugar-tong splint, followed by functional coaptation brace) or open reduction and internal fixation (ORIF; plate and screw construct). The primary outcome measure was the Disability Shoulder, Arm, Hand (DASH) score assessed at 2-, 6-, 16-, 24-, and 52-weeks. Secondary outcomes included the Short Musculoskeletal Functional Assessment (SMFA), the Constant Shoulder Score, range of motion (ROM), and radiographic parameters. Independent samples t-tests and Chi-squared analyses were used to compare treatment groups. The DASH, SMFA, and Constant Score were modelled over time using a multiple variable mixed effects model. A total of 180 patients were randomized, with 168 included in the final analysis. There were 84 patients treated nonoperatively and 84 treated with ORIF. There was no significant difference between the two treatment groups for age (mean = 45.4 years, SD 16.5 for nonoperative group and 41.7, SD 17.2 years for ORIF group; p=0.16), sex (38.1% female in nonoperative group and 39.3% female in ORIF group; p=0.87), body mass index (mean = 27.8, SD 8.7 for nonoperative group and 27.2, SD 6.2 for ORIF group; p=0.64), or smoking status (p=0.74). There was a significant improvement in the DASH scores at 6 weeks in the ORIF group compared to the nonoperative group (mean=33.8, SD 21.2 in the ORIF group vs. mean=56.5, SD=21.1 in the nonoperative group; p < 0 .0001). At 4 months, the DASH scores were also significantly better in the ORIF group (mean=21.6, SD=19.7 in the ORIF group vs. mean=31.6, SD=24.6 in the nonoperative group; p=0.009. However, there was no difference in DASH scores at 12-month follow-up between the groups (mean=8.8,SD=10.9 vs. mean=11.0, SD=16.9 in the nonoperative group; p=0.39). Males had improved DASH scores at all timepoints compared with females. There was significantly quicker time to union (p=0.016) and improved position (p < 0 .001) in the ORIF group. There were 13 (15.5%) nonunions in the nonoperative group and four (4.7%) combined superficial and deep infections in the ORIF group. There were seven radial nerve palsies in the nonoperative group and five (a single iatrogenic) radial nerve palsies in the ORIF group. This large RCT comparing operative and nonoperative treatment of humeral diaphyseal fractures found significantly improved functional outcome scores in patients treated surgically at 6 weeks and 4 months. However, the early functional improvement did not persist at the 12-month follow-up. There was a 15.5% nonunion rate, which required surgical intervention, in the nonoperative group and a similar radial nerve palsy rate between groups

Proximal humeral shaft fractures are commonly treated with long straight locking plates endangering the radial nerve distally. The aim of this study was to investigate the biomechanical competence in a human cadaveric bone model of 90°-helical PHILOS plates versus conventional straight PHILOS plates in proximal third comminuted humeral shaft fractures. Eight pairs of humeral cadaveric humeri were instrumented using either a long 90°-helical plate (group1) or a straight long PHILOS plate (group2). An unstable proximal humeral shaft fracture was simulated by means of an osteotomy maintaining a gap of 5cm. All specimens were tested under quasi-static loading in axial compression, internal and external rotation as well as bending in 4 directions. Subsequently, progressively increasing internal rotational loading until failure was applied and interfragmentary movements were monitored by means of optical motion tracking. Flexion/extension deformation (°) in group1 was (2.00±1.77) and (0.88±1.12) in group2, p=0.003. Varus/valgus deformation (°) was (6.14±1.58) in group1 and (6.16±0.73) in group2, p=0.976. Shear (mm) and displacement (°) under torsional load were (1.40±0.63 and 8.96±0.46) in group1 and (1.12±0.61 and 9.02±0.48) in group2, p≥0.390. However, during cyclic testing shear and torsional displacements and torsion were both significantly higher in group 1, p≤0.038. Cycles to catastrophic failure were (9960±1967) in group1 and (9234±1566) in group2, p=0.24. Although 90°-helical plating was associated with improved resistance against varus/valgus deformation, it demonstrated lower resistance to flexion/extension and internal rotation as well as higher flexion/extension, torsional and shear movements compared to straight plates. From a biomechanical perspective, 90°-helical plates performed inferior compared to straight plates and alternative helical plate designs with lower twist should be investigated in future paired cadaveric studies

Abstract. Objectives. Operative management of distal humerus fractures is challenging. In the past, plates were manually contoured intraoperatively, however this was associated with high rates of fixation failure, nonunion and metalwork removal. Anatomically pre-contoured distal humerus locking plates have since been developed. Owing to the rarity of distal humeral fractures, literature regarding outcomes of anatomically pre-contoured locking plates is lacking and patient numbers are often small. The purpose of this study is to investigate the outcomes of these patients. Methods. We retrospectively identified patients with distal humeral fractures treated at our institution from 2009–2018. Inclusion criteria were patients with a distal humeral fracture, who underwent two-column plate fixation with anatomically pre-contoured locking plates. Clinical records and radiographs were reviewed to elicit outcome measures, including range of motion, complications and reoperation rate. Results. We identified 50 patients with mean age of 55 years (range 17–96 years). Mean length of follow up was 5.2 years. AO fracture classification Type A occurred most frequently (46%), followed by Type B (22%) and Type C (32%). Low energy mechanisms of injury predominated in 72% of patients. Mean time from injury to fixation was seven days. Mean range of motion at the elbow was 13–123o postoperatively. The overall reoperation rate was 22%, the majority of which required subsequent removal of prominent metalwork (18%). The incidence of nonunion, heterotopic ossification, deep infection and neuropathy requiring decompression was 2% each. Fixation failure occurred in only one patient however the fracture went on to heal. Conclusions. Previously reported reoperation rates with manually contoured plates were as high as 44%, which is twice our reported rate. Modern locking plates are no longer subject to implant failure (previously 27% reported metalwork failure rate). Likewise, heterotopic ossification and non-union have also reduced, highlighting that modern plates have significantly improved overall patient outcomes. 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 report the incidence of implant-related complications, further operations, and their influence on the outcome in a series of patients who underwent primary reverse total shoulder arthroplasty (RTSA). Methods. The prospectively collected clinical and radiological data of 797 patients who underwent 854 primary RTSAs between January 2005 and August 2018 were analyzed. The hypothesis was that the presence of complications would adversely affect the outcome. Further procedures were defined as all necessary operations, including reoperations without change of components, and partial or total revisions. The clinical outcome was evaluated using the absolute and relative Constant Scores (aCS, rCS), the Subjective Shoulder Value (SSV) scores, range of motion, and pain. Results. The overall surgical site complication rate was 22% (188 complications) in 152 patients (156 RTSAs; 18%) at a mean follow-up of 46 months (0 to 169). The most common complications were acromial fracture (in 44 patients, 45 RTSAs; 5.3%), glenoid loosening (in 37 patients, 37 RTSAs; 4.3%), instability (in 23 patients, 23 RTSAs; 2.7%), humeral fracture or loosening of the humeral component (in 21 patients, 21 RTSAs; 2.5%), and periprosthetic infection (in 14 patients, 14 RTSAs; 1.6%). Further surgery was undertaken in 79 patients (82 RTSAs) requiring a total of 135 procedures (41% revision rate). The most common indications for further surgery were glenoid-related complications (in 23 patients, 23 RTSAs; 2.7%), instability (in 15 patients, 15 RTSAs; 1.8%), acromial fractures (in 11 patients, 11 RTSAs; 1.3%), pain and severe scarring (in 13 patients, 13 RTSAs; 1.5%), and infection (in 8 patients, 8 RTSAs; 0.9%). Patients who had a complication had significantly worse mean rCS scores (57% (SD 24%) vs 81% (SD 16%)) and SSV scores (53% (SD 27%) vs 80% (SD 20%)) compared with those without a complication. If revision surgery was necessary, the outcome was even further compromised (mean rCS score: 51% (SD 23%) vs 63% (SD 23%); SSV score: 4% (SD 25%) vs 61% (SD 27%). Conclusion. Although the indications for, and use of, a RTSA are increasing, it remains a demanding surgical procedure. We found that about one in five patients had a complication and one in ten required further surgery. Both adversely affected the outcome. Cite this article: Bone Joint J 2022;104-B(3):401–407

The June 2023 Shoulder & Elbow Roundup. 360. 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

The December 2023 Shoulder & Elbow Roundup. 360. looks at: Clavicle fractures: is the evidence changing practice?; Humeral shaft fractures, and another meta-analysis…let’s wait for the trials now!; Hemiarthroplasty or total elbow arthroplasty for distal humeral fractures…what does the registry say?; What to do with a first-time shoulder dislocation?; Deprivation indices and minimal clinically important difference for patient-reported outcomes after arthroscopic rotator cuff repair; Prospective randomized clinical trial of arthroscopic repair versus debridement for partial subscapularis tears; Long-term follow-up following closed reduction and early movement for simple dislocation of the elbow; Sternoclavicular joint reconstruction for traumatic acute and chronic anterior and posterior instability

Aims. It is important to understand the rate of complications associated with the increasing burden of revision shoulder arthroplasty. Currently, this has not been well quantified. This review aims to address that deficiency with a focus on complication and reoperation rates, shoulder outcome scores, and comparison of anatomical and reverse prostheses when used in revision surgery. Methods. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) systematic review was performed to identify clinical data for patients undergoing revision shoulder arthroplasty. Data were extracted from the literature and pooled for analysis. Complication and reoperation rates were analyzed using a meta-analysis of proportion, and continuous variables underwent comparative subgroup analysis. Results. A total of 112 studies (5,379 shoulders) were eligible for inclusion, although complete clinical data was not ubiquitous. Indications for revision included component loosening 20% (601/3,041), instability 19% (577/3,041), rotator cuff failure 17% (528/3,041), and infection 16% (490/3,041). Intraoperative complication and postoperative complication and reoperation rates were 8% (230/2,915), 22% (825/3,843), and 13% (584/3,843) respectively. Intraoperative and postoperative complications included iatrogenic humeral fractures (91/230, 40%) and instability (215/825, 26%). Revision to reverse total shoulder arthroplasty (TSA), rather than revision to anatomical TSA from any index prosthesis, resulted in lower complication rates and superior Constant scores, although there was no difference in American Shoulder and Elbow Surgeons scores. Conclusion. Satisfactory improvement in patient-reported outcome measures are reported following revision shoulder arthroplasty; however, revision surgery is associated with high complication rates and better outcomes may be evident following revision to reverse TSA. Cite this article: Bone Jt Open 2021;2(8):618–630

The choice of whether to perform antegrade intramedullary nailing (IMN) or plate fixation (PF) poses a conundrum for the surgeon who must strike the balance between anatomical restoration while reducing elbow and shoulder functional impairment. Most humeral middle third shaft fractures are amenable to conservative management given the considerable acceptable deformity and anatomical compensation by patients. This study is concerned with the patient reported outcomes regarding shoulder and elbow function for IMN and PF respectively. A prospective cohort study following up all the cases treated surgically for middle third humeral fractures from 2016 to 2022 at a single centre. Telephonically an analogue pain score, an American Shoulder and Elbow Society (ASES) score for shoulder function and the Oxford Elbow score (OES) for elbow function were obtained. One hundred and three patients met the inclusion criteria. Twenty four patients participated in the study, fifteen had IMN (62.5%) and nine had PF (37.5%.). The shoulder function outcomes showed no statistical difference with an average ASES score of sixty-six for the IMN group and sixty-nine for the PF group. Women and employed individuals expressed greater functional impairment. Hand dominance has no impact on the scores of elbow and shoulder function post operatively. The impairment of abduction score post antegrade nailing was higher in the antegrade nailing group than the plated group. The OES demonstrated greater variance in elbow function in the PF group with the IMN group expressing greater elbow disfunction. This study confirms that treatment of middle third humerus shaft fractures by plate fixation is marginally superior to antegrade intramedullary nailing in preserving elbow function and abduction ability

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 June 2024 Children’s orthopaedics Roundup. 360. looks at: Proximal femoral unicameral bone cysts: is ESIN the answer?; Hybrid-mesh casts in the conservative management of paediatric supracondylar humeral fractures: a randomized controlled trial; Rate and risk factors for contralateral slippage in adolescents treated for slipped capital femoral epiphysis; CRP predicts the need to escalate care after initial debridement for musculoskeletal infection; Genu valgum in paediatric patients presenting with patellofemoral instability; Nusinersen therapy changed the natural course of spinal muscular atrophy type 1: what about spine and hip?; The necessity of ulnar nerve exploration and translocation in open reduction of medial humeral epicondyle fractures in children

Aims. The aim of this study was to determine the current incidence and epidemiology of humeral diaphyseal fractures. The secondary aim was to explore variation in patient and injury characteristics by fracture location within the humeral diaphysis. Methods. Over ten years (2008 to 2017), all adult patients (aged ≥ 16 years) sustaining an acute fracture of the humeral diaphysis managed at the study centre were retrospectively identified from a trauma database. Patient age, sex, medical/social background, injury mechanism, fracture classification, and associated injuries were recorded and analyzed. Results. A total of 900 fractures (typical 88.9%, n = 800/900; pathological 8.3%, n = 75/900; periprosthetic 2.8%, n = 25/900) were identified in 898 patients (mean age 57 years (16 to 97), 55.5% (n = 498/898) female). Overall fracture incidence was 12.6/100,000/year. For patients with a typical fracture (n = 798, mean age 56 years (16 to 96), 55.1% (n = 440/798) female), there was a bimodal distribution in men and unimodal distribution in older women (Type G). A fall from standing was the most common injury mechanism (72.6%, n = 581/800). The majority of fractures involved the middle-third of the diaphysis (47.6%, n = 381/800) followed by the proximal- (30.5%, n = 244/800) and distal-thirds (n = 175/800, 21.9%). In all, 18 injuries (2.3%) were open and a radial nerve palsy occurred in 6.7% (n = 53/795). Fractures involving the proximal- and middle-thirds were more likely to occur in older (p < 0.001), female patients (p < 0.001) with comorbidities (p < 0.001) after a fall from standing (p < 0.001). Proximal-third fractures were also more likely to occur in patients with alcohol excess (p = 0.003) and to be classified as AO-Orthopaedic Trauma Association type B or C injuries (p < 0.001). Conclusion. This study updates the incidence and epidemiology of humeral diaphyseal fractures. Important differences in patient and injury characteristics were observed based upon fracture location. Injuries involving the proximal- and middle-thirds of the humeral diaphysis should be considered as fragility fractures. Cite this article: Bone Joint J 2020;102-B(11):1475–1483

Aims. The aim of this study was to report the mid-term clinical outcome of cemented unlinked J-alumina ceramic elbow (JACE) arthroplasties when used in patients with rheumatoid arthritis (RA). Patients and Methods. We retrospectively reviewed 87 elbows, in 75 patients with RA, which was replaced using a cemented JACE total elbow arthroplasty (TEA) between August 2003 and December 2012, with a follow-up of 96%. There were 72 women and three men, with a mean age of 62 years (35 to 79). The mean follow-up was nine years (2 to 14). The clinical condition of each elbow before and after surgery was assessed using the Mayo Elbow Performance Index (MEPI, 0 to 100 points). Radiographic loosening was defined as a progressive radiolucent line of >1 mm that was completely circumferential around the prosthesis. Results. The mean MEPI scores significantly improved from 40 (10 to 75) points preoperatively to 95 (30 to 100) points at final follow-up (p < 0.0001). Complications were noted in ten elbows (ten patients; 11%). Two had an intraoperative humeral fracture which was treated by fixation and united. One had a postoperative fracture of the olecranon which united with conservative treatment and one had a radial neuropathy which resolved. Further surgery was required for one with a dislocation, three with an ulnar neuropathy and one with a postoperative humeral fracture. Revision with removal of the components was performed in one elbow due to deep infection. There was no radiographic evidence of loosening around the components.With any revision surgery or revision with implant removal as the endpoint, the rates of survival up to 14 years were 93% (95% confidence interval (CI), 83.9 to 96.6) and 99% (95% CI 91.9 to 99.8), respectively, as determined by Kaplan-Meier analysis. Conclusion. With the appropriate indications, the mid-term clinical performance of the cemented JACE TEA is reliable and comparable to other established TEAs in the management of the elbow in patients with RA. Cite this article: Bone Joint J 2018;100-B:1066–73

Abstract. Background/Objectives. The incidence of reverse total shoulder replacement (rTSR) implantation is increasing globally, but apprehension exists regarding complications and associated challenges. We retrospectively analysed the senior author's series of rTSR from a tertiary centre using the VAIOS shoulder system, a modular 4th generation implant. We hypothesised that the revision rTSR cohort would have less favourable outcomes and more complications. Methods. 114 patients underwent rTSR with the VAIOS system, over 7 years. The primary outcome was implant survival. Secondary outcomes were Oxford shoulder scores (OSS), radiographic analysis (scapular notching, tuberosity osteolysis, and periprosthetic radiolucent lines) and complications. Results. There were 55 Primary rTSR, 31 Revision rTSR and 28 Trauma rTSR. Implant survival: Primary rTSR- 0 revisions, average 3.35-year follow-up. Revision rTSR-1 revision (4.17%), average 3.52-year follow-up. Trauma rTSR- 1 revision (3.57%), average 4.56-year follow-up OSS: Average OSS improved from 15.39 to 33.8 (Primary rTSR) and from 15.11 to 29.1 (Revision rTSR). Average post-operative OSS for the Trauma rTSR was 31.4 Radiological analysis and complications: Low incidence of scapular notching One hairline fracture below the tip of stem, noted incidentally, which required no treatment. One periprosthetic fracture after alcohol related fall. Treated non-surgically One joint infection requiring two-stage revision to rTSR. One dislocation noted at 2 year follow up. This patient had undergone nerve grafting within 6 months of rTSR for axillary nerve injury sustained during the original fracture dislocation. One acromial fracture with tibial and distal humeral fracture after a fall. Conclusions. The 4th generation modular VAIOS implant is a reliable option for various indications. The revision rTSR cohort had favourable outcomes with low complication rates. In this series, early-to-medium term results suggest lower revision rates and good functional outcomes when compared to published reports. We plan to monitor long-term implant survivorship and patient reported outcomes. Declaration of Interest. (a) fully declare any financial or other potential conflict of interest

In order to achieve satisfactory reduction of complex distal humeral fractures, adequate exposure of the fracture fragments and the joint surface is required. Several surgical exposures have been described for distal humeral fractures. We report our experience using the anconeus pedicle olecranon flip osteotomy approach. This involves detachment of the triceps along with a sliver of olecranon, which retains the anconeus pedicle. We report the use of this approach in ten patients (six male, four female) with a mean age of 38.4 years (28 to 51). The mean follow-up was 15 months (12 to 18) with no loss to follow-up. Elbow function was graded using the Mayo Score. The results were excellent in four patients, good in five and fair in one patient. The mean time to both fracture and osteotomy union was 10.6 weeks (8 to 12) and 7.1 weeks (6 to 8), respectively. We found this approach gave reliably good exposure for these difficult fractures enabling anatomical reduction and bicondylar plating without complications. . Cite this article: Bone Joint J 2014;96-B:1252–7

The management of distal humeral fractures in low-demand patients with osteoporotic bone remains controversial. Total elbow arthroplasty (TEA) has been recommended for cases where achieving stable ORIF can be difficult. The ‘bag of bones’ technique, (early movement with fragments accepted in their displaced position), is now rarely considered as it is commonly believed to confer a poor functional result. The aim of this study was to present the short- and medium-term functional outcomes following the primary conservative treatment of distal humeral fractures in elderly and low-demand patients. We carried out a retrospective case note and radiograph review of all patients (n=40) aged 50 years or more, with distal humeral fractures treated conservatively at our institution over a six-year period. Short-term function was assessed using the Broberg and Morrey (B&M) score. Medium term function was assessed by telephone interview (n=20) using the Oxford Elbow Score (OES), QuickDASH and a pain questionnaire. The mean post-injury B&M score improved from 42 points at 6 weeks to 67 points by 3 months. By four years, surviving patients had a mean OES of 30 points, a mean QuickDASH of 38 points, and 95% reported a functional range of elbow flexion. Those with fracture non-union experienced greater pain on repetitive elbow activities, but no difference in rest pain, compared with patients whose fractures had united. The cumulative 1-year rate of fracture union was 53%, while the 5-year mortality approached 40%. Conservative management of distal humeral fractures confers a reasonable functional result to the patient whilst avoiding the substantial surgical risks associated with primary ORIF or TEA

The primary aim was to identify patient and injury factors independently associated with humeral diaphyseal fracture nonunion after non-operative management. The secondary aim was to determine the effect of management (operative/non-operative) on nonunion. Over a ten-year period, 734 humeral diaphyseal fractures (732 consecutive patients) were retrospectively identified from a trauma database. Follow-up was available for 663 fractures (662 patients; median age 57yrs [16–96], 54% female [n=359/662]) which formed the study cohort. Patient and injury characteristics were recorded. There were 523 patients (79%) managed non-operatively and 139 (21%) managed operatively. Outcome (union/nonunion) was determined from medical records and radiographs. Median follow-up was five months (1.2–74). Nonunion occurred in 22.7% of non-operatively managed injuries (n=119/524). Multivariate analysis demonstrated pre-injury NSAIDs (adjusted OR [AOR] 40.8, 95% CI 2.6–632.3; p=0.008), being underweight (BMI <18.5kg/m2; AOR 7.3, 95% CI 1.3 to 40.2; p=0.022), overweight (BMI 25–29.9kg/m2; AOR 2.5, 95% CI 1.1 to 5.9; p=0.034) and class II obesity (BMI 35–39.9kg/m2; AOR 4.5, 95% CI 1.4 to 15.5; p=0.014) were independently associated with an increased risk of nonunion. Operative fixation was independently associated with a lower risk of nonunion (2.9%, n=4/139) than non-operative management (AOR for non-operative/operative 11.0, 95% CI 2.8 to 43.6; p=0.001). Based upon these results, five patients would need to undergo operative fixation to avoid one nonunion. Pre-injury NSAIDs and BMI were independently associated with nonunion following non-operative management of a humeral diaphyseal fracture. Operative fixation was the independent factor most strongly associated with a lower risk of nonunion

Introduction and purpose: The most frequent neurological complication of humeral fractures is radial nerve palsy. Most patients with humeral fractures and radial nerve palsy recover with conservative treatment. But a small percentage of patients require surgical treatment; these are patients who show no clinical improvement of their nerve lesion after 3 months of conservative treatment, those with an open fracture, an associated vascular lesion, secondary radial palsy or patients who require open fracture osteosynthesis. The aim of this study is to assess and analyze humeral fractures with radial palsy that have required surgical treatment. Materials and methods: A prospective pre and postoperative study with a protocol was carried out between 1999 and 2007 in which 28 patients with humeral fractures and radial palsy required surgical treatment. Of the patients studied 10 were women and 18 were men. Their ages varied from 18 to 74 years of age. As to the type of radial palsy, it was primary in 11 patients, secondary in 2 patients (included in the fracture callus) and postoperative in 15. Neurolysis was performed in 20 patients and fascicular grafts were used in 8. Results: Time to fracture healing was 14.2 + 5.6 weeks. The period of radial nerve recovery was 7.2 + 5.7 months. Neurolysis was performed in 20 patients and fascicular grafts in 8. There were 20 complete recoveries, 4 incomplete but useful, in 4 cases there was no recovery and palliative surgery was subsequently performed. Conclusions: Surgical treatment of humeral fractures with radial palsy is indicated in patients who show no clinical improvement of their nerve lesion after 3 months of conservative treatment, those with an open fracture, an associated vascular lesion, secondary radial paralysis or in patients who require an open fracture osteosynthesis. Functional recovery rates are high if surgery is carried out during the appropriate period of time. Treatment is neurolysis or fascicular grafts. Palliative surgery is reserved for cases in which complete recovery is not achieved

Peri-prosthetic fractures around implants in the proximal humerus can present substantial challenges. Most individuals who undergo upper limb arthroplasty tend to be osteopenic to begin with, and the anatomy of the proximal humerus does not provide an excess of bone to work with. Therefore, peri-prosthetic fractures pose difficulties to rotator cuff function and implant stability. There are multiple classification systems, but series are small and the classification does not always lead to treatment algorithms. Risk factors for humeral fractures after shoulder arthroplasty include endosteal notching, cortical perforation, varus malalignment, stem perforation, ipsilateral shoulder and elbow arthroplasties, and loose stems. Many of these risk factors are directly related to technical errors at the time of surgery. Poor exposure can lead to aberrant starting point and errors in reaming. Oversized prostheses can lead to cortical perforation or even stem perforation. Proper positioning of the patient on the table and surgical releases help avoid these technical errors. Peri-prosthetic fractures should be carefully evaluated radiographically for stability. Two important considerations: 1. Is the implant stable? 2. Is the fracture stable? Generally, if the implant is unstable, the implant must be revised. In the setting of a stable implant, many humeral fractures can be treated nonoperatively. Many fractures at or below the level of the tip of the implant can be treated as typical humeral fractures. Options for fixation include plates with cables or long stem prostheses which bypass the fracture. Displaced tuberosity fractures are treated with suture or wire fixation. Risk factors for a poor outcome include increased time to union, skin breakdown, and stiff shoulder

Humeral diaphysis fractures consist a rather frequent injury. The aim of our study is to evaluate the results of the treatment of humeral diaphysis fractures with the use of an interlocking intramedullary nail. During the period March 1999 – December 2001, 25 intramedullary nailings were performed in 24 patients with a humeral fracture (16 women and 8 men), aged 26–81 years (Average: 57.1 years) using a Russell-Taylor humeral nail. There were 16 cases of acute humeral fractures, 3 cases of pathologic fractures, and 6 cases of delayed union or non-union. Follow-up ranged from 6 to 36 months (Average: 20 months). Fracture union was recorded, and the results were evaluated according to the scoring system of Neer. No immediate postoperative complications were recorded. The final result was excellent in 9 cases (36%), good in 12 (48%), unsatisfactory in 3 (12%), while there was one failure (4%), where a reoperation was required. Fracture union was achieved within 4 months in 21 cases (84%), while 2 cases of delayed union and 2 non-unions were recorded. Interlocking intramedullary nailing offers a dependable solution in the treatment of humeral diaphysis fractures, providing a very satisfactory functional outcome and a high union rate. It offers an excellent option in the treatment of pathologic fractures of the humerus, as well as in severely comminuted fractures and humeral fractures in polytrauma patients

This study was designed to answer the question “Is there a difference in outcome following operative management of AO type C distal humerus fractures for patients with associated injuries compared to those with isolated injuries?” Our hypothesis was that patients with associated injuries would have worse outcomes compared to those with isolated injuries. Fifty-eight patients with fifty-eight fractures managed with ORIF were included. Hospital records, clinic notes and radiographs of these patients were retrospectively reviewed. MFA and DASH scores were prospectively obtained after patients were identified (mean 37.4 months post injury, range 6–74 months). Thirty-two patients had isolated distal humeral fractures while twenty-six patients had distal humeral fractures with associated injuries. The mean MFA of patients with isolated injuries was significantly lower than for patients with associated injuries (27.2 vs 41.7, p = 0.01). There was no difference in DASH scores between the two groups (23.7 vs 29.1, p = 0.34). The mean postoperative arc of motion was one hundred and seven degrees for isolated injuries and seventy-five degrees for patients with associated injuries (p=0.006). Surgical release for stiffness was required for two patients (6%) in the isolated group and ten patients (38%) in the associated injuries group (p=0.003). Outcomes for isolated distal humeral fractures in this study were comparable to previously published literature. Patients who sustain associated injuries at the time of distal humeral fracture have more stiffness and a worse outcome on a global outcome score, but a similar outcome on a limb specific outcome score

Purpose: Currently, there is little information available on the management and outcome of intra-operative periprosthetic humeral fractures during shoulder arthroplasty. The purpose of this study was to report on the incidence, management, and outcome of intra-operative periprosthetic humeral fractures. Method: Between 1980 and 2002, forty-six intra-operative periprosthetic humeral fractures occurred during shoulder arthroplasty at our institution. Thirty-six fractures occurred during primary total shoulder arthroplasty, five during primary hemiarthroplasty and four during revision shoulder arthroplasty. Twenty-one fractures involved the greater tuberosity, 16 the humeral shaft, 6 were metaphyseal and 2 fractures involved the greater tuberosity and extended to the humeral shaft. All patients were followed for a minimum of two years (mean, 7.5 years). At final follow-up, the Simple Shoulder Test (SST) and ASES scores were calculated and preoperative, postoperative, and most recent radiographs were examined for fracture healing and implant integrity. Results: The incidence of intra-operative humerus fractures at our institution was 1.5%. All fractures healed at mean of 13 weeks (range, 6 to 56 weeks). At a mean final follow-up of 90 months (range, 25 to 194 months), the mean forward elevation was 108° and the mean external rotation was 39°. The mean SST was 6 and the mean ASES score was 61. Four patients underwent revision shoulder surgery, two for shoulder instability, one for a massive rotator cuff tear, and one for another periprosthetic humerus fracture that occurred after a fall. Complications included transient nerve injuries in six patients and four fractures displaced postoperatively which were then managed nonoperatively to healing. Conclusion: The data from this study suggest that although intra-operative fractures have a high rate of healing, there was a significant rate of associated complications including transient nerve injuries and fracture displacement. Patients with intra-operative fractures also appear to have less forward elevation at final follow-up when compared to patients who have not sustained an intra-operative humeral fracture

The fractures of the humerus shaft and of the proximal humerus in childhood turn off less than 1% of all fractures. Healing is unproblematic, according the literature the non operative treatment is the treatment of choice. Under the influence of the ESIN (Elastic Stable Intramedullary Nailing) the readiness to operate children’s fractures has changed completely. The reasons for it are multiple. According to this trend, also is to recognize a change in the treatment of the humeral fractures in childhood obviously. The presentation on hand shall show the reasons of this paradigm change more nearly. The classic indications for the operative therapy of humeral fractures were: 3∞ open fractures, comminuted fractures, secondary complications. We have asked whether, today, this concept is still valid in Europe. The tendency towards more operative treatment becomes apparent in the documentation of children’s fractures that has started by the international working group for children’s trauma in collaboration with the AO – Doc in 1991. We think every unstable humerus fracture should be stabilized today. We posit in the rest, that if a general anaesthesia for reduction of humeral fracture is indicated, we aim at a definitive, stable and save fixation, i.e. potentially unstable fractures should be reduced in the OR. In our hands and relying on our experience we prefer to stabilize humeral fractures with ESIN

We present the results of the use of a functional brace (Sarmiento) for the treatment of diaphyseal humeral fractures. 576 patients with humeral fractures (AO classification A1, 2, 3 and B1, 2) were treated in the period from 1984 to 2009. None of them had neurovascular damage. Initially the patients were treated with a U-shape slab or a “Velpeau” bandage. After three weeks The Sarmiento brace was applied, provided that the reduction was acceptable (anterior angulation < 20°, varus deformity < 30°, shortening < 3cm). RESULTS97.5% of the fractures examined united (562/576). Duration of bone healing 8–11 weeks. Successfully used for treatment of compound fractures (Gustilo I). The Sarmiento Brace is to be used only in patients who thin, ambulatory and with full range of movement of the shoulder joint. The majority of the diaphyseal humeral fractures is successfully treated conservatively

Introduction and Aims: To evaluate the results of humeral nailing with the new Fixion inflatable humeral nail. Method: We retrospectively studied 42 patients with acute humeral fractures (20), delayed and non-union (12) and pathological fractures (10), who where treated with an inflatable humeral nail and had a minimum follow-up of six months. Our primary outcome measures were clinical and radiological union. Secondary outcome measures were revision of the nail, screening time and operative time. We made a clinical assessment of the patients using the Constant score of the shoulder and a measure of health-related quality of life, using the EuroQol EQ-5D questionnaire. Results: In patients with acute fractures 16/19 (84%) went on to clinical and radiological union (1/20 patients died four weeks post-operatively from bronchopneumonia). All of the patients with delayed and non-union of humeral fractures went on to clinical and radiological union. In the patients with pathological fractures, the nail provided good palliative symptom relief. Average screening time was 40.5 seconds (21–107). Average operative time was 71 minutes (26–142). Constant score of the shoulder had a median of 67 (SIQ 46.5–77.5) in the affected arm and 87 (SIQ 74–89) in the normal arm. Conclusion: The treatment of humeral fractures using the inflatable intramedullary nail is a simple and safe technique, avoiding the time and complications associated with distal locking. Its seems to be an appropriate technique with excellent results in those patients with delayed and non-union of humeral fractures, and provides effective palliation in patients with pathological fractures. Its efficacy in patients with acute fractures is comparable to other intramedullary nails. In our experience, it is particularly effective in the multiply injured and the infirm because of the speed and ease of insertion

Introduction: Conservative treatment of humeral diaphyseal fractures yields reliable union rates with satisfactory clinical outcome. The high incidence of shoulder complications following intramedullary fixation of humeral fractures has led clinicians to consider other less invasive treatment modalities. There is a growing body of evidence supporting the role of functional bracing in the conservative management of these fractures. Aims: To compare the outcome of patients with humeral fractures treated non-operatively using functional bracing and those treated by internal fixation. Methods: Retrospective clinical and radiographic study of two groups of patients with humeral diaphyseal fractures matched for age, sex and mechanism of injury. The study group consisted of 46 patients who had presented to our institution between January 1999 and July 2002 with closed diaphyseal humeral fractures. Mean follow-up was 21 months 96–42 months). Patients were assessed for pain, range of motion, return to work and sporting activities. Group 1 comprised of patients who underwent functional bracing whereas Group 2 underwent internal fixation. There were 12 males and 10 females in Group 1, with a mean age of 42 (16–75 years). Group 2 comprised 13 males and 11 females, with a mean age of 37 years (20–80 years). Fourteen patients were treated with antegrade locked intramedullary nailing, whereas 10 patients underwent plate osteosynthesis. All functional braces were specifically moulded and customised for each patient by the senior upper limb occupational therapist. Three patients were lost to follow-up (Group 2). Results: All patients treated with functional bracing went on to union at an average of 13 weeks (10–18 weeks). There were no major complications in this group. Two patients had residual loss of shoulder range of motion. Two patients had radial nerve palsies at presentation, which recovered fully. Of the twenty-one patients treated operatively, four required further procedures. Three patients had removal of IM nails with ORIF and bone grafting. One patient went on to non-union following ORIF, and had subsequent bone grafting. Eight patients developed restricted shoulder function, four requiring manipulations under anaesthesia. Conclusion: Functional bracing of humeral diaphyseal fractures is a safe, non-invasive treatment providing reliable outcome and high rates of union. In this retrospective study, we found the results following functional bracing to be superior to that following internal fixation. Close supervision and patient compliance with treatment and rehabilitation is empiric to a satisfactory outcome in these patients

The October 2015 Shoulder & Elbow Roundup. 360 . looks at: Culture time important in propionibacterium acnes; Microvascularisation of the cuff footprint; Degenerative cuff tears: evidence for repair; Middle ground in distal humeral fractures?; Haste needed in elbow heterotopic ossification; Iatrogenic frozen shoulder; Salvage of failed humeral fixation

The aim of management of an adult distal humeral fracture is to restore mobility, stability and pain-free elbow function. Good results are usually achieved in the majority of fractures treated with ORIF, but the management of comminuted fractures in elderly, frail patients with osteoporotic bone remains controversial. The literature focuses on elbow replacement if stable internal fixation cannot be achieved, with “bag-of-bones” management now rarely discussed eg. key-note paper - 10 successful cases reported by Brown RF & Morgan RG in 1971 (JBJS 53-B(3):425-428). We present the experience in two units in which conservative management has been actively adopted in selected cases by consultants with a subspecialty interest in the elbow. All patients over the age of 60 with distal humeral fractures (2007 – 2009) who had been treated conservatively were reviewed clinically and radiologically. Duration of follow-up and outcome, including the Oxford and quick DASH scores, were recorded, with the fractures classified using the AO system. There were 25 patients, 19 female and 6 male. 19/25 patients have been successfully treated conservatively with a mean Range Of Movement: Extension/Flexion: 45/125, Pronation/Supination 74/70. Only 5 underwent subsequent total elbow replacement and one delayed ORIF. There is a significant complication rate following surgical treatment with ORIF or elbow replacement in elderly, frail patients, including infection, painful non-union and/or stiffness. We believe that there is a role for initial conservative treatment in selected patients with low, displaced, comminuted humeral fractures in osteoporotic bone. Initial early mobilisation as pain allows can give good functional results without the risks of operation. It does not preclude future surgery if conservative treatment fails, but this is not required in the majority of cases

Humeral resurfacing arthroplasty has been advocated as an alternative to stemmed humeral component designs given its ability to preserve proximal bone stock. Further, these implants have become more attractive given the possibility of stem-related complications including humeral fracture, stress shielding, and osteolysis; complications that may necessitate fixation, revision to long stem components, or reverse total shoulder arthroplasty. As more total shoulder arthroplasties are performed in younger patient populations, the likelihood of increased revision procedures is inevitable. Maintaining proximal bone stock in these cases with use of a resurfacing arthroplasty not only facilitates explant during revision arthroplasty, but preservation of proximal metaphyseal bone facilitates reimplantation of components. Clinical results of these resurfacing components have demonstrated favorable results similar to stemmed designs. Unfortunately, resurfacing arthroplasty may not be as ideal as was hoped with regard to recreating native humeral anatomy. Further, resurfacing arthroplasty may increase the risk of peri-prosthetic humeral fracture, and lack of a formal humeral head cut makes glenoid exposure more difficult, which may be associated with a higher degree of neurovascular injury. Stemless humeral components are designed for strong metaphyseal fixation and avoid the difficulty with glenoid exposure seen in resurfacing designs, as these components require a formal humeral head cut. Early clinical outcomes of a single stemless design demonstrated significant improvements in clinical outcome scores, without evidence of component migration, subsidence or loosening. The only mid-term clinical results of stemless design implants are seen with the Arthrex Eclipse system (Arthrex, Naples, FL). In a prospective study involving 78 patients at 5-year follow-up, significant improvements were observed in clinical outcome scores. While there was evidence of proximal stress shielding in an older population, this did not influence shoulder function. The overall revision rate was 9% at 5 years, with no component necessitating revision as a result of humeral component loosening. Resurfacing arthroplasty and stemless humeral components in total shoulder arthroplasty remain attractive options to preserve proximal metaphyseal bone stock, avoiding stem-related complications. Early and mid-term clinical outcomes are comparable to stemmed designs and demonstrate no evidence of humeral component loosening

Aim: The purpose of the present retrospective study was to evaluate reasonable routine transposition of the ulnar nerve in bicondylar humeral fractures. Material and method: From 1996 to 2007 112 bicondylar fractures were operated. 88 pateints (47 women and 41 men) were followed up for average 56 months. Average age was 48 (14–80) years. Open fractures were 17. Fractures were distributed by the AO classification as follows: type C1.2 – 16, C1.3 – 10, C2.1 – 22, C2.2 – 7, C2.3 – 3, C3.1 – 17, C3.2 – 8 and C3.3 -5. All fractures were operated by the AO method with dorsal approach, osteotomy of the olecranon (83 fractures) and fixation with 2 plates. In 47 cases the ulnar nerve was routinely anteriorly transposed and for the rest 41 patients transposition was not done. Results: From 47 patients with routine anterior transposition 7 had Mc Gowan I dysfunction that was resolved in 3 months. From 41 patients without transposition 9 had a type Mc Gowan I dysfunction. There was no statistical significance between the two groups. (p> 0,05). However, 12 to 18 months later 3 patients from the group without transposition with type C1.3, C3.1 and C3.3 fractures returned with late postoperative nerve palsy Mc Gowan II and III. They were treated by neurolysis and transposition. Conclusion: Routine anterior transposition of the ulnar nerve is not reasonable in every type of bicondylar humeral fractures. The type of the bicondylar fracture defines whether the nerve transposition is reasonable or not. In low bycondilar humeral fractures and type C3 fractures the nerve transposition is obligatory

In light of the growing number of elderly osteopenic patients with distal humeral fractures, we discuss the history of their management and current trends. Under most circumstances operative fixation and early mobilisation is the treatment of choice, as it gives the best results. The relative indications for and results of total elbow replacement versus internal fixation are discussed

Introduction: Fractures of the elbow constitute about 7% of adult fractures; distal humerus fractures account for less than half of all elbow fractures. There is evidence, however, that incidence is increasing. Investigators in Finland performed a retrospective review of hospital admission records between 1970 and 1995 and found that the age-adjusted increase in incidence in women older than 60 years had more than doubled. Treatment of intraarticular comminuted distal humeral fractures is a surgical challenge, adequate reduction of the joint surface demands avoidance of residual step or gap of the articular surface and providing a stable fracture fixation. Aim: To evaluate our initial experience in internal fixation by using bioabsorbable screws by treatment of patients suffered from comminuted distal humeral fractures. Material and methods: 5 patients with sever intraarticular comminuted distal humeral fractures were treated using bioabsorbable screws. A standard transolecranon approach was used. Internal fixation was performed using lateral and medial plates. Additional bioabsorbable screws (pins) were used to fix separate intraarticuar fragments of the distal humeral bone. Results: By follow up all fractures were healed with out secondary displacement of fractures. All five patients returned to the preoperative activity, ROM of operated joints was in functional limits. Insertion bioabsorbable screws thorough articular surface allows preserve intraarticular bone fragments on the place until solid consolidation without need in additional operative procedure of removing implanted devices. Conclusion: Our experience suggests that the bioabsorbable screws can serve as useful augmentation in surgical repair of severe intraarticular comminuted fractures of the elbow joint. Future clinical study

Introduction: The FIXION® IM HUMERUS and FIXION®IL HUMERUS are expandable intramedullary nails, designed for humeral fractures. We present our results with this new type of intramedullary nailing system. Materials and Methods: The FIXION® HUMERUS NAILING SYSTEM consists of an expandable nail. Once in position, the nail expands by inflation of saline under controlled pressure. The FIXION® IM HUMERUS nail is inserted without reaming and no interlocking screws are required, thus reducing x-ray exposure both of operating room staff and patients as well as reducing operation time. The FIXION® IL HUMERUS included the option for proximal interlocking screws and is designed for proximal or distal humeral fractures. Results: We have used the system to stabilize humeral fractures with 53 patients since May 2002. Postoperative radiographic evaluation demonstrated correct axial alignment in all cases. Until now, our patients have made a satisfactory recovery with early pain-free mobilisation. Good callus formation was noted about 10 weeks after the procedure. As complications we also saw 3 non unions with the FIXION® IM HUMERUS, no infections or radial nerve injuries and no adverse events after the revision of the non unions to a FIXION® IL HUMERUS. Conclusion: The FIXION® HUMERAL NAILING SYSTEM offers an innovative and effective device for minimally invasive and biological surgery with substantially less O.R. and fluoroscopy times, with a low rate of complications

Introduction: Distal humeral fractures represent a constant challenge to the most experienced surgeon. This is the first report of the use of an unlinked prosthesis for the treatment of distal humeral fractures in elderly persons. Materials and Methods: From July 2000 to June 2001, 9 iBP elbow arthroplasties were performed in patients with acute fractures of the distal humerus. The average age of the group was 71 years. The mean interval between injury and TER was 11 days. The follow-up period averaged 12 months (range 5 to 16). Results: Functional outcome was evaluated with patient-completed questionnaires. All patients had a flexion contracture of the elbow ranging from 15 to 30 degrees. All patients were able to perform daily activities, pain relief was satisfactory and patient satisfaction was high. All elbows met the criteria for functional motion and were stable at the latest follow-up examination. There were no major complications such as dislocation, ulnar nerve dysfunction or deep infection. Conclusion: Unlinked non-congruous elbow arthroplasty when combined with a surgical exposure that allows proper soft tissue balance and instrumentation that enables correct positioning of the components can be a successful alternative in the management of acute distal humeral fractures in selected patients when conventional fixation is not a viable option

Introduction: Twenty-four proximal humeral fractures were treated by surgical internal fixation with locked antegrade intramedullary nail. The purpose of this paper was to assess the clinical outcomes after treatment with antegrade humeral nail inplanted with an interval rotator split. Material and Methods: We present a consecutive series of 24 patients with proximal and diaphyseal humeral fractures treated with the Telegraph. ®. nail inserted trough the interval rotators. There were six proximal, seven bifocal interesting the third proximal and shaft and eleven diaphyseal humeral fractures fracture. Results: The mean follow-up was 22 months with a range from 12 to 32 months, nineteen of the 24 patients were available for follow-up. All but two fractures progressed to healing. The mean Constant score were 80, Relative Constant score were 94,6%. Conclusion: Intramedullary antegrade nail insert trough the interval rotator without violating rotator cuff results in good clinical outcomes and with certain fracture types can be an effective and satisfactory device

Aims. Conservative treatment of moderately displaced proximal humeral head fractures yields good clinical results, but secondary fragment displacement may occur. Identification of those fractures at risk of displacement may influence initial decision-making. Methods. A total of 163 shoulders in 162 patients with conservatively treated isolated proximal humeral fractures were included. The fractures occurred between January 2015 and May 2018. The mean age of the patients was 69 years (26 to 100) and the mean follow-up was 144 days (42 to 779). The fractures were classified according to Neer. Scores for osteoporosis (Tingart, Deltoid Tuberosity Index (DTI)) and osteoarthritis (OA) of the glenohumeral joint were assessed. Translation of the head on follow-up radiographs of more than 10 mm was defined as displacement. Eccentric head index (EHI) describes the offset of the humeral head centre in relation to the diaphyseal axis. The ratio was estimated on anteroposterior (AP) and Neer views. Medial hinge was considered intact if the medial cortex proximal and distal to the fracture was in line on AP view. Results. Secondary fracture displacement occurred in 41 patients (25.2%). Clinical risk factors were alcohol abuse (odds ratio (OR) 6.8; 95% confidence interval (CI) 1.3 to 36; p = 0.025) and previously diagnosed osteoporosis (OR 4.6; 95% CI 0.6 to 34; p = 0.136). Age (OR 1.1; 95% CI 1.0 to 1.1; p = 0.003) and sex (OR 0.9; 95% CI 0.3 to 2.8; p = 0.867) were not independent factors. Radiological risk factors were OA grade 3 (OR 16.4; 95% CI 0.25 to 37.6; p = 0.107) and osteoporosis with the DTI (OR 10; 95% CI 0.8 to 250; p = 0.031) being more predictive than the Tingart score (OR 2.3; 95% CI 0.8 to 4.7; p = 0.041). A high EHI (AP/Neer > 0.4, OR 18.9; 95% CI 2.1 to 30.9/3.0; 95% CI 1.1 to 8.0; p = 0.002/p = 0.033) and a disrupted medial hinge (OR 3.7; 95% CI 1.1 to 12.6; p = 0.039) increased the risk of secondary displacement significantly. Neer classification had no influence. Conclusion. During conservative treatment, a quarter of patients showed secondary fracture displacement of at least 10 mm. Patients with alcohol abuse, severe OA, and osteoporosis are at risk. Newly defined EHI and disrupted medial hinge are relevant predictors for secondary displacement. Cite this article: Bone Joint J 2020;102-B(7):881–889

A radial nerve palsy complicates 1.8 to 17% (mean 11%) diaphyseal humeral fractures (13.7% in our series of 156 humeral fractures and nonunions treated by external fixation – Tsiagadigui, 2000). In about 75%, it is a primary lesion, related to the fracture before any attempt at treatment. In 60%, the fracture, most commonly with an oblique fracture line, involves the middle third. In children, a supracondylar fracture may be complicated by radial nerve palsy. Most nerve lesions correspond to neurapraxia or axonotmesis, due to traction or compression associated with bone angular deformity. Unfrequently, the nerve is impaled or severed by bone fragments, or may be trapped within the fracture in case of a spiral oblique middle or distal third humeral fracture with lateral displacement of the distal fragment. Iatrogenic injury during internal fixation or entrapment within periosteal callus are occasionally observed. The classical indications for early radial nerve exploration include open fractures requiring surgical debridement, or fractures with vascular compromise, or when the osteosynthesis is done by a plate. In all other cases, we recommend to investigate the integrity of the radial nerve by echography. In the absence of discontinuity, spontaneous neurological recovery is likely to occur and is monitored clinically and by electromyography; prevention of joint contracture is done by physiotherapy and by a wrist splint, maintaining the joint in slight dorsiflexion. In case of persistent palsy, neurolysis is indicated several months after the initial injury, the precise delay depending on the level of the fracture. Palliative treatment by tendon transfers offers in cases of persistent palsy excellent functional results. Tendon transfers may be indicated early after the fracture, in case of an irreparable radial nerve lesion

Aims. Displaced fractures of the lateral condyle of the humerus are frequently managed surgically with the aim of avoiding nonunion, malunion, disturbances of growth and later arthritis. The ideal method of fixation is however not known, and treatment varies between surgeons and hospitals. The aim of this study was to compare the outcome of two well-established forms of surgical treatment, Kirschner wire (K-wire) and screw fixation. Patients and Methods. A retrospective cohort study of children who underwent surgical treatment for a fracture of the lateral condyle of the humerus between January 2005 and December 2014 at two centres was undertaken. Pre, intraoperative and postoperative characteristics were evaluated. A total of 336 children were included in the study. Their mean age at the time of injury was 5.8 years (0 to 15) with a male:female patient ratio of 3:2. A total of 243 (72%) had a Milch II fracture and the fracture was displaced by > 2 mm in 228 (68%). In all, 235 patients underwent K-wire fixation and 101 had screw fixation. . Results. There was a higher rate of nonunion with K-wire fixation (p = 0.02). There was no difference in Baumann’s angle, carrying angle or the rate of major complications between the two groups. No benefit was obtained by immobilizing the elbow for more than four weeks in either group. No short-term complications were seen when fixation crossed the lateral ossific nucleus. Conclusions. Fixation of lateral condylar humeral fractures in children using either K-wires or screws gives satisfactory results. Proponents of both techniques may find justification of their methods in our data, but prospective, randomized trials with long-term follow-up are required to confirm the findings, which suggest a higher rate of nonunion with K-wire fixation. Cite this article: Bone Joint J 2018;100-B:387–95

The August 2023 Shoulder & Elbow Roundup360 looks at: Motor control or strengthening exercises for rotator cuff-related shoulder pain? A multi-arm randomized controlled trial; Does the choice of antibiotic prophylaxis influence reoperation rate in primary shoulder arthroplasty?; Common shoulder injuries in sport: grading the evidence; The use of medial support screw was associated with axillary nerve injury after plate fixation of proximal humeral fracture using a minimally invasive deltoid-splitting approach; MRI predicts outcomes of conservative treatment in patients with lateral epicondylitis; Association between surgeon volume and patient outcomes after elective shoulder arthroplasty; Arthroscopic decompression of calcific tendinitis without cuff repair; Functional outcome after nonoperative management of minimally displaced greater tuberosity fractures and predictors of poorer patient experience.

Aim: To describe and evaluate the use of the limited contact plate in complex humeral shaft fractures. Certain sub-groups of humeral shaft fractures can be very difficult to treat. These ‘complex fractures’ include fractures in very osteoporotic bone, those associated with shoulder or elbow prosthesis, non-unions and those associated with intra articular extensions and dislocations. The AO limited contact plate (LCP) is a new form of fixation whether the screw heads lock into the holes in the plate. The plate is not designed to cause compression and does not need to lie perfectly adjacent to the bone. Methods: A prospective study of six consecutive complex humeral shaft fractures treated with LCP plate. Rate of union, complications, and subjective and objective outcome (DASH scores) are analyzed. Results: Union occurred in 9/10 patients. The final patient is progressing to union. There were no serious complications. Good subjective and objective outcome in all patients. Conclusion: This heterogeneous series of complex and complicated humeral shaft fractures all pose significant management problems. Treatment with the LCP plate demonstrated good results with no significant complications. This completely new rational for treatment seems particularly suitable for the treatment of complex or complicated humeral shaft fractures

Aims

Both anatomical and reverse total shoulder arthroplasty (aTSA and rTSA) provide functional improvements. A reported benefit of aTSA is better range of motion (ROM). However, it is not clear which procedure provides better outcomes in patients with limited foward elevation (FE). The aim of this study was to compare the outcome of aTSA and rTSA in patients with glenohumeral osteoarthritis (OA), an intact rotator cuff, and limited FE.

Mid-shaft humeral fractures in adults are common these days and often present with a management dilemma between operative and non-operative treatment. This study evaluates the outcome of such fractures treated non-operatively over a span of 10 years. In this retrospective study, a review of case notes and radiographs of patients whose mid-shaft humerus fractures were treated non-operatively between 1994 and 2004 was done. Those younger than 16 years and/or who had surgery primarily were excluded. Various factors including patient demographics, mechanism of injury, AO fracture classification and time to union were studied. Mean patient follow-up was 4 years and 6 months. The Oxford shoulder score was used for functional assessment. There was a total of 43 patients, mostly men with involvement of the dominant arm. 5 patients required open reduction and internal fixation with bone grafting for non-union. The average Oxford shoulder score was 18. The majority of patients could resume their jobs and the average time to union was 9 weeks. We conclude from this study that there is a high union rate in the mid-shaft humeral fractures in adults treated non-operatively, with an acceptable functional outcome

Total elbow arthroplasty (TEA) has been shown to be a treatment option for elderly patients with complex distal humeral fractures and osteoporotic bone. The published results have often included rheumatoid patients who traditionally would be expected to do well from elbow arthroplasty. Only short-term results have been published using this technique in non-rheumatoid patients. The current study contains the largest number and longest follow-up of non-rheumatoid patients whose fractures have been treated with a non-custom TEA. In total there were 26 patients, mean age 72 years, 22 female and 4 male, 25% dominant arm. The mean follow-up was of 5 years. There was 1 case of loosening, 1 radial nerve palsy and 2 cases of heterotrophic ossification. At final review the mean range of flexion/extension was 97.5 degrees and the mean range of pronation/supination was 151.75 degrees. The mean Mayo Elbow Performance score was 92. We would suggest that TEA provides a very satisfactory outcome in elderly patients with complex distal humeral fractures, the benefit of which can be observed at a mean of 5 years

The April 2024 Shoulder & Elbow Roundup³⁶⁰ looks at: Acute rehabilitation following traumatic anterior shoulder dislocation (ARTISAN): pragmatic, multicentre, randomized controlled trial; Prevalence and predisposing factors of neuropathic pain in patients with rotator cuff tears; Are two plates better than one? The clavicle fracture reimagined; A single cell atlas of frozen shoulder capsule identifies features associated with inflammatory fibrosis resolution; Complication rates and deprivation go hand in hand with total shoulder arthroplasty; Longitudinal instability injuries of the forearm; A better than “best-fit circle” method for glenoid bone loss assessment; 3D supraspinatus muscle volume and intramuscular fatty infiltration after arthroscopic rotator cuff repair.

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 August 2014 Shoulder & Elbow Roundup. 360 . looks at: Myofibroblasts perhaps not implicated in post-traumatic elbow stiffness; olecranon tip biomechanically sound for coranoid reconstruction; obesity and elbow replacement don’t mix; single column plating successful for extra-articular distal humeral fractures; satisfaction not predictable in frozen shoulder; tenodesis and repair both acceptable in Grade II SLAP tears; glenoid bone grafting is effective and glenohumeral articular lesions best seen with an arthroscope

Aims

Arthroplasties of the elbow, including total elbow arthroplasty, radial head arthroplasty, distal humeral hemiarthroplasty, and radiocapitellar arthroplasty, are rarely undertaken. This scoping review aims to outline the current research in this area to inform the development of future research.

Cubitus varus following paediatric supra-condylar humeral fracture represents a complex three-dimensional malunion. This affects cosmesis, function and subsequent distal humeral fracture risk. Operative correction is however difficult with high complication rates. We present the 40-year Yorkhill experience of managing this deformity. From a total of 3220 supracondylar humeral fractures, 40 cases of post-traumatic cubitus varus were identified. There were ten undisplaced fractures, treated in cast, and thirty displaced fractures. Five were treated in cast, thirteen manipulated (MUA), four MUA+k-wires, seven ORIF (six k-wire, one steinman pin) and one in skeletal-traction. Sixteen malunions were treated operatively. The mean pre-operative varus was 19°. All had cosmetic concerns, three mild pain, one paraesthesia/weakness and three reduced movement (ROM). The operative indication was cosmetic in fifteen and functional in one (concern about instability). Twelve patients had lateral closing-wedge osteotomies; three complex/3D osteotomies (dome, unspecified rotational, antero-lateral wedge) and two had attempted 8-plate guided-growth correction. Complications occurred in eight patients (50 %): Fixation was lost in three (two staples, one k-wiring), incomplete correction in six (both 8-plates, both staples, two standard plates) and one early wound infection requiring metalwork removal resulting in deformity recurrence. One patient underwent revision lateral wedge osteotomy with full deformity correction but marked ROM restriction (20–100°) secondary to loose bodies. Those without complications were satisfied (50 %). All patients with residual deformity were unsatisfied. 1 patient with keloid scarring was unsatisfied despite deformity correction. Varus malunion is uncommon (1 %) but needs to be guarded against. It tended to occur in displaced fractures treated with MUA and cast alone. We therefore recommend additional pin fixation in all displaced fractures. Deformity correction should only be attempted in those with significant symptomatic deformity due to the high complication/dissatisfaction rates. Staple osteotomy fixation and 8-plate guided growth correction are not recommended

Aims

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.

We evaluated the use of unreamed expanding nails in prophylactic stabilization of impending fractures in patients with multiple bone mets. During 2004–2008 we treated 25 impending fractures due to metastasis (11 male, 14 female patients) with so-called expanding intramedullary nails. All they had multiple bone mets and signs of impending fracture due to extensive osteolysis. We stabilized 6 impending humeral fractures, 15 femoral and 1 tibial with antegrade nailing and 3 pertrochanteric with cephalomedullary nailing. Fluoroscopy was used to check the nail entry-point. No medullary reaming was performed. The nails were not interlocked at the mid-shaft but fixed rather firmly within the medullary cavity after introducing normal saline under pressure that expands its walls. The operation time ranged from 12min (humerus) to 25min (pertrochanteric). No blood transfusion was necessary. On follow-up (8–41 mos) all patients were reviewed. In all cases the risk of impending fracture was remarkably decreased. The patients with humeral fractures regained function quickly. The patiens with lower limb fractures were mobilized immediately post-op and were allowed to walk with TWB. Surgery of impending fractures of long bones in patients with multiple bone mets is palliative. It aims in safer patient’s mobilization, fracture risk reduction, pain control and function restoration in order to render the patient capable to continue the treatment for the main disease. The expanding nailing is indicated in selected cases as it can be inroduced quickly and effectively with minimal blood loss and morbidity

Intra-articular distal humeral fractures in the elderly are difficult to treat. There is evidence in the literature to support the use of both Open Reduction and Internal Fixation (ORIF) and Total Elbow Arthroplasty (TEA) as primary procedures, although we have been unable to find any direct comparisons of outcome. This study reports the results of ORIF in 12 elderly patients with distal humeral fractures and compares the outcome with 12 matched patients who had undergone TEA. All procedures were performed by two experienced Consultant Surgeons. The Coonrad-Morrey TEA was used in all cases of TEA and a double-plating technique was used in all ORIFs. Both groups of patients were similar with respect to fracture configuration, age, sex, co-morbidity and hand dominance. The mean follow-up in both groups of patients was over 30 months. At final review, patients who had had a TEA had a mean Mayo score of 91 and a range of flexion/extension of 90 degrees. There was 1 superficial wound infection that resolved with antibiotics, 1 temporary radial nerve palsy, and 1 case of heterotrophic ossification The ORIF group had a mean Mayo score of 89 (p> 0.05) and a range of flexion/extension of 112 degrees (P=0.03). There was 1 case of heterotrophic ossification, 2 cases of ulnar nerve compression that needed decompression and 1 superficial wound infection that resolved with antibiotics. All the fractures united. This study indicates that both treatment modalities can lead to excellent results. ORIF has the advantage of preserving the joint and once union has occurred has a low risk of long term complications

Total elbow arthroplasty (TEA) has been shown to be a treatment option for elderly patients with complex distal humeral fractures and osteoporotic bone. The published results have often included rheumatoid patients who traditionally would be expected to do well from elbow arthroplasty. Only short-term results have been published using this technique in non-rheumatoid patients The current study contains the largest number and longest follow-up of non-rheumatoid patients whose fractures have been treated with a non-custom TEA. In total there were 26 patients, mean age 72 years, 22 female and 4 male, 25% dominant arm. All had a minimum of 5 years follow-up. There was 1 case of loosening, 1 radial nerve palsy and 2 cases of heterotrophic ossification. At final review the mean range of flexion/extension was 97.5 degrees and the mean range of pronation/supination was 151.75 degrees. The mean Mayo Elbow Performance score was 92. We would suggest that TEA provides a very satisfactory outcome in elderly patients with complex distal humeral fractures, the benefit of which can be observed for at least 5 years

There is little information about the management of peri-prosthetic fracture of the humerus after total shoulder replacement (TSR). This is a retrospective review of 22 patients who underwent a revision of their original shoulder replacement for peri-prosthetic fracture of the humerus with bone loss and/or loose components. There were 20 women and two men with a mean age of 75 years (61 to 90) and a mean follow-up 42 months (12 to 91): 16 of these had undergone a previous revision TSR. Of the 22 patients, 12 were treated with a long-stemmed humeral component that bypassed the fracture. All their fractures united after a mean of 27 weeks (13 to 94). Eight patients underwent resection of the proximal humerus with endoprosthetic replacement to the level of the fracture. Two patients were managed with a clam-shell prosthesis that retained the original components. The mean Oxford shoulder score (OSS) of the original TSRs before peri-prosthetic fracture was 33 (14 to 48). The mean OSS after revision for fracture was 25 (9 to 31). Kaplan-Meier survival using re-intervention for any reason as the endpoint was 91% (95% confidence interval (CI) 68 to 98) and 60% (95% CI 30 to 80) at one and five years, respectively. There were two revisions for dislocation of the humeral head, one open reduction for modular humeral component dissociation, one internal fixation for nonunion, one trimming of a prominent screw and one re-cementation for aseptic loosening complicated by infection, ultimately requiring excision arthroplasty. Two patients sustained nerve palsies. Revision TSR after a peri-prosthetic humeral fracture associated with bone loss and/or loose components is a salvage procedure that can provide a stable platform for elbow and hand function. Good rates of union can be achieved using a stem that bypasses the fracture. There is a high rate of complications and function is not as good as with the original replacement