The aim of this abstract is to show that acute osteomyelitis is one of the most feared complication of orthopedic surgery. A rapid and aggressive treatment is mandatory in order to avoid significant bone loss, joint destruction and, in most cases, salvage of the limb. After apparent cure of the infection, sequelae must be addressed. In this case, the joint destruction was important, so reconstruction procedures where impossible. In a superficial and relatively small joint such as the elbow, it is preferred to do an arthrodesis than an arthroplasty because the risk of reactivation of the infection with implant involvement is very important.

We present a case report of a 69 years old woman, who had a supra-intra-condylar fracture (AO 13-C1) of the right humerus. She was treated with open reduction and internal fixation with 2 internal lag screws and 2 external lag screws. After 6 weeks, she was admitted with a dislocated elbow associated with pain, loss of limb function, cubita nerve palsy and a purulent discharge from the surgical wound. She started vancomycin and was submitted to surgery with debriment, hardware removal and fixation with an external fixator was used. The local signs of infection disappeared progressively. After normalization of the laboratory parameters of infection, the patient was submitted to an elbow arthrodesis using a posterior contour plate.

The elbow achieved solid fixation and infection was eradicated, at least for the time being, allowing the patient to use the upper limb in her daily live activities.

The treatment of post operative acute osteomyilits is challenging, In this case, after apparent solution of the infection, a solid fixation of the elbow was achieved, allowing the use of the upper limb in the patient daily activities.

Patients using a neutral rotation brace post proximal humerus fracture fixation have improved functional outcome and external rotation of the shoulder compared to patients using a standard polysling.

Patients who have proximal humerus fracture fixation with extramedullary plates and screws have a risk of reduced range of movement especially external rotation. Gerber et al showed that the average external rotation after fixation of proximal humeral fractures was 39 degrees in their patient cohort compared to a normal range of 80–100 degrees. This can lead to reduced function and poor patient related outcomes. Geiger et al showed that in a cohort of 28 patients, poor functional outcome was noted in 39.3% with an average Constant-Murley Score of 57.9.

Current practice is to utilise a polysling holding the shoulder in internal rotation post-shoulder fixation. Patients usually wear the sling for up to 6 weeks. We believe that this increases the risk of adhesion formation with the shoulder in internal rotation in the shoulder joint. Therefore this can cause loss of external rotation in the shoulder joint. We believe that holding the shoulder in a neutral alignment, with a neutral rotation brace post-fixation, will enable an increased rate of external rotation post-operatively thus improving external rotation and functional outcome

There is currently no literature comparing the different slings used post-operatively and we believe that this study would be the first of its kind. It would have a substantial change in the way clinicians manage proximal humeral fractures and will potentially reduce the numbers of re-operations to divide adhesions or perform capsular releases. Secondary benefits include a potential earlier return to full function and work and improved patient satisfaction.

Study proposal: Prospective Randomised Controlled Trial of the neutral rotation brace compared to the standard, currently used, polysling post proximal humerus fracture fixation. No blinding of either participants or clinicians. Three surgeons utilising similar fixation techniques via the deltopectoral approach and using Philos plate fixation (Synthes Ltd.). Standardised post-operative rehabilitation protocol for all patients.

Follow up: clinical review and postal outcomes for 1 year

Primary outcomes: Post operative functional outcome scores (Oxford, DASH, EQL) obtained at 6 weeks, 9 weeks, 3 months and 1 year). These will be compared to scores taken pre-operatively.

Secondary outcomes: Clinical review at 6 weeks, 3 months and 1 year with range of movement measurements. Radiographs also taken at 6 weeks and 3 months to assess union. Patient questionnaire at 1 year (with outcome scores) assessing patient return to work, complications and patient satisfaction

Inclusion criteria: Proximal humeral fractures requiring operative intervention with extramedullary plate fixation (i.e. fractures displaced by 1cm and/or angulated by 45 degrees or more). Age>18.

Exclusion Criteria: Patients having intra-operative findings of complete Pectoralis major rupture or if operative exposure requires complete Pectoralis major tenotomy. (These patients need to be held in internal rotation with a standard polysling to allow healing of the Pectoralis major tendon).

Aim. Treatment for distal third shaft fractures of humerus is very challenging especially if its comminuted and bone is osteopenic. They are commonly treated with plating. Plating has complications of iatrogenic radial nerve palsy. We report our case series of distal third fractures of humerus treated with retrograde Halder Humeral Nail. Materials and methods. Since 1994 to 2010 we have 576 fractures of humerus treated with retrograde Halder Humeral nail. Of these 45 were distal third extra articular fractures of humerus. Average age of patients at the time of surgery was 30.4 years (Range 15–82 years, Median 33 years). Of 45 patients 26 were females and 19 males.3 out of 45 had non union at the time of presentation. The nail was locked distally with one or two screws and proximally with a screw and tripwire. The entry point of the nail was roof of olecranon fossa (contrary to standard retrograde nails where it is an inch above olecranon fossa) This design of nail allows it be used for even very distal fractures. All patients were followed till clinical and radiological signs of union. 1 patient was lost to follow up. Results. Average time to fracture healing was 13.9 weeks (Range 9–36 weeks). There were 2 cases of non union, one healed at 9 months with 2. nd. surgery. The other non union was asymptomatic and did not agree for further surgery. There was one reported case of infection.7 patients had nail removal electively on request. All the patients achieved full range of elbow and shoulder movement. No reported cases of iatrogenic radial nerve palsy. Conclusion. Our results of distal third fractures of humerus treated with retrograde Halder Humeral Nail are excellent. It avoids big exposure as needed in plating and complication of iatrogenic radial nerve palsy

The widely used Fracture Risk Assessment Tool (FRAX) estimates a 10-year probability of major osteoporotic fracture (MOF) using age, sex, body mass index, and seven clinical risk factors, including prior history of fracture. Prior fracture is a binary variable in FRAX, although it is now clear that prior fractures affect future MOF risk differently depending on their recency and site. Risk of MOF is highest in the first two years following a fracture and then progressively decreases with time – this is defined as imminent risk. Therefore, the FRAX tool may underestimate true fracture risk and result in missed opportunities for earlier osteoporosis management in individuals with recent MOF. To address this, multipliers based on age, sex, and fracture type may be applied to baseline FRAX scores for patients with recent fractures, producing a more accurate prediction of both short- and long-term fracture risk. Adjusted FRAX estimates may enable earlier pharmacologic treatment and other risk reduction strategies. This study aimed to report the effect of multipliers on conventional FRAX scores in a clinical cohort of patients with recent non-hip fragility fractures. After obtaining Research Ethics Board approval, FRAX scores were calculated both before and after multiplier adjustment, for patients included in our outpatient Fracture Liaison Service who had experienced a non-hip fragility fracture between June 2020 and November 2021. Patients age 50 years or older, with recent (within 3 months) forearm (radius and/or ulna) or humerus fractures were included. Exclusion criteria consisted of patients under the age of 50 years or those with a hip fracture. Age- and sex-based FRAX multipliers for recent forearm and humerus fractures described by McCloskey et al. (2021) were used to adjust the conventional FRAX score. Low, intermediate and high-risk of MOF was defined as less than 10%, 10-20%, and greater than 20%, respectively. Data are reported as mean and standard deviation of the mean for continuous variables and as proportions for categorical variables. A total of 91 patients with an average age of 64 years (range = 50-97) were included. The majority of patients were female (91.0%), with 73.6% sustaining forearm fractures and 26.4% sustaining humerus fractures. In the forearm group, the average MOF risk pre- and post-multiplier was 16.0 and 18.8, respectively. Sixteen percent of patients (n = 11) in the forearm group moved from intermediate to high 10-year fracture risk after multiplier adjustment. Average FRAX scores before and after adjustment in the humerus group were 15.7 and 22.7, respectively, with 25% (n = 6) of patients moving from an intermediate risk to a high-risk score. This study demonstrates the clinically significant impact of multipliers on conventional FRAX scores in patients with recent non-hip fractures. Twenty-five percent of patients with humerus fractures and 16% of patients with forearm fractures moved from intermediate to high-risk of MOF after application of the multiplier. Consequently, patients who were previously ineligible for pharmacologic management, now met criteria. Multiplier-adjusted FRAX scores after a recent fracture may more accurately identify patients with imminent fracture risk, facilitating earlier risk reduction interventions

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

Objectives. Distal humerus fractures in elderly population are often comminuted and presents multiple challenges. When managed with fixation the results are often complicated with stiffness, pain, and reduced function while total elbow replacement is fraught with lifelong restrictions on load bearing which can significantly affect elderly patients who rely assistive devices for ambulation. Elbow hemiarthroplasty however, presents a viable alternative in these cases. This series evaluates the results of the distal humerus hemiarthroplasty in a single centre. Designs and methods. Data was collected retrospectively. Comprehensive case reviews were done to collect demographic, intra-operative and post-operative data. Fractures were classified as per AO classification. The primary outcome was functional outcome and range of motion (ROM). The secondary outcomes were complications and patient satisfaction. Results. 22 cases were included in this study from 2016 – 2023 majority being females (n=18). Mean age was 74years (SD −11.2). Majority fractures were AO type C3 (n=15) with two A2 type fractures managed for non-union. Pre-existing bone on bone arthritis was present in 3 cases and CT scan was done for 12 patients to assess fracture configuration. Excluding those treated for non- union the median time between fracture and surgery was 8.5 days. Follow-up of more than 6 months was available for 16 patients with median follow-up of 18 months. ROM was available for 17 patients with 13 (50%) patients having functional ROM. No patients had full extension and there was a mean lag of 20. 0. Mean flexion was 118.2. 0. Nearly 2/3. rd. patients (73%- n=16) were satisfied with the surgery with no problems in activity of daily living. Complications seen were ulnar neuropathy (n=3), heterotopic ossification(n=2) and periprosthetic fracture (n=1). Conclusion. This single centre study suggests good outcomes following distal humerus hemiarthroplasty. It is a reasonable alternative to fixation and total elbow arthroplasty in complex fractures

Olecranon Osteotomy is a common approach used in the management of intraarticular distal humerus fractures. Significant complication rates have been associated with this procedure, including non-union rates of 0–13% and implant removal rates between 12–86%. This study is a multicentre retrospective study involving the largest cohort of olecranon osteotomies in the literature, examining implant fixation types, removal rates and associated complications. Patients were identified between 2007 and 2017 (minimum one year follow-up) via Canadian Classification of Health Interventions (CCI) coding and ICD9/10 codes by our health region's data information service. CCI intervention codes were used to identify patients who underwent surgery for their fracture with an olecranon osteotomy. Reasons for implant removal were identified from a chart review. Our primary outcome was implant removal rates. Categorical data was assessed using Chi square test and Fischer's Exact test. Ninety-nine patients were identified to have undergone an olecranon osteotomy for treatment of a distal humerus fracture. Twenty patients had their osteotomy fixed with a plate and screws and 67 patients were fixed with a tension band wire. Eleven patients underwent “screw fixation”, consisting of a single screw with or without the addition of a wire. One patient had placement of a cable-pin system. Of patients who underwent olecranon osteotomy fixation, 34.3% required implant removal. Removal rates were: 28/67 for TBW (41.8%), 6/20 plates (30%), 0/1 cable-pin and 0/11 for osteotomies fixed with screw fixation. Screw fixation was removed less frequently than TBW p<.006. TBW were more commonly removed than all other fixation types p<.043. Screws were less commonly removed than all other fixation types p<.015. TBW were more likely to be removed for implant irritation than plates, p<.007, and all other implants p<.007. The average time to removal was 361 days (80–1503 days). A second surgeon was the surgeon responsible for the removal in 10/34 cases (29%). TBWs requiring removal were further off the olecranon tip than those not removed p=.006. TBWs were associated with an OR of 3.29 (CI 1.10–9.84) for implant removal if implanted further than 1mm off bone. Nonunion of the osteotomy occurred in three out of 99 patients (3%). K-wires through the anterior ulnar cortex did not result in decreased need for TBW removal. There was no relation between plate prominence and the need for implant removal. There was no association between age and implant removal. The implant removal rate was 34% overall. Single screw fixation was the best option for osteotomy fixation, as 0/11 required hardware removal, which was statistically less frequent than TBW at 28/67. Screw fixation was removed less frequently than TBW and screw fixation was less commonly removed than all other fixation types. Only 6/20 (30%) plates required removal, which is lower than previously published rates. Overall, TBW were more commonly removed than all other fixation types and this was also the case if hardware irritation was used as the indication for removal. Nonunion rates of olecranon osteotomy were 3%

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

We aimed to assess the functional outcomes of elderly patients with isolated comminuted distal humerus fractures that were managed non-operatively. Retrospective analysis of patients over 65 years presenting to our unit between 2005–2015 was undertaken. 67 patients were identified, 7 had immediate TEA, 41 died and 5 were lost to follow-up leaving 14 available for review. Mean Follow-up was 55 months(range 17–131) Patient functional outcomes were measured using VAS scores for pain at rest and during activity, and the Oxford Elbow Score (OES). Need for conversion to TEA and complications were recorded. The mean age at injury was 76 years(range 65–90) of which 79%(11/14) were females. The mean score on the OES was 46(range 29 – 48). The mean VAS score at rest was 0.4(range 0–6) and the mean VAS score during activity was 1.3(range 0–9). 93%(13/14) of patients reported no pain (0 out of 10 on the numeric scale for pain) in their injured elbow at rest and 79%(11/14) reported no pain during activity. No patients converted to TEA and there were no complications. Non-operative management of comminuted distal humerus fractures should be considered for elderly patients, avoiding surgical risks whilst giving satisfactory functional outcomes in this low demand group

Introduction. Pathologic humerus fractures secondary to metastases are associated with significant pain, morbidity, loss of function, and diminished quality of life. Here we report our experience with stabilisation using intramedullary polymethylmethacrylate (PMMA) cement and non-locking plates. Methods. A retrospective review was undertaken of patients treated at a tertiary musculoskeletal oncology centre from 1989 to 2009. Patients who underwent surgery for an impending or completed pathologic humerus fracture with a diagnosis of metastatic disease or myeloma were included. All patients underwent intralesional curettage of the tumour followed by fixation with intramedullary PMMA and plating. Results. Clinical records were available for 63 patients who underwent the above procedure. There were 43 males and 20 females. In 48 (76%) there was a pathologic fracture at presentation, while in 15 (24%) it was impending. The most common histology was myeloma (22%) followed by lung and renal carcinoma which were 21% each. Complications occurred in 14 (22%) cases, and 7 (11%) required re-operation. The most common cause for re-operation was disease progression (5 of 7). At latest follow-up, 85% had no or mild pain and 80% required no or minimal assistance with activities of daily life (ADLs). Conclusion. Intralesional tumour resection and stabilisation of pathologic humerus fractures with the described technique has several attributes. It provides immediate, absolute rigidity and enables early pain relief and return of function without the need for osseous union. The patient's local disease burden is reduced, which alleviates tumour-related pain and slows disease progression. Finally, this technique is user-friendly and cost-effective as it does not require equipment or devices that are unavailable to community orthopaedic surgeons. The cemented plate technique provides a durable option for the treatment of impending and completed pathologic humerus fractures

Purpose of the study. To evaluate the outcome of the Modified French osteotomy for the correction of cubitus varus resulting from a supracondylar distal humerus fracture in children. Description of methods. A retrospective review of 90 children, aged 3 to 14, who underwent a modified French osteotomy between 1986 and 2012 for the correction of cubitus varus as a result of a supracondylar distal humerus fracture. Case notes and radiographs were reviewed. The carrying angle was measured clinically and radiologically pre-operatively, post-operatively and at latest follow up. Comparison was made with the unaffected side. The outcome was graded as good if the correction of the carrying angle was within 5 degrees of the unaffected side, satisfactory if the correction was more than 5 degrees of the unaffected side but cubitus valgus was restored and poor if there was persistence of cubitus varus post correction. Any intra-operative and post-operative complications were documented. Summary of results. The average age at the time of osteotomy was 8 years. Sixty-two percent of the patients were male. The left elbow was affected 61% of the time. The average delay from time of fracture to osteotomy was 24 months. The average post-operative follow up was 3.5 months. With regard to the correction of the cubitus varus, 83% of patients had a good outcome, 17% had a satisfactory outcome, with no poor outcomes. Post-operative complications were documented in 6 patients, 3 of which required re-operation. Conclusion. The modified French osteotomy has been shown to be a safe and effective treatment for cubitus varus following supracondylar distal humerus fractures in children. NO DISCLOSURES

Background. Peri-prosthetic humerus fractures are relatively uncommon occurrences that can be difficult to manage non-operatively. Locking plate technology has enhanced the surgical management of these fractures. We describe an osteosynthesis technique utilizing a locking plate with eccentrically placed screw holes to place “skive screws” in the proximal end of the plate to achieve fixation around the stem of the implant. Methods. A retrospective review of prospectively collected data was performed for a consecutive series of patients treated with this skive screw technique from May 2011 to September 2014. Seven patients presented with postoperative type B peri-prosthetic humerus fractures. Average follow-up was 24 months. Radiographic analysis was performed on most recent postoperative imaging. Clinical outcomes were assessed using VAS pain, ASES total score, ASES functional score, SST, SANE, range of motion and strength. Results. At an average of follow-up of 24 months, all patients demonstrated fracture healing. Functional outcomes were limited with only two patients achieving forward elevation above 90 degrees and average ASES Function score was 27.5. Pain relief was nearly uniform with an average VAS Pain score of 0.5 (Figure 1). Conclusions. Peri-prosthetic humeral shaft fractures can be successfully treated with hybrid fixation technique using a locking plate with eccentric holes that facilitate placement of proximal “skive screws”. Using this technique, a 100% union rate was observed with excellent pain relief

Surgeries for reverse total shoulder arthroplasty (RTSA) significantly increased in the last ten years. Initially developed to treat patients with cuff tear arthropathy (CTA) and pseudoparalysis, wider indications for RTSA were described, especially complex proximal humerus fractures. We previously demonstrated in patients with CTA a different sequence of muscular activation than in normal shoulder, with a decrease in deltoid activation, a significant increase of upper trapezius activation and slight utility of the latissimus dorsi. There is no biomechanical study describing the muscular activity in patients with RTSA for fractures. The aim of this work is to describe the in vivo action of RTSA in patients with complex fractures of the proximal humerus. We conducted an observational prospective cohort study comparing 9 patients with RTSA for complex humerus fracture (surgery more than 6 months, healed tuberosities and rehabilitation process achieved) and 10 controls with normal shoulder function. Assessment consisted in a synchronized analysis of range of motion (ROM) and muscular activity on electromyography (EMG) with the use of 7 bipolar cutaneous electrodes, 38 reflective markers and 8 motion-recording cameras. Electromyographic results were standardized and presented in muscular activity (RMS) adjusted with maximal isometric contractions according to the direction tested. Five basic movements were evaluated (flexion, abduction, neutral external rotation, external rotation in 90° of abduction and internal rotation in 90° of abduction). Student t-test were used for comparative descriptive analysis (p < 0,05). The overall range of motion with RTSA is very good, but lower than the control group: flexion 155.6 ± 10 vs 172.2 ± 13.9, p<0.05, external rotation at 90° 55.6 ± 25 vs 85.6 ± 8.8, p<0,05, internal rotation at 90° 37.8 ± 15.6 vs 52.2 ± 12, p<0,05. The three heads of the deltoid are more stressed during flexion and abduction in the RTSA group (p. The increased use of the 3 deltoid chiefs does not support the hypothesis proposed by Grammont when the RTSA is performed for a complex proximal humerus fracture. This can be explained by the reduced dispalcement of the rotation center of the shoulder in these patients compared to those with CTA. These patients also didn't present shoulder stiffness before the fracture. The maximal muscle activity of the trapezius in flexion and of the latissimus dorsi in flexion and abduction had not been described to date. These new findings will help develop better targeted rehabilitation programs. In addition, the significant role of the latissimus dorsi must question the risks of its transfer (L'Episcopo procedure) to compensate for external rotation deficits

Introduction:. Distal humerus fractures as well as elbow fracture dislocation are often accompanied by soft tissue damage that warrants early fixation with an external fixator. The distal humerus is a hazardous area for placement of an external fixator due to the close proximity of the radial nerve to the humerus in this area. No known safe zone has been identified on the lateral border of the humerus to avoid radial nerve damage. The aim of this study was to record the incidence of radial nerve damage by placing two 4 mm pins into the humerus and to note the relation of the nerve to the pins. Methods:. Two 4 mm pins used to fix an external fixator were drilled into the lateral border of the humerus at points 100 mm and 70 mm proximal to the lateral epicondyle of both arms of 39 cadavers. The 30 mm interval between the pins is the interval between the pins in a pinblock of a commonly-used external fixator. The arms were dissected by medical students and the incidence of radial nerve damage was recorded. Statistical analysis was done using a Fischer's exact test to identify the incidence of nerve damage relative to pin insertion. The number of damaged nerves was compared to the number of non-damaged nerves. A design based Chi Square test was carried out to test left and right arms. The proportions of interest were estimated along a 95% confidence interval. Results:. The radial nerve was hit (damaged) by 56.4% of the proximal and 20.5% of the distal pins. The radial nerve ran posterior to the proximal pin in 2.57% of arms and 0% to the distal pin. Conclusion:. Although no clear safe zone could be established, pins should be placed closer than 100 mm from the lateral epicondyle and as posterior on the humerus as possible to minimize the risk for radial nerve damage. Keywords: Radial nerve, external fixation, humerus fractures

Adequate exposure is a prerequisite for treatment of distal humeral fractures. In this study, we compared the clinico-radiological and functional outcome of TRAP approach with that of olecranon osteotomy for distal humerus fractures. 27 patients with distal humerus fractures were randomized into 2 groups: Group 1 (n=14, TRAP approach), Group 2 (n=13, Olecranon osteotomy). All patients were operated with bi-columnar fixation. All patients were mobilized from day 2. Follow-up evaluation was done at 1, 3, 6 and 12 months. All patients achieved union. The mean surgical time was higher in group 1 (120 min) as compared to group 2 (100 min). The final ROM was higher in group 1 (1160) as compared to group 2 (850). Two patients in group 2 needed posterior release. 5 patients in group 2 had hardware complications related to olecranon osteotomy and needed removal. Two patients in Group 1 had transient ulnar nerve paraesthesias. There was no difference in triceps power in both groups. Our results demonstrate that TRAP approach is extensile and safe enough in treating these complex fractures with better final ROM and fewer complications

Aims

The standard of wide tumour-like resection for chronic osteomyelitis (COM) has been challenged recently by adequate debridement. This paper reviews the evolution of surgical debridement for long bone COM, and presents the outcome of adequate debridement in a tertiary bone infection unit.

Background. Level 1 studies for fracture management of upper extremity fractures remains rare. The influence of these studies on management trends has yet to be evaluated. The purpose of this study was to examine alterations in national trends managing mid-shaft clavicle and intra-articular distal humerus fractures (DHF) surrounding recent Level 1 publications. Methods. We retrospectively reviewed a comprehensive Medicare (2005–2012) and Humana (2007–2014) patient population database within the PearlDiver supercomputer (Warsaw, IN, USA) for DHF and mid-shaft clavicle fractures, respectively. Non-operative management and open reduction internal fixation (ORIF) were reviewed for mid-shaft clavicle fractures. ORIF and total elbow arthroplasty (TEA) were reviewed for DHF. Total use and annual utilization rates were investigated using age limits defined in the original Level 1 studies. Results. A total of 4,929 clavicle patients between 15 and 59 years, and 106,535 DHF patients greater than 65 years of age were coded. There was no significant change in annual volume of mid-shaft clavicle fractures and DHF coded (p=0.078 and p=0.614, respectively). Among clavicle patients there was a significant increase in ORIF utilization following the publication of the Level 1 study (p=0.002), and a strong, positive correlation was evident (p=0.007). No significant change in annual TEA (p=0.515) utilization for DHF was seen. Conclusion. A significant increase in the utilization of ORIF for clavicular fractures was observed following the publication of supporting Level 1 evidence. This was not observed following similar evidence in managing DHF, as no increase in utilization of TEA was observed

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

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

Aim. To analyse the results of the use of Recombinant Bone Morphogenic Protein (BMP-7) for treatment of fracture nonunions at our institution. Material and methods. From 2001 to 2006, 23 patients with fracture nonunion were treated with BMP-7 for bone healing. There were 14 male and 9 females. The mean age of patients was 45 years (Range 21-76 yrs). There were 11 femoral, 9 tibial and 3 humerus fractures. There were 4 open injuries. The average number of operations before BMP-7 insertion was 2.66 (Range 0-6). The mean time between the injury and BMP insertion was 54 months (Range 5-312). 9 patients had previous autologous bone graft inserted without union. Results. All the fracture went on to unite within an average of 7 months (Range 4-16). 4 patients had BMP-7 insertion on its own. In another 3 patients it was mixed with allograft. In the rest of 16 patients BMP-7 was mixed with autologous bone graft. 2 patients needed BMP-7 insertion on 2 separate occasions. In all except 1 patient the original fixation of the fracture had to be revised. There were no complications from the use of BMP-7. Conclusion. Use of recombinant BMP-7 lead to fracture union in all our patients. We believe that the use of BMP-7 improved the chances of fracture healing in persistent nonunions and it is safe and easy to use