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

The management of closed fractures of the humerus with an associated nerve palsy remains controversial. With very little written about this injury in children, we present the case of a three-year-old child with a closed humeral shaft fracture in whom surgical exploration and reconstruction of the radial nerve with a sural nerve graft was performed three months after injury. The child regained full function. To the best of our knowledge, this is the first such case to be reported in the English literature

Methods

Between 2005 and 2012, 50 patients (23 female, 27 male) with nonunion of the humeral shaft were included in this retrospective study. The mean age was 51.3 years (14 to 88). The patients had a mean of 1.5 prior operations (sd 1.2;1 to 8).

All patients were assessed according to a specific risk score in order to devise an optimal and individual therapy plan consistent with the Diamond Concept. In 32 cases (64%), a change in the osteosynthesis to an angular stable locking compression plate was performed. According to the individual risk an additional bone graft and/or bone morphogenetic protein-7 (BMP-7) were applied.

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

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

Arthritis of the glenohumeral joint accompanied by an irreparable tear of the rotator cuff can cause severe pain, disability and loss of function, particularly in the elderly population. Anatomical shoulder arthroplasty requires a functioning rotator cuff, however, reverse shoulder arthroplasty is capable of addressing both rotator cuff disorders and glenohumeral deficiencies. The Aequalis Reversed Shoulder Prosthesis design is based on two bio-mechanical principles by Grammont; a medialized center of rotation located inside the glenoid bone surface and second, a 155 degree angle of inclination. Combined, they increase the deltoid lever arm by distalizing the humerus and make the prosthesis inherently stable. 24 consecutive primary reverse total shoulder arthroplasties were performed by a single surgeon for arthritis with rotator cuff compromise and 1 as a revision for a failed primary total shoulder replacement between December 2009 and October 2012. Patients were assessed postoperatively with the use of the DASH score, Oxford shoulder score, range of shoulder motion and plain radiography with Sirveaux score for scapular notching. Mean age at the time of surgery was 72.5 years (range 59 to 86). Average follow up time was 19.4 months (range 4 to 38). Functional outcome scores from our series were comparable with patients from other follow up studies of similar prosthesis design. All patients showed improvement in range of shoulder movement postoperatively. Complications included one dislocation, one acromion fracture and one humeral shaft fracture. No cases of deep infection were recorded. Overall, the short-term clinical results were promising for this series of patients and indicate reverse shoulder arthroplasty as an appropriate treatment for this group of patients

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

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

1. It appears that fracture of the humeral shaft occurs more often in persons over fifty. This incidence corresponds with that found in a study carried out by the Pennsylvania Orthopaedic Society in 1959. 2. The middle third of the bone is the most vulnerable portion of the shaft, where transverse fracture and radial nerve palsy most commonly occur. 3. Most fractures of the shaft of the humerus are best treated by simple splintage. The degree of radiological deformity that can be accepted is far greater than in other long bones. In this group anterior bowing of 20 degrees or varus of 30 degrees was present before it became clinically obvious and even then the function of the limb was good. 4. Internal fixation is only occasionally indicated but operation on the middle third of the bone increased the chances of delayed union. 5. In the treatment of delayed union intramedullary fixation and the application of slivers of iliac bone is effective in stimulating the fracture to join

Purpose: To evaluate the assumption that reaming is the main reason for problems of shoulder function (pain – restricted range of motion) after antegrade intramedullary nailing of humerus (unless impingement of fixation material on the rotator cuff or acromion occurs). Materials – Methods: From January 1999 until March 2003 55 patients underwent unreamed antegrade intra-medullary nailing for treatment of recent fractures of the humeral shaft. Two different intramedullary nailing systems were used, that do not protrude from the humeral shaft and that do not require reaming for insertion. Patients with concomitant problems or complications that could affect the final functional result were excluded from the study (e.g. multiple injuries, brachial plexus lesions, etc.). The remaining 32 patients were examined for postoperative pain and functional problems in the shoulder joint. Results: No patient complained of persistent shoulder pain. Range of motion was found comparable to that of the other shoulder. Conclusions: Reaming seems to exert a harmful influence on the rotator cuff, due to direct injury caused by the reamers as they are inserted and withdrawn from the humeral head. Furthermore it is possible that bone reaming products, accumulating under the rotator cuff, contribute to the persistence of pain and loss of motion

Aims: The evaluation of the results of surgical treatment of humeral shaft fractures with intramedullary nailing (I.N.) after twelve month follow up. Methods: This study involves 18 patiens with fracture of the humeral shaft, treated operatively with I.N. of A.O. type, in a 4-year period (Jan 1998- Feb 2001). 17 were available to follow up examination. 16 men and 2 women with average 25 years of age were followed for a mean period of a year. Indication for the prosedure was the inability to maintain closed reduction. In 11 patiens the nail was inserted below the great tuberosity. The rest underwent retrograde I.N. All nails were proximally locked and x- were distally locked too. Closed reduction was achieved in 15 cases. The nail was inserted manually (with no hammer use) in all cases. Results: Clinical and radiological healing was apparent in all fractures between the 4th and 6th p.o. month. Full active motion was achieved in 8th p.o. week. There were 3 p.o. radial nerve palsies. Two of them resolved six months later. Residual pain of the shoulder was noted in one case. Conclusions: Nailing of the humeral shaft fractures using AO-type nail is a reliable method of treatment, giving very good final results. Advantages are: minimal surgical trauma, less blood loss, shorter operative time and earlier mobilization

Background: The purpose of this retrospective study was to analyze the results of closed intramedullary fixation of pathological humeral shaft fractures with unreamed humeral nail (UHN). Patients & Methods: Nine patients who had ten pathological fractures of the humeral shaft secondary to metastatic disease were included in the study. All fractures were stabilized with unreamed humeral nailing with use of a closed anterograde technique. The mean patient age was sixty-three (range, fifty to 78), male to female ratio 1:8 and left humerus was involved in five, right in three patients and one patient had bilateral pathological humeral shaft fracture. Results: The blood loss was unremarkable in seven patients (8 procedures). Two patients were given totally 3 units of pack cells after the surgery and these were the only patients who had additional surgeries during the same operation due to their additional pathological fractures. The mean duration of hospitalization after the operation was 6.5 days (range, two to 16 days). All of the ten extremities had a return to nearly normal function within 6 weeks after nailing. Relief of pain was rated as good in all but one patient. Seven patients received adjuvant therapy during the 3 months period before and after the procedure. Five patients died at a mean of 3.5 months (range, one to 9 months). There were no early or late complications related to surgery except one patient who developed cellulitis after the surgery. The fracture was united in all of the extremities in patients who survived for at least 3 months and had radiographs available. Conclusion: Unreamed humeral nailing of the pathological humeral shaft fractures provides immediate stability and pain relief, minimum morbidity and early return of function to the extremity

Aim: End result study of closed intramedullary nailing of humerus fractures. Materials & methods: Between 1995–2003, 42 patients with fracture of the humeral shaft, were selected to be treated by I.N. The average age was 48 years old (17years–82years) The Selection criteria were: α) loss of closed reduction (24 patients), b) pathological fractures (5 patients), c) non-union following external fixation (2 patients) and d) delay of union (7 patients). The intramedullary nail was inserted through a proximal entry point via a transdeltoid incision. In 25 cases the entry point was below the greater tuberosity to avoid rotator cuff injury and in 18 cases the entry point was intraarticular. All nails were locked either proximal (41) or distally (1). Open technique was required for 21 cases. Passive full range of motion of elbow and shoulder joint was encouraged after the second postoperative day. Active assisted exercises were initiated the second postoperative week. Bone healing was confirmed by clinical and radiological findings. Shoulder mobility was evaluated by the Constant-Murley scoring system. Results: The average follow-up time was 21 months (9 months–8 years).All fractures were finally healed. The average healing time was 13 weeks (8weeks–13weeks). Patients with extraarticular entry point of the nail had full passive shoulder motion between the 2th and the 4th postoperative week, whereas patients with intraarticular nail application presented delayed passive shoulder motion with final limitation of the normal range of motion. Seven patients had painful shoulder motion 3 months postoperatively. There were 4 patients with neurapraxia of the radial nerve installed posttraumatic, who had full recovery 3 months later. There was one proximal migrated nail, which required revision. None of the patients required nail removal. Conclusions: Intramedullary nailing of humeral shaft fractures seems to be a reliable method of treatment. Shoulder mobilization after anterograde insertion of the nail can be easily restored with proper choice of entry point and proper physiotherapy program. The advantages of this method include: shorter operative time, less blood loss, small incision with minimal soft tissue damage. Extraarticular nail insertion should be the entry point of choice as there is no trauma to the rotator cuff

Introduction and Objectives: In this retrospective study, we have evaluated the results of treatment of non-unions of the humeral diaphysis using plate osteosynthesis. Materials and Methods: This is a retrospective study covering the years 1997–2002, with a total of 135 fractures of the humeral shaft: 84% were treated orthopaedically and 16% surgically by means of plate osteosynthesis. We present 14 cases of humeral non-union, all of which occurred after orthopaedic treatment, and 12 of which were surgically treated by means of plate osteosynthesis (the other 2 declined surgical treatment). The most common cause of fracture was accidental fall, and of the 12 cases, 11 were female, and 1 was male. Mean age was 67.6 years. Initial orthopaedic treatments included the following: in 9 cases U-splint + sling, in 1 case U-splint + Velpeau sling, in 2 cases hanging cast + Poulipen. Of these, the initial bandaging was replaced with braces after 2.5-3 months. Definitive surgical treatment was delayed an average of 8.1 months. We used the Müller-AO fracture classification system. There were 4 cases with 12B12, 3 cases with 12A12, 1 case with 12A11, 1 case with 12B22, 1 case with 12B11, 1 case with 12B21, and 1 case with 12A21. Surgical treatment was performed in 7 cases with LD-DCP plates, in 3 cases with DCP plates, in 1 case with a T-plate, and in 1 case with a straight plate. Corticocancellous bone grafts were transferred from the iliac crest in 9 of 12 cases. Results: Bone healing was achieved in 11 of 12 surgical cases (one case without radiographic consolidation due to detachment of the plate due to trauma). In 2 cases there was a limitation of shoulder abduction at 85° and elbow extension -10°. In one case, there was repeat treatment due to failure of osteosynthesis. In two of the surgical cases, definitive BA will be measured upon completion of rehabilitation. Complications included 2 temporary radial palsies that recovered both motor and sensory function, one distal detachment of the plate due to previous trauma that had borderline BA and was non-painful. There was one case in which consolidation did not occur and where the humeral artery was injured iatrogenically during surgery (the same one that required repeat surgical intervention). There was one case of infection of the site of osteosynthesis due to Pseudomonas aeruginosa, which responded well to initial antibiotic treatment, and no material needed to be removed. Discussion and Conclusions: Plate osteosynthesis is an effective treatment for non-unions of the humeral shaft and yields good joint mobility and few complications (similar to the results of other treatment methods) and must be performed by experienced surgeons

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 August 2024 Trauma Roundup³⁶⁰ looks at: Does topical vancomycin prevent fracture-related infections in closed fractures undergoing open reduction and internal fixation? A randomized controlled trial; Is postoperative splinting advantageous after upper limb fracture surgery?; Does suprapatellar nailing resolve knee pain?; Locking versus non-locking plate fixation in comminuted talar neck fractures: a biomechanical study using cadaveric specimens; Revolutionizing recovery metrics: PROMIS versus SMFA in orthopaedic trauma care; Dorsal hook plating of patella fractures: reliable fixation and satisfactory outcomes; The impact of obesity on subtrochanteric femur fracture outcomes; Low-dose NSAIDs (ketorolac) and cytokine modulation in orthopaedic polytrauma: a detailed analysis.

Periprosthetic fractures occur in approximately 1–3% of case series. Periprosthetic fractures are associated with revision surgery with difficult exposure, osteoporosis, large canal filling non-cemented stem design, overreaming of the medullary canal, and excessive external rotation with inadequate exposure. Periprosthetic fractures can be intentional when removing a well-fixed humeral stem. In this circumstance a longitudinal unicortical osteotomy along the anterior length of the stem will allow for stem and cement removal without fragmentation of the humeral bone. Periprosthetic fractures are classified as occurring intraoperative versus postoperative as well as the location of the fracture in relation to the stem. Most intraoperative humeral fractures and all diaphyseal fractures should be x-rayed at the time of their occurrence to determine the fracture configuration, the best exposure for repair, and the length of the stem required to internally fix the fracture. Under ideal circumstances the stem should be of sufficient length to extend two cortical widths past the distal most extent of the fracture site. For fractures limited to one or both of the tuberosities, the surgical neck, or metaphyseal-diaphyseal junction, a standard length prosthetic is sufficient. For diaphyseal fractures a long stem prosthetic is necessary. In the vast majority of fractures in which the fracture fragment is displaced, open reduction and cerclage fixation with heavy suture or wire is needed. For fractures in which the proximal bone is intact and of good quality thereby providing good prosthetic fixation and rotational stability, the diaphyseal fracture can be anatomically reduced and secured with two or three cerclage wires (Dall Meyers cables or the equivalent). In this case a non-cemented long stem prosthetic is preferred. When a cemented stem is used, it is necessary to insure that cement is not extruded from the fracture site. This is accomplished by having adequate surgical exposure of the fracture, an anatomic reduction, and secure fixation before you place the cement and stem. Extruded cement may result in nerve injury or nonunion. Intentional longitudinal fractures require direct exposure of the length of the osteotomy to control its length and displacement. It is advised to pass the cerclage wires prior to making the osteotomy. In the humerus, the osteotomy is best made just lateral to the biceps groove with an osteotome. The osteotome is placed to the depth of the stem and through the cement mantle when this is present. When the osteotomy is nearly to the length of the stem the osteotome is placed at the proximal extent of the osteotomy at approximately the mid-level of the biceps groove to a depth of the stem and then turned. This will crack the cement mantle of the opposite side of the medullary canal and open the anterior cortex. It results in a stable fracture of the humeral shaft but allows easy removal of the stem and facilitates removal of the stem from both the proximal aspect of the medullary canal and from the osteotomy site. After completion of the stem and cement removal the cerclage wires are tightened and the new stem is inserted. When secure fixation is achieved with a periprosthetic fracture, regardless of the type of fracture, the postoperative rehabilitation is the same as a routine arthroplasty and the results and time for recovery is unchanged. Nonoperative treatment of periprosthetic fractures are reserved for the postoperative fracture occurring below the stem in a patient with a well-fixed and a functioning prosthetic, or in patients that have medical contraindication to revision surgery. A functional hinged brace can be used to help in reduction of these fractures and immobilisation of the fracture site. The braces are difficult to use and are less effective in patients with a large soft tissue envelope. Skin problems and nonunions or malunions can occur. In most cases when there is an inadequate reduction, difficult immobilisation, or stem involvement, it is best to operate soon after the fracture as late revisions in the setting of a nonunion or malunion are difficult surgical challenges

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

We describe 11 cases of posterior fracture-dislocation of the shoulder that required open reduction and fixation. Difficulties with access through anterior approaches led us to use the superior subacromial approach. This is an extension of the approach often used to expose the rotator cuff; the joint is opened by splitting the supraspinatus tendon 5 mm behind the cuff interval. The glenoid, proximal humerus and any fracture fragments can be seen from above, allowing reduction of the dislocation and osteosynthesis to be performed with minimal risk of damage to the humeral head and its blood supply. The proximity of the axillary nerve limits the exposure of the proximal humeral shaft. The superior subacromial approach is ideal for posterior dislocation with fracture of the articular segment, but is not suitable when there is a fracture of the proximal humeral shaft

Aim: To evaluate the technique of percutaneously harvested bone graft mixed with morphogenic bone protein and endoscopically delivered to ununited long bone fractures. Methods: Thirty-eight patients with established delayed union of long bone fractures were bone-grafted endoscopically. Morphogenic bone protein (OP1) was used in 12 cases and the graft was supplemented with calcium sulphate pellets (Osteoset). The minimum follow-up was eight months. The study group included eight femoral shaft fractures, two humeral shaft fractures and the remainder were tibial shaft fractures. Results: Four fractures failed to unite with this technique. Two femoral shaft non-unions required repeat surgery, one humeral shaft non-union and one tibial shaft non-union required supplementary grafting and fixation. The technique requires radiological imaging to supplement endoscopic preparation and graft delivery. For tibial fractures this can be used as a day-stay technique but most patients required one night in hospital. Conclusions: Endoscopic bone grafting can be supplemented with graft substitute (Osteoset) and morphogenic protein (OP1). It is as effective as standard open ‘onlay’ grafting but good fixation of the fracture is necessary before graft and supplements are effective