Aims. This study aims to describe a new method that may be used as a supplement to evaluate humeral rotational alignment during intramedullary nail (IMN) insertion using the profile of the perpendicular peak of the greater tuberosity and its relation to the transepicondylar axis. We called this angle the greater tuberosity version angle (GTVA). Methods. This study analyzed 506 cadaveric humeri of adult patients. All humeri were CT scanned using 0.625 × 0.625 × 0.625 mm cubic voxels. The images acquired were used to generate 3D surface models of the humerus. Next, 3D landmarks were automatically calculated on each 3D bone using custom-written C++ software. The anatomical landmarks analyzed were the transepicondylar axis, the humerus anatomical axis, and the peak of the perpendicular axis of the greater tuberosity. Lastly, the angle between the transepicondylar axis and the greater tuberosity axis was calculated and defined as the GTVA. Results. The value of GTVA was 20.9° (SD 4.7°) (95% CI 20.47° to 21.3°). Results of analysis of variance revealed that females had a statistically significant larger angle of 21.95° (SD 4.49°) compared to males, which were found to be 20.49° (SD 4.8°) (p = 0.001). Conclusion. This study identified a consistent relationship between palpable anatomical landmarks, enhancing IMN accuracy by utilizing 3D CT scans and replicating a 20.9° angle from the greater tuberosity to the transepicondylar axis. Using this angle as a secondary reference may help mitigate the complications associated with malrotation of the humerus following IMN. However, future trials are needed for clinical validation. Cite this article: Bone Jt Open 2024;5(10):929–936

Aims. The objective of this study was to compare simulated range of motion (ROM) for reverse total shoulder arthroplasty (rTSA) with and without adjustment for scapulothoracic orientation in a global reference system. We hypothesized that values for simulated ROM in preoperative planning software with and without adjustment for scapulothoracic orientation would be significantly different. Methods. A statistical shape model of the entire humerus and scapula was fitted into ten shoulder CT scans randomly selected from 162 patients who underwent rTSA. Six shoulder surgeons independently planned a rTSA in each model using prototype development software with the ability to adjust for scapulothoracic orientation, the starting position of the humerus, as well as kinematic planes in a global reference system simulating previously described posture types A, B, and C. ROM with and without posture adjustment was calculated and compared in all movement planes. Results. All movement planes showed significant differences when comparing protocols with and without adjustment for posture. The largest mean difference was seen in external rotation, being 62° (SD 16°) without adjustment compared to 25° (SD 9°) with posture adjustment (p < 0.001), with the highest mean difference being 49° (SD 15°) in type C. Mean extension was 57° (SD 18°) without adjustment versus 24° (SD 11°) with adjustment (p < 0.001) and the highest mean difference of 47° (SD 18°) in type C. Mean abducted internal rotation was 69° (SD 11°) without adjustment versus 31° (SD 6°) with posture adjustment (p < 0.001), showing the highest mean difference of 51° (SD 11°) in type C. Conclusion. The present study demonstrates that accounting for scapulothoracic orientation has a significant impact on simulated ROM for rTSA in all motion planes, specifically rendering vastly lower values for external rotation, extension, and high internal rotation. The substantial differences observed in this study warrant a critical re-evaluation of all previously published studies that examined component choice and placement for optimized ROM in rTSA using conventional preoperative planning software. Cite this article: Bone Joint J 2024;106-B(11):1284–1292

Aims. Fracture-related infection (FRI) is commonly classified based on the time of onset of symptoms. Early infections (< two weeks) are treated with debridement, antibiotics, and implant retention (DAIR). For late infections (> ten weeks), guidelines recommend implant removal due to tolerant biofilms. For delayed infections (two to ten weeks), recommendations are unclear. In this study we compared infection clearance and bone healing in early and delayed FRI treated with DAIR in a rabbit model. Methods. Staphylococcus aureus was inoculated into a humeral osteotomy in 17 rabbits after plate osteosynthesis. Infection developed for one week (early group, n = 6) or four weeks (delayed group, n = 6) before DAIR (systemic antibiotics: two weeks, nafcillin + rifampin; four weeks, levofloxacin + rifampin). A control group (n = 5) received revision surgery after four weeks without antibiotics. Bacteriology of humerus, soft-tissue, and implants was performed seven weeks after revision surgery. Bone healing was assessed using a modified radiological union scale in tibial fractures (mRUST). Results. Greater bacterial burden in the early group compared to the delayed and control groups at revision surgery indicates a retraction of the infection from one to four weeks. Infection was cleared in all animals in the early and delayed groups at euthanasia, but not in the control group. Osteotomies healed in the early group, but bone healing was significantly compromised in the delayed and control groups. Conclusion. The duration of the infection from one to four weeks does not impact the success of infection clearance in this model. Bone healing, however, is impaired as the duration of the infection increases. Cite this article: Bone Joint Res 2024;13(3):127–135

Aims. The aim of this study was to investigate the outcome of periprosthetic fractures of the humerus and to assess the uniformity of the classifications used for these fractures (including those around elbow and/or shoulder arthroplasties) by performing a systematic review of the literature. Methods. A systematic search was conducted using the National Institute for Health and Care Excellence Healthcare Databases Advance Search. For inclusion, studies had to report clinical outcomes following the management of periprosthetic fractures of the humerus. The protocol was registered on the PROSPERO database. Results. Overall, 40 studies were included, involving a total of 210 patients. The fractures were reported using very heterogeneous classification systems, as were the functional outcome scores. A total of 60 patients had nonoperative treatment with a 50% rate of nonunion. Fixation was undertaken in 99 patients; successful union was obtained in 93 (93%). Revision of either the humeral stem or the whole arthroplasty was reported in 79 patients with a high rate of union (n = 66; 84%), and a mean rate of complications of 29% (0% to 41%). Conclusion. This study highlighted a lack of uniformity in classifying these fractures and reporting the outcome of their treatment. The results may help to inform decision-making with patients, particularly about the rate of complications of nonoperative treatment. There is a need to improve the reporting of the pattern of these fractures using a uniform classification system, and the harmonization of the collection of data relating to the outcome of treatment. Based on this review, we propose a minimum dataset to be used in future studies. Cite this article: Bone Joint J 2022;104-B(4):416–423

Aims. The aim of this study was to investigate the feasibility of application of a 3D-printed megaprosthesis with hemiarthroplasty design for defects of the distal humerus or proximal ulna following tumour resection. Methods. From June 2018 to January 2020, 13 patients with aggressive or malignant tumours involving the distal humerus (n = 8) or proximal ulna (n = 5) were treated by en bloc resection and reconstruction with a 3D-printed megaprosthesis with hemiarthroplasty, designed in our centre. In this paper, we summarize the baseline and operative data, oncological outcome, complication profiles, and functional status of these patients. Results. Preparation of the prosthesis was a mean of 8.0 days (SD 1.5), during which time no patients experienced tumour progression. The mean operating time and intraoperative blood loss were 158.1 minutes (SD 67.6) and 176.9 ml (SD 187.8), respectively. All of the prostheses were implanted successfully. During a mean follow-up of 25.7 months (SD 7.8), no patients died, but four had complications (two superficial wound problems, one temporary palsy of radial nerve, and one dislocation). No aseptic loosening, structural failure, infection, heterotopic ossification, or degenerative arthritis was seen in this study. The mean flexion of the elbow was 119.6° (SD 15.9°) and the mean extension lag was 11.9° (SD 13.8°). The mean Musculoskeletal Tumor Society 93 score and Mayo Elbow Performance Score were 28.4 (SD 0.9) and 97.7 (SD 4.4), respectively. Conclusion. The custom-made, 3D-printed megaprosthesis with hemiarthroplasty is a feasible option for functional reconstruction after resection of a tumour in the distal humerus or proximal ulna. Cite this article: Bone Joint J 2022;104-B(6):747–757

Aims. The purpose of this study was to report the long-term results of extendable endoprostheses of the humerus in children after the resection of a bone sarcoma. Methods. A total of 35 consecutive patients treated with extendable endoprosthetic replacement of the humerus in children were included. There were 17 boys and 18 girls in the series with a median age at the time of initial surgery of nine years (interquartile range (IQR) 7 to 11). Results. The median follow-up time was 10.6 years (IQR 3.9 to 20.4). The overall implant survival at ten years was 75%. Complications occurred in 13 patients (37%). Subluxation at the proximal humerus occurred in 19 patients (54%) but only six (17%) were symptomatic. Subluxation was seen more commonly in children under the age of nine years (86%) than in those aged nine years or more (33%) (p = 0.002). Implant failure occurred in nine patients (26%): the most common cause was aseptic loosening (four patients, 11%). Lengthening of the implant was carried out in 23 patients (66%). At final follow up, three patients had a limb that was shortened by 5 cm or more. The mean Musculoskeletal Tumor Society (MSTS) functional score was 79% (73% to 90%). Conclusion. Extendable endoprosthetic replacement is a reliable method of reconstructing humerus after excision of a bone sarcoma. Children who are less than nine years old have a high risk of subluxation. Cite this article: Bone Joint J 2020;102-B(1):64–71

Objectives. The goal of this study is to investigate the relation between indicators of osteoporosis (i.e., bone mineral density (BMD), and Cortical Index (CI)) and the complexity of a fracture of the proximal humerus as a result of a low-energy trauma. Methods. A retrospective chart review of 168 patients (mean age 67.2 years, range 51 to 88.7) with a fracture of the proximal humerus between 2007 and 2011, whose BMD was assessed at the Fracture Liaison Service with Dual Energy X-ray Absorptiometry (DXA) measurements of the hip, femoral neck (FN) and/or lumbar spine (LS), and whose CI and complexity of fracture were assessed on plain anteroposterior radiographs of the proximal humerus. Results. No significant differences were found between simple and complex fractures of the proximal humerus in the BMD of the hip, FN or LS (all p > 0.3) or in the CI (p = 0.14). Only the body mass index was significantly higher in patients with a complex fracture compared with those with a simple fracture (26.9 vs 25.2; p = 0.05). Conclusion. There was no difference in BMD of the hip, FN, LS or CI of the proximal humerus in simple compared with complex fractures of the proximal humerus after a low-energy trauma. Factors other than the BMD and CI, for example body mass index, may play a more important role in the complexity of this fracture. Cite this article: J.W.A.M. den Teuling, B.S. Pauwels, L. Janssen, C.E. Wyers, H. M. J. Janzing, J.P.W. van den Bergh, J. W. Morrenhof. The Influence of bone mineral density and cortical index on the complexity of fractures of the proximal humerus. Bone Joint Res 2017;6:584–589. DOI: 10.1302/2046-3758.610.BJR-2017-0080

Aims. Restoring the pre-morbid anatomy of the proximal humerus is a goal of anatomical shoulder arthroplasty, but reliance is placed on the surgeon’s experience and on anatomical estimations. The purpose of this study was to present a novel method, ‘Statistical Shape Modelling’, which accurately predicts the pre-morbid proximal humeral anatomy and calculates the 3D geometric parameters needed to restore normal anatomy in patients with severe degenerative osteoarthritis or a fracture of the proximal humerus. Materials and Methods. From a database of 57 humeral CT scans 3D humeral reconstructions were manually created. The reconstructions were used to construct a statistical shape model (SSM), which was then tested on a second set of 52 scans. For each humerus in the second set, 3D reconstructions of four diaphyseal segments of varying lengths were created. These reconstructions were chosen to mimic severe osteoarthritis, a fracture of the surgical neck of the humerus and a proximal humeral fracture with diaphyseal extension. The SSM was then applied to the diaphyseal segments to see how well it predicted proximal morphology, using the actual proximal humeral morphology for comparison. Results. With the metaphysis included, mimicking osteoarthritis, the errors of prediction for retroversion, inclination, height, radius of curvature and posterior and medial offset of the head of the humerus were 2.9° (± 2.3°), 4.0° (± 3.3°), 1.0 mm (± 0.8 mm), 0.8 mm (± 0.6 mm), 0.7 mm (± 0.5 mm) and 1.0 mm (± 0.7 mm), respectively. With the metaphysis excluded, mimicking a fracture of the surgical neck, the errors of prediction for retroversion, inclination, height, radius of curvature and posterior and medial offset of the head of the humerus were 3.8° (± 2.9°), 3.9° (± 3.4°), 2.4 mm (± 1.9 mm), 1.3 mm (± 0.9 mm), 0.8 mm (± 0.5 mm) and 0.9 mm (± 0.6 mm), respectively. Conclusion. This study reports a novel, computerised method that accurately predicts the pre-morbid proximal humeral anatomy even in challenging situations. This information can be used in the surgical planning and operative reconstruction of patients with severe degenerative osteoarthritis or with a fracture of the proximal humerus. Cite this article: Bone Joint J 2017;99-B:927–33

Aims. We review our experience of Coonrad-Morrey total elbow arthroplasty (TEA) for fractures of the distal humerus in non-rheumatoid patients with a minimum of ten years follow-up. Patients and Methods. TEA through a triceps splitting approach was peformed in 37 non-rheumatoid patients for a fracture of the distal humerus between 1996 and 2004. One patient could not be traced and 17 had died before the tenth anniversary of their surgery. This left 19 patients with a minimum follow-up of ten years to form the study group. Of these, 13 patients were alive at the time of final review. The other six had died, but after the tenth anniversary of their elbow arthroplasty. Their clinical and radiological data were included in the study. . Results. The mean follow-up of the 19 patients was 156 months (120 to 210). Two patients in the study group had undergone revision. One further patient had undergone a two-stage revision for infection but died before ten-year follow-up. Six other patients in the study group had evidence of loosening or wear of their bushings. Two were clinically symptomatic and were offered revision surgery. Male patients showed higher incidence of loosening and wear. Survivorship, with revision and definite loosening as end-points, was 89.5% at ten years in those patients followed for a minimum of ten years and 86% in the whole group of 36 patients. Conclusion. This study shows that only 53% of non-rheumatoid patients who undergo TEA for a fracture of the distal humerus survive to the tenth anniversary of their index procedure. For those that survive, TEA provides acceptable outcomes in terms of function and implant survival. Take home message: The surgeons undertaking these procedures should be aware of the long-term revision rates and also the gender difference in the rates of loosening. Cite this article: Bone Joint J 2016;98-B:381–6

Aims. The aim of this study was to analyze the results of reverse shoulder arthroplasty (RSA) in patients with type 1 sequelae of a fracture of the proximal humerus in association with rotator cuff deficiency or severe stiffness of the shoulder. Patients and Methods. A total of 38 patients were included: 28 women and ten men. Their mean age at the time of arthroplasty was 73 years (54 to 91). Before the RSA, 18 patients had been treated with open reduction and internal fixation following a fracture. A total of 22 patients had a rotator cuff tear and 11 had severe stiffness of the shoulder with < 0° of external rotation. The mean follow-up was 4.3 years (1.5 to 10). The Constant score and the range of movement of the shoulder were recorded preoperatively and at final follow-up. Preoperatively, radiographs in two planes were performed, as well as CT or arthro-CT scans; radiographs were also performed at final follow-up. Results. The mean Constant score improved from 25 points (5 to 47) preoperatively to 57 points (15 to 81) postoperatively. The mean forward elevation of the shoulder increased from 73° (10° to 130°) preoperatively to 117° (15° to 170°) postoperatively. Previous surgery did not influence the outcome. Patients with rotator cuff tears had lower Constant scores than patients without (p = 0.037). Those with preoperative stiffness of the shoulder had lower postoperative external rotation compared with patients without stiffness (p = 0.046). There was no radiographic evidence of loosening. Three complications occurred, leading to revision surgery in two patients. In all, 17 patients rated their result as very good (45%), another 17 as good (45%), two as satisfactory (5%), and two as unsatisfactory (5%). Discussion. RSA is an effective form of treatment for patients with type 1 sequelae of a fracture of the proximal humerus associated with rotator cuff deficiency or stiffness of the shoulder, with high rates of satisfaction. Rotator cuff tears and stiffness of the shoulder had an adverse effect on the clinical outcome. Cite this article: Bone Joint J 2018;100-B:318–23

Aims. Resection of the proximal humerus for the primary malignant bone tumour sometimes requires en bloc resection of the deltoid. However, there is no information in the literature which helps a surgeon decide whether to preserve the deltoid or not. The aim of this study was to determine whether retaining the deltoid at the time of resection would increase the rate of local recurrence. We also sought to identify the variables that persuade expert surgeons to choose a deltoid sparing rather than deltoid resecting procedure. Patients and Methods. We reviewed 45 patients who had undergone resection of a primary malignant tumour of the proximal humerus. There were 29 in the deltoid sparing group and 16 in the deltoid resecting group. Imaging studies were reviewed to assess tumour extension and soft-tissue involvement. The presence of a fat rim separating the tumour from the deltoid on MRI was particularly noted. The cumulative probability of local recurrence was calculated in a competing risk scenario. Results. There was no significant difference (adjusted p = 0.89) in the cumulative probability of local recurrence between the deltoid sparing (7%, 95% confidence interval (CI) 1 to 20) and the deltoid resecting group (26%, 95% CI 8 to 50). Patients were more likely to be selected for a deltoid sparing procedure if they presented with a small tumour (p = 0.0064) with less bone involvement (p = 0.032) and a continuous fat rim on MRI (p = 0.002) and if the axillary nerve could be identified (p = 0.037). Conclusion. A deltoid sparing procedure can provide good local control after resection of the proximal humerus for a primary malignant bone tumour. A smaller tumour, the presence of a continuous fat rim and the identification of the axillary nerve on pre-operative MRI will persuade surgeons to opt for a deltoid resecting procedure. Cite this article: Bone Joint J 2017;99-B:1244–9

The humerus is a common site for skeletal metastases in the adult. Surgical stabilisation of such lesions is often necessary to relieve pain and restore function. These procedures are essentially palliative and should therefore provide effective relief from pain for the remainder of the patient’s life without the need for further surgical intervention. We report a retrospective analysis of 35 patients (37 nails) with symptomatic metastases in the shaft of the humerus which were treated by locked, antegrade nailing. There were 27 true fractures (73.0%) and ten painful deposits (27.0%). Relief from pain was excellent in four (11.4%), good in 29 (82.9%) and fair in two (5.7%) on discharge. Function was improved in all but one patient. One case of palsy of the radial nerve was noted. The mean postoperative survival was 7.1 months (0.2 to 45.5) which emphasises the poor prognosis in this group of patients. There were no failures of fixation and no case in which further surgery was required. Antegrade intramedullary nailing is an effective means of stabilising the humerus for the palliative treatment of metastases. It relieves pain and restores function to the upper limb with low attendant morbidity

Patients with pain and loss of shoulder function due to nonunion of a fracture of the proximal third of the humerus may benefit from reverse total shoulder replacement. This paper reports a prospective, multicentre study, involving three hospitals and three surgeons, of 35 patients (28 women, seven men) with a mean age of 69 years (46 to 83) who underwent a reverse total shoulder replacement for the treatment of nonunion of a fracture of the proximal humerus. Using Checchia’s classification, nine nonunions were type I, eight as type II, 12 as type III and six as type IV. The mean follow-up was 51 months (24 to 99). Post-operatively, the patients had a significant decrease in pain (p < 0.001), and a significant improvement in flexion, abduction, external rotation and Constant score (p < 0.001), but not in internal rotation. A total of nine complications were recorded in seven patients: six dislocations, one glenoid loosening in a patient who had previously suffered dislocation, one transitory paresis of the axillary nerve and one infection. Reverse total shoulder replacement may lead to a significant reduction in pain, improvement in function and a high degree of satisfaction. However, the rate of complications, particularly dislocation, was high. Cite this article: Bone Joint J 2014;96-B:1239–43

Fractures and nonunions of the proximal humerus are increasingly treated by open reduction and internal fixation. The extended deltopectoral approach remains the most widely used for this purpose. However, it provides only limited exposure of the lateral and posterior aspects of the proximal humerus. We have previously described the alternative extended deltoid-splitting approach. In this paper we outline variations and extensions of this technique that we have developed in the management of further patients with these fractures

Bone loss secondary to primary or metastatic lesions of the proximal humerus remains a challenging surgical problem. Options include preservation of the joint with stabilisation using internal fixation or resection of the tumour with prosthetic replacement. Resection of the proximal humerus often includes the greater tuberosity and adjacent diaphysis, which may result in poor function secondary to loss of the rotator cuff and/or deltoid function. Preservation of the joint with internal fixation may reduce the time in hospital and peri-operative morbidity compared with joint replacement, and result in a better functional outcome. We included 32 patients with pathological fractures of the proximal humerus in this study. Functional and radiological assessments were performed. At a mean follow-up of 17.6 months (8 to 61) there was no radiological evidence of failure of fixation. The mean revised musculoskeletal Tumour Society functional score was 94.6% (86% to 99%). There was recurrent tumour requiring further surgery in four patients (12.5%). Of the 22 patients who were employed prior to presentation all returned to work without restrictions. The use of a locking plate combined with augmentation with cement extends the indications for salvage of the proximal humerus with good function in patients with pathological and impending pathological fractures

The management of radial nerve palsy associated with fractures of the shaft of the humerus has been disputed for several decades. This study has systematically reviewed the published evidence and developed an algorithm to guide management. We searched web-based databases for studies published in the past 40 years and identified further pages through manual searches of the bibliography in papers identified electronically. Of 391 papers identified initially, encompassing a total of 1045 patients with radial nerve palsy, 35 papers met all our criteria for eligibility. Meticulous extraction of the data was carried out according to a preset protocol. The overall prevalence of radial nerve palsy after fracture of the shaft of the humerus in 21 papers was 11.8% (532 palsies in 4517 fractures). Fractures of the middle and middle-distal parts of the shaft had a significantly higher association with radial nerve palsy than those in other parts. Transverse and spiral fractures were more likely to be associated with radial nerve palsy than oblique and comminuted patterns of fracture (p < 0.001). The overall rate of recovery was 88.1% (921 of 1045), with spontaneous recovery reaching 70.7% (411 of 581) in patients treated conservatively. There was no significant difference in the final results when comparing groups which were initially managed expectantly with those explored early, suggesting that the initial expectant treatment did not affect the extent of nerve recovery adversely and would avoid many unnecessary operations. A treatment algorithm for the management of radial nerve palsy associated with fracture of the shaft of the humerus is recommended by the authors

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

Fractures of the proximal humerus can lead to malalignment of the humeral head, necrosis and post-traumatic osteoarthritis. In such cases surface replacement might be a promising option. A total of 28 shoulders with glenohumeral arthritis subsequent to a fracture underwent surface replacement arthroplasty of the humeral head in patients with a mean age of 60 years (35 to 83). On the basis of the inclination of the impacted head, post-traumatic arthritis was divided into three types: type 1, an impacted fracture of the head in an anatomical position (seven cases); type 2, a valgus impacted fracture (13 cases); type 3, a varus impacted fracture (eight cases). The outcome was measured by means of the Constant score. According to the Boileau classification of the sequelae of fractures of the proximal humerus, all 28 patients had a final result of intra-capsular category 1. The mean Constant score for the 28 shoulders increased from 23.2 points (2 to 45) pre-operatively to 55.1 points (20 to 89) at a mean of 31 months (24 to 66) post-operatively. Valgus impacted fractures had significantly better results (p < 0.039). Surface replacement arthroplasty can provide good results for patients with post-traumatic osteoarthritis of the shoulder. Their use avoids post-operative complications of the humeral shaft, such as peri-prosthetic fractures. Further surgery can be undertaken more easily as the bone stock is preserved

We reviewed the clinical and radiological results of six patients who had sustained traumatic separation of the distal epiphysis of the humerus at birth. The correct diagnosis was made from plain radiographs and often supplemented with ultrasonography, MRI and arthrography. An orthopaedic surgeon saw two patients within two days of birth, and the other four were seen at between nine and 30 days. The two neonates underwent unsuccessful attempts at closed reduction. In the remaining patients, seen after the age of eight days, no attempt at reduction was made. All six displaced fractures were immobilised in a cast with the elbow at 90° of flexion and the forearm pronated. When seen at a mean of 58 months (16 to 120) after injury, the clinical and radiological results were excellent in five patients, with complete realignment of the injury. In one patient the forearm lay in slightly reduced valgus with the elbow in full extension. Traumatic separation of the distal epiphysis of the humerus may be missed on the maternity wards and not diagnosed until after discharge from hospital. However, even when no attempt is made to reduce the displaced epiphysis, a good clinical result can be expected

Aims. A pragmatic multicentre randomised controlled trial (PROFHER) was conducted in United Kingdom National Health Service (NHS) hospitals to evaluate the clinical effectiveness and cost effectiveness of surgery compared with non-surgical treatment for displaced fractures of the proximal humerus involving the surgical neck in adults. . Methods. A cost utility analysis from the NHS perspective was performed. Differences between surgical and non-surgical treatment groups in costs and quality adjusted life years (QALYs) at two years were used to derive an estimate of the cost effectiveness of surgery using regression methods. . Results. Patients randomised to receive surgical intervention accumulated mean greater costs and marginally lower QALYs than patients randomised to non-surgery. The surgical intervention cost a mean of £1758 more per patient (95% confidence intervals (CI) £1126 to £2389). Total QALYs for the surgical group were smaller than those for non-surgery -0.0101 (95% CI -0.13 to 0.11). The probability of surgery being cost effective was less than 10% given the current NICE willingness to pay at a threshold of £20 000 for an additional QALY. The results were robust to sensitivity analyses. Discussion. The results suggest that current surgical treatment is not cost effective for the majority of displaced fractures of the proximal humerus involving the surgical neck in the United Kingdom’s NHS. Take home message: The results of this trial do not support the trend of increased surgical treatment for patients with displaced fractures of the proximal humerus involving the surgical neck within the United Kingdom NHS. Cite this article: Bone Joint J 2016;98-B:152–9

Failed internal fixation of a fracture of the proximal humerus produces many challenges with limited surgical options. The aim of this study was to evaluate the clinical outcomes after the use of a reverse shoulder arthroplasty under these circumstances. Between 2007 and 2012, 19 patients (15 women and four men, mean age 66 years; 52 to 82) with failed internal fixation after a proximal humeral fracture, underwent implant removal and reverse shoulder arthroplasty (RSA). The mean follow-up was 36 months (25 to 60). The mean American Shoulder and Elbow Score improved from 27.8 to 50.1 (p = 0.019). The mean Simple Shoulder Test score improved from 0.7 to 3.2 (p = 0.020), and the mean visual analogue scale for pain improved from 6.8 to 4.3 (p = 0.012). Mean forward flexion improved from 58.7° to 101.1° (p < 0.001), mean abduction from 58.7° to 89.1° (p = 0.012), mean external rotation from 10.7° to 23.1° (p = 0.043) and mean internal rotation from buttocks to L4 (p = 0.034). A major complication was recorded in five patients (26%) (one intra-operative fracture, loosening of the humeral component in two and two peri-prosthetic fractures). A total of 15 patients (79%) rated their outcome as excellent or good, one (5%) as satisfactory, and three (16%) as unsatisfactory. . An improvement in outcomes and pain can be expected when performing a RSA as a salvage procedure after failed internal fixation of a fracture of the proximal humerus. Patients should be cautioned about the possibility for major complications following this technically demanding procedure. Cite this article: Bone Joint J 2015;97-B:967–72

Objectives. The objective of this study was to perform a meta-analysis of all randomised controlled trials (RCTs) comparing surgical and non-surgical management of fractures of the proximal humerus, and to determine whether further analyses based on complexity of fracture, or the type of surgical intervention, produced disparate findings on patient outcomes. Methods. A systematic review of the literature was performed identifying all RCTs that compared surgical and non-surgical management of fractures of the proximal humerus. Meta-analysis of clinical outcomes was performed where possible. Subgroup analysis based on the type of fracture, and a sensitivity analysis based on the type of surgical intervention, were also performed. Results. Seven studies including 528 patients were included. The overall meta-analysis found that there was no difference in clinical outcomes. However, subgroup and sensitivity analyses found improved patient outcomes for more complex fractures managed surgically. Four-part fractures that underwent surgery had improved long-term health utility scores (mean difference, MD 95% CI 0.04 to 0.28; p = 0.007). They were also less likely to result in osteoarthritis, osteonecrosis and non/malunion (OR 7.38, 95% CI 1.97 to 27.60; p = 0.003). Another significant subgroup finding was that secondary surgery was more common for patients that underwent internal fixation compared with conservative management within the studies with predominantly three-part fractures (OR 0.15, 95% CI 0.04 to 0.63; p = 0.009). Conclusion. This meta-analysis has demonstrated that differences in the type of fracture and surgical treatment result in outcomes that are distinct from those generated from analysis of all types of fracture and surgical treatments grouped together. This has important implications for clinical decision making and should highlight the need for future trials to adopt more specific inclusion criteria. Cite this article: S. Sabharwal, N. K. Patel, D. Griffiths, T. Athanasiou, C. M. Gupte, P. Reilly. Trials based on specific fracture configuration and surgical procedures likely to be more relevant for decision making in the management of fractures of the proximal humerus: Findings of a meta-analysisBone Joint Res 2016;5:470–480. DOI: 10.1302/2046-3758.510.2000638

We describe a method of pinning extension supracondylar fractures of the humerus in children. Following closed reduction, a posterior intrafocal wire is inserted and a second lateral wire added when needed for rotational stability. Between May 2002 and November 2005 we performed this technique in 69 consecutive patients. A single posterior wire was used in 29 cases, and two wires in 40. The mean follow-up was two years (21 to 30 months). The results were assessed according to Flynn’s criteria. In the single-wire group there were 21 excellent, five good and one poor result. Two patients were lost to follow-up. In the two-wire group there were 32 excellent, two good and three poor results. Three were lost to follow-up. The poor results were due to a failure to achieve adequate reduction, fixation or both. We conclude that the intact posterior periosteal hinge can be used successfully in the clinical situation, giving results that compare well with other techniques of pinning. The posterior route offers an attractive alternative method for fixation of supracondylar fractures of the humerus in children

We have studied the three-dimensional geometry of the proximal humerus on human cadaver specimens using a digitised measuring device linked to a computer. Our findings demonstrated the variable shape of the proximal humerus as well as its variable dimensions. The articular surface, which is part of a sphere varies individually in its orientation as regards inclination and retroversion, and it has variable medial and posterior offsets. These variations cannot be accommodated by the designs of most contemporary humeral components. Although good clinical results can be achieved with current modular and non-modular components their relatively fixed geometry prevents truly anatomical restoration in many cases. To try to restore the original three-dimensional geometry of the proximal humerus, we have developed a new type of humeral component which is modular and adaptable to the individual anatomy. Such adaptability allows correct positioning of the prosthetic head in relation to an individual anatomical neck, after removal of the marginal osteophytes. The design of this third-generation prosthesis respects the four geometrical variations which have been demonstrated in the present study. These are inclination, retroversion, medial offset and posterior offset

Aims. We aimed to identify the pattern of nerve injury associated with paediatric supracondylar fractures of the humerus. Patients and Methods. Over a 17 year period, between 1996 and 2012, 166 children were referred to our specialist peripheral nerve injury unit. From examination of the medical records and radiographs were recorded the nature of the fracture, associated vascular and neurological injury, treatment provided and clinical course. Results. Of the 166 patients (111 male, 55 female; mean age at time of injury was seven years (standard deviation 2.2)), 26 (15.7%) had neurological dysfunction in two or more nerves. The injury pattern in the 196 affected nerves showed that the most commonly affected nerve was the ulnar nerve (43.4%), followed by the median (36.7%) and radial (19.9%) nerves. A non-degenerative injury was seen in 27.5%, whilst 67.9% were degenerative in nature. Surgical exploration of the nerves was undertaken in 94 (56.6%) children. The mean follow-up time was 12.8 months and 156 (94%) patients had an excellent or good clinical outcome according to the grading of Birch, Bonney and Parry. Conclusion. Following paediatric supracondylar fractures we recommend prompt referral to a specialist unit in the presence of complete nerve palsy, a positive Tinel’s sign, neuropathic pain or vascular compromise, for consideration of nerve exploration. . Take home message: When managed appropriately, nerve recovery and clinical outcomes for this paediatric population are extremely favourable. Cite this article: Bone Joint J 2016;98-B:851–6

Aims. The aims of this study were to estimate the cost of surgical treatment of fractures of the proximal humerus using a micro-costing methodology, contrast this cost with the national reimbursement tariff and establish the major determinants of cost. Methods. A detailed inpatient treatment pathway was constructed using semi-structured interviews with 32 members of hospital staff. Its content validity was established through a Delphi panel evaluation. Costs were calculated using time-driven activity-based costing (TDABC) and sensitivity analysis was performed to evaluate the determinants of cost. Results. The mean cost of the different surgical treatments was estimated to be £3282. Although this represented a profit of £1138 against the national tariff, hemiarthroplasty as a treatment choice resulted in a net loss of £952. Choice of implant and theatre staffing were the largest cost drivers. Operating theatre delays of more than one hour resulted in a loss of income. Discussion. Our findings indicate that the national tariff does not accurately represent the cost of treatment for this condition. Effective use of the operating theatre and implant discounting are likely to be more effective cost containment approaches than control of bed-day costs. Take home message: This cost analysis of fractures of the proximal humerus reinforces the limitations of the national tariff within the English National Health Service, and underlines the importance of effective use of the operating theatre, as well as appropriate implant procurement where controlling costs of treatment is concerned. Cite this article: Bone Joint J 2016;98-B:249–59

Aims. Fixation of osteoporotic proximal humerus fractures remains challenging even with state-of-the-art locking plates. Despite the demonstrated biomechanical benefit of screw tip augmentation with bone cement, the clinical findings have remained unclear, potentially as the optimal augmentation combinations are unknown. The aim of this study was to systematically evaluate the biomechanical benefits of the augmentation options in a humeral locking plate using finite element analysis (FEA). Methods. A total of 64 cement augmentation configurations were analyzed using six screws of a locking plate to virtually fix unstable three-part fractures in 24 low-density proximal humerus models under three physiological loading cases (4,608 simulations). The biomechanical benefit of augmentation was evaluated through an established FEA methodology using the average peri-screw bone strain as a validated predictor of cyclic cut-out failure. Results. The biomechanical benefit was already significant with a single cemented screw and increased with the number of augmented screws, but the configuration was highly influential. The best two-screw (mean 23%, SD 3% reduction) and the worst four-screw (mean 22%, SD 5%) combinations performed similarly. The largest benefits were achieved with augmenting screws purchasing into the calcar and having posteriorly located tips. Local bone mineral density was not directly related to the improvement. Conclusion. The number and configuration of cemented screws strongly determined how augmentation can alleviate the predicted risk of cut-out failure. Screws purchasing in the calcar and posterior humeral head regions may be prioritized. Although requiring clinical corroborations, these findings may explain the controversial results of previous clinical studies not controlling the choices of screw augmentation

We studied the epidemiology of 401 fractures of the shaft of the humerus in 397 patients aged 16 years or older. The incidence was 14.5 per 100 000 per year with a gradually increasing age-specific incidence from the fifth decade, reaching almost 60 per 100 000 per year in the ninth decade. Most were closed fractures in elderly patients which had been sustained as the result of a simple fall. The age distribution in women was characterised by a peak in the eighth decade while that in men was more even. Simple fractures were by far the most common and most were located in the middle or proximal shaft. The incidence of palsy of the radial nerve was 8% and fractures in the middle and distal shaft were most likely to be responsible. Only 2% of the fractures were open and 8% were pathological. These figures are representative of a population with a low incidence of high-energy and penetrating trauma, which probably reflects the situation in most European countries

Fractures of the proximal humerus with concomitant vascular injury are rare in children. We describe the presentation, diagnosis, and treatment of a fracture of the proximal humerus in association with an axillary artery injury in a child

Recent reports have suggested that a delay in the management of type-III supracondylar fractures of the humerus does not affect the outcome. In this retrospective study we examined whether the timing of surgery affected peri-operative complications, or the need for open reduction. There were 171 children with a closed type-III supracondylar fracture of the humerus and no vascular compromise in our study. They were divided into two groups: those treated less than eight hours from presentation to the Accident and Emergency Department (126 children), and those treated more than eight hours from presentation (45 children). There were no differences in the rate of complications between the groups, but children waiting more than eight hours for reduction were more likely to undergo an open reduction (33.3% vs 11.2%, p < 0.05) and there was a weak correlation (p = 0.062) between delay in surgery and length of operating time. Consequently, we would still recommend treating these injuries at the earliest opportunity

Secure fixation of displaced proximal fractures of the humerus is a challenging problem. A total of 32 patients with acutely displaced three- or four-part proximal fractures of the humerus were treated by open reduction and internal fixation using the proximal humeral internal locking system (PHILOS) plate. There were 23 women and nine men with a mean age of 59.9 years (18 to 87). Data were collected prospectively and the outcomes were assessed using the Constant score. The mean follow-up was for 11 months (3 to 24). In 31 patients (97%) the fracture united clinically and radiologically at a mean of 10 weeks (8 to 24). The mean Constant score at final review was 66.5 (30 to 92). There was no significant difference in outcome when comparing patients aged more than 60 years (18 patients) with those aged less than 60 years (14 patients) (t-test, p = 0.8443). There was one case each of nonunion, malunion and a broken screw in the elderly population. This plate provides an alternative method of fixation for fractures of the proximal humerus. It provides a stable fixation in young patients with good-quality bone sufficient to permit early mobilisation. Failure of the screws to maintain fixation in the elderly remains a problem

We used an inverted shoulder arthroplasty in 43 consecutive patients with a mean age of 78 years (65 to 97) who had sustained a three- or four-part fracture of the upper humerus. All except two were reviewed with a mean follow-up of 22 months (6 to 58). The clinical outcome was satisfactory with a mean active anterior elevation of 97° (35° to 160°) and a mean active external rotation in abduction of 30° (0° to 80°). The mean Constant and the mean modified Constant scores were respectively 44 (16 to 69) and 66% (25% to 97%). Complications included three patients with reflex sympathetic dystrophy, five with neurological complications, most of which resolved, and one with an anterior dislocation. Radiography showed peri-prosthetic calcification in 36 patients (90%), displacement of the tuberosities in 19 (53%) and a scapular notch in ten (25%). Compared with conventional hemiarthroplasty, satisfactory mobility was obtained despite frequent migration of the tuberosities. However, long-term results are required before reverse shoulder arthroplasty can be recommended as a routine procedure in complex fractures of the upper humerus in the elderly

We describe a lateral approach to the distal humerus based on initial location of the superficial branches of the radial nerve, the inferior lateral cutaneous nerve of the arm and the posterior cutaneous nerve of the forearm. In 18 upper limbs the superficial branches of the radial nerve were located in the subcutaneous tissue between the triceps and brachioradialis muscles and dissected proximally to their origin from the radial nerve, exposing the shaft of the humerus. The inferior lateral cutaneous nerve of the arm arose from the radial nerve at the lower part of the spiral groove, at a mean of 14.2 cm proximal to the lateral epicondyle. The posterior cutaneous nerve of the forearm arose from the inferior lateral cutaneous nerve at a mean of 6.9 cm (6.0 to 8.1) proximal to the lateral epicondyle and descended vertically along the dorsal aspect of the forearm. The size and constant site of emergence between the triceps and brachioradialis muscles constitute a readily identifiable landmark to explore the radial nerve and expose the humeral shaft

A series of 26 children was referred to our specialist unit with a ‘pink pulseless hand’ following a supracondylar fracture of the distal humerus after a mean period of three months (4 days to 12 months) except for one referred after almost three years. They were followed up for a mean of 15.5 years (4 to 26). The neurovascular injuries and resulting impairment in function and salvage procedures were recorded. The mean age at presentation was 8.6 years (2 to 12). There were eight girls and 18 boys. Only four of the 26 patients had undergone immediate surgical exploration before referral and three of these four had a satisfactory outcome. In one child the brachial artery had been explored unsuccessfully at 48 hours. As a result 23 of the 26 children presented with established ischaemic contracture of the forearm and hand. Two responded to conservative stretching. In the remaining 21 the antecubital fossa was explored. The aim of surgery was to try to improve the function of the hand and forearm, to assess nerve, vessel and muscle damage, to relieve entrapment and to minimise future disturbance of growth. Based on our results we recommend urgent exploration of the vessels and nerves in a child with a ‘pink pulseless hand’, not relieved by reduction of a supracondylar fracture of the distal humerus and presenting with persistent and increasing pain suggestive of a deepening nerve lesion and critical ischaemia

The medial periosteal hinge plays a key role in fractures of the head of the humerus, offering mechanical support during and after reduction and maintaining perfusion of the head by the vessels in the posteromedial periosteum. We have investigated the biomechanical properties of the medial periosteum in fractures of the proximal humerus using a standard model in 20 fresh-frozen cadaver specimens comparable in age, gender and bone mineral density. After creating the fracture, we displaced the humeral head medial or lateral to the shaft with controlled force until complete disruption of the posteromedial periosteum was recorded. As the quality of periosteum might be affected by age and bone quality, the results were correlated with the age and the local bone mineral density of the specimens measured with quantitative CT. Periosteal rupture started at a mean displacement of 2.96 mm (. sd. 2.92) with a mean load of 100.9 N (. sd. 47.1). The mean maximum load of 111.4 N (. sd. 42.5) was reached at a mean displacement of 4.9 mm (. sd. 4.2). The periosteum was completely ruptured at a mean displacement of 34.4 mm (. sd. 11.1). There was no significant difference in the mean distance to complete rupture for medial (mean 35.8 mm (. sd. 13.8)) or lateral (mean 33.0 mm (. sd. 8.2)) displacement (p = 0.589). The mean bone mineral density was 0.111 g/cm. 3. (. sd. 0.035). A statistically significant but low correlation between bone mineral density and the maximum load uptake (r = 0.475, p = 0.034) was observed. This study showed that the posteromedial hinge is a mechanical structure capable of providing support for percutaneous reduction and stabilisation of a fracture by ligamentotaxis. Periosteal rupture started at a mean of about 3 mm and was completed by a mean displacement of just under 35 mm. The microvascular situation of the rupturing periosteum cannot be investigated with the current model

Four-part fractures of the upper end of the humerus are uncommon injuries and there is still dispute about the best form of management. A retrospective study of 32 patients with these injuries has shown that non-operative management is frequently followed by persistent pain, stiffness and dysfunction of the shoulder. A prospective study of 49 patients with this injury presenting at the Bristol Royal Infirmary has shown that reconstruction of the upper end of the humerus with insertion of a Neer prosthesis will usually restore comfort and function. Whichever regimen is employed, disability is prolonged and dedicated physiotherapy is essential in their management

Endoprosthetic replacement of the proximal humerus has been performed in our unit on 25 occasions between 1950 and 1982. The indication for surgery was destruction of the proximal half of the humerus so extensive that the only alternatives were reconstruction or amputation. Of the patients with tumours two died from metastases, and three from unrelated causes; local recurrence necessitated amputation in two patients. Minor complications were frequent, but there were no deep infections and, after 1964, no prosthesis became loose. Active shoulder movement after operation was considerably limited, but passive movement was good and function of the elbow and hand were preserved

We studied 100 patients who had undergone endoprosthetic replacement of the proximal humerus between 1976 and 1998. The outcome was assessed with regard to the survivorship of the patients, the salvaged limbs and the prostheses. Function was determined in the 47 surviving patients, of whom 30 were assessed using the Musculo-Skeletal Tumour Society (MSTS) rating scale and 38 completed the Toronto Extremity Salvage Score (TESS) questionnaire. The median age of the patients was 34 years (10 to 80). The mean follow-up period for surviving patients was nine years (2 to 20). The mean MSTS score at follow-up was 79% and the mean TESS score was 72%. The length of bone which was resected influenced the functional outcome. Abduction of the shoulder was to 45° in most patients. The overall survival was 42% at ten years and that of the limb without amputation 93%. The survival of the prostheses using mechanical failure as the endpoint was 86.5% at 20 years. Endoprosthetic replacement of the proximal humerus is a predictable procedure providing reasonable function of the arm with a low rate of complications at long-term follow-up

A single antegrade Rush nail was used to treat 37 fractures of the distal humerus extending to the olecranon fossa and up to 6.5 cm proximal to it. In order to stabilise the fracture, the bent tip of the Rush nail was directed into the lateral epicondylar ridge. This gave immediate stability. All the fractures united without residual stiffness of the shoulder or elbow

We investigated the functional outcome in patients who underwent reverse shoulder replacement (RSR) after removal of a tumour of the proximal humerus. A total of 16 patients (ten women and six men) underwent this procedure between 1998 and 2011 in our hospital. Five patients died and one was lost to follow-up. Ten patients were available for review at a mean follow-up of 46 months (12 to 136). Eight patients had a primary and two patients a secondary bone tumour. At final follow up the mean range of active movement was: abduction 78° (30° to 150°); flexion 98° (45° to 180°); external rotation 32° (10° to 60°); internal rotation 51° (10° to 80°). The mean Musculoskeletal Tumor Society score was 77% (60% to 90%) and the mean Toronto Extremity Salvage Score was 70% (30% to 91%). Two patients had a superficial infection and one had a deep infection and underwent a two-stage revision procedure. In two patients there was loosening of the RSR; one dislocated twice. All patients had some degree of atrophy or pseudo-atrophy of the deltoid muscle. Use of a RSR in patients with a tumour of the proximal humerus gives acceptable results. Cite this article: Bone Joint J 2013;95-B:1551–5

In 45 patients we assessed the functional results and complications for three different reconstructive procedures after resection of primary tumors of the proximal humerus. An osteoarticular allograft was used in 11, a clavicula pro humero operation in 15 and a tumour prosthesis in 19. The glenoid was resected with the proximal humerus in 25 patients. The axillary nerve was resected in 42 patients. The complication rate was lowest after reconstruction with a tumour prosthesis. The clavicula pro humero operation resulted in the most revisions. Cumulative survival rates for all the reconstructive procedures were similar. At follow-up at two years the functional results for the three reconstructive procedures were the same with a mean functional rating of 79% (Musculoskeletal Tumor Society). Excision of the glenoid had no influence on the functional result. Our findings indicate that the use of a tumour prosthesis is the most reliable limb-salvage procedure for the proximal humerus. The clavicula pro humero is an appropriate procedure if a prosthesis cannot be used

We investigated the function of biceps in 18 patients (19 shoulders) with lesions of the rotator cuff. Their mean age was 59 years. Another series of 18 patients (19 shoulders) with normal rotator cuffs as seen on MRI acted as a control group. Their mean age was 55 years. A brace was used to maintain contraction of biceps during elevation. Anteroposterior radiographs were obtained with the arm elevated at 0°, 45° and 90° with and without contraction of biceps. The distance between the centre of the head of the humerus and the glenoid was compared in the two groups. We found that in the group with tears there was significantly greater proximal migration of the head of the humerus at 0° and 45° of elevation without contraction of biceps but depression of the head of the humerus at 0°, 45° and 90° when biceps was functioning. We conclude that biceps is an active depressor of the head of the humerus in shoulders with lesions of the rotator cuff

Aims

The treatment of late presenting fractures of the lateral humeral condyle in children remains controversial.

Between 1969 and 1985 26 patients with destructive lesions of the distal humerus were treated by endoprosthetic replacement; each implant was custom-made and incorporated part of the distal humerus or the entire bone as well as a hinged total elbow replacement. Recurrence occurred in three of the patients with tumours, and three prostheses were removed because of deep infection in patients with previously compound injuries of the elbow. Another three loosened without infection, but none needed revision or removal and no amputations resulted. Other complications included nerve palsies, but the only deaths were from metastases. A useful range of elbow movement, with a stable arm and good hand function, was achieved in every patient

In 1980, we developed a specially designed brace for treating supracondylar fractures of the humerus in children, along with an easy and safe technique of reduction by skeletal traction. This method, which takes into consideration only the medial tilting and anterior angulation of the distal fragment, achieves complete reduction, ignoring any lateral, posterior and minor rotational displacements of the fragment. Skeletal traction is applied through a screw inserted into the olecranon and the angulation at the fracture site is reduced regardless of the anatomical position without manipulation. We treated 193 children with displaced supracondylar fractures of the humerus using this method between 1980 and 2001. Only four children (2%) developed cubitus varus. The majority obtained an excellent range of movement at the elbow; one had a 25° limitation of flexion. This technique is an effective and easy method of treating supracondylar fractures of the humerus in children

We reviewed 20 patients who had undergone a Coonrad-Morrey total elbow arthroplasty after resection of a primary or metastatic tumour from the elbow or distal humerus between 1980 and 2002. Eighteen patients underwent reconstruction for palliative treatment with restoration of function after intralesional surgery and two after excision of a primary bone tumour. The mean follow-up was 30 months (1 to 192). Five patients (25%) were alive at the final follow-up; 14 (70%) had died of their disease and one of unrelated causes. Local control was achieved in 15 patients (75%). The mean Mayo Elbow Performance Score improved from 22 (5 to 45) to 75 points (55 to 95). Four reconstructions (20%) failed and required revision. Seven patients (35%) had early complications, the most frequent being nerve injury (25%). There were no infections or wound complications although 18 patients (90%) had radiotherapy, chemotherapy or both. The Coonrad-Morrey total elbow arthroplasty provides good relief from pain and a good functional outcome after resection of tumours of the elbow. The rates of complications involving local recurrence of tumour (25%) and nerve injury (25%) are of concern

In this study, we describe a morphological classification for greater tuberosity fractures of the proximal humerus. We divided these fractures into three types: avulsion, split and depression. We retrospectively reviewed all shoulder radiographs showing isolated greater tuberosity fractures in a Level I trauma centre between July 2007 and July 2012. We identified 199 cases where records and radiographs were reviewed and included 79 men and 120 women with a mean age of 58 years (23 to 96). The morphological classification was applied to the first 139 cases by three reviewers on two occasions using the Kappa statistic and compared with the AO and Neer classifications. The inter- and intra-observer reliability of the morphological classification was 0.73 to 0.77 and 0.69 to 0.86, respectively. This was superior to the Neer (0.31 to 0.35/0.54 to 0.63) and AO (0.30 to 0.32/0.59 to 0.65) classifications. The distribution of avulsion, split and depression type fractures was 39%, 41%, and 20%, respectively. This classification of greater tuberosity fractures is more reliable than the Neer or AO classifications. These distinct fracture morphologies are likely to have implications in terms of pathophysiology and surgical technique. Cite this article: Bone Joint J 2014;96-B:646–51

Aims. The PROximal Fracture of the Humerus Evaluation by Randomisation (PROFHER) randomised clinical trial compared the operative and non-operative treatment of adults with a displaced fracture of the proximal humerus involving the surgical neck. The aim of this study was to determine the long-term treatment effects beyond the two-year follow-up. Patients and Methods. Of the original 250 trial participants, 176 consented to extended follow-up and were sent postal questionnaires at three, four and five years after recruitment to the trial. The Oxford Shoulder Score (OSS; the primary outcome), EuroQol 5D-3L (EQ-5D-3L), and any recent shoulder operations and fracture data were collected. Statistical and economic analyses, consistent with those of the main trial were applied. Results. OSS data were available for 164, 155 and 149 participants at three, four and five years, respectively. There were no statistically or clinically significant differences between operative and non-operative treatment at each follow-up point. No participant had secondary shoulder surgery for a new complication. Analyses of EQ-5D-3L data showed no significant between-group differences in quality of life over time. Conclusion. These results confirm that the main findings of the PROFHER trial over two years are unchanged at five years. Cite this article: Bone Joint J 2017;99-B:383–92

Fractures of the distal third of the humerus may be complicated by complete lesions of the radial nerve which may be entrapped or compressed by bone fragments. Indirect reduction and internal fixation may result in a permanent nerve lesion. We describe the treatment of these lesions by insertion of a bridge plate using the minimally-invasive percutaneous technique. Six patients were operated on and showed complete functional recovery. Healing of the fractures occurred at a mean of 2.7 months (2 to 3) and complete neurological recovery by a mean of 2.3 months (1 to 5). In one patient infection occurred which resolved after removal of the implant

1. A case of massive osteolysis of the right humerus is described. Diseased bone was resected leaving only the lower part of the humerus. The resected bone was replaced by a titanium prosthesis. 2. The diagnosis, etiology, prognosis and treatment of the condition are briefly discussed

In 42 elderly patients, 33 women and nine men with a mean age of 72 years, we treated displaced fractures of the proximal humerus (34 three-part, 8 four-part) using a blade plate and a standard deltopectoral approach. Functional treatment was started immediately after surgery. We reviewed 41 patients at one year and 38 at final follow-up at 3.4 years (2.4 to 4.5). At the final review, all the fractures had healed. The clinical results were graded as excellent in 13 patients, good in 17, fair in seven, and poor in one. The median Constant score was 73 ± 18. Avascular necrosis of the humeral head occurred in two patients (5%). We conclude that rigid fixation of displaced fractures of the proximal humerus with a blade plate in the elderly patient provides sufficient primary stability to allow early functional treatment. The incidence of avascular necrosis and nonunion was low. Restoration of the anatomy and biomechanics may contribute to a good functional outcome when compared with alternative methods of fixation or conservative treatment. Regardless of the age of the patients, we advocate primary open reduction and rigid internal fixation of three- and four-part fractures of the proximal humerus

Between 1995 and 2000, 19 consecutive patients with fractures of the distal humerus were treated by primary total elbow replacement using the Coonrad-Morrey prosthesis. No patient had inflammatory or degenerative arthritis of the elbow. The mean age at the time of injury was 73 years (61 to 95). According to the AO classification, 11 patients had suffered a C3 injury, two a B3 and two an A3. One fracture was unclassified. Two patients died from unrelated causes and one was unable to be assessed because of concurrent illness. The mean time to follow-up was three years (1 to 5.5). At follow-up 11 patients (68%) reported no pain, four (25%) had mild pain with activity and one had mild pain at rest. The mean flexion arc was 24° to 125°. The mean supination was 90° (70 to 100) and pronation 70° (50 to 110). No elbow was unstable. The mean Disabilities of the Arm, Shoulder and Hand score was 23 (0.92 to 63.3) and the mean Mayo elbow performance score was 93 (80 to 100). Of the 16 patients, 15 were satisfied with the outcome. Radiological evaluation revealed only one patient with a radiolucent line at the cement-bone interface. It was between 1 and 2 mm in length, was present on the initial postoperative radiograph and was non-progressive at the time of follow-up. Primary total elbow arthroplasty is an acceptable option for the management of comminuted fractures of the distal humerus in elderly patients when the configuration of the fracture and the quality of the bone make reconstruction difficult

We examined differences in the rate of open reduction, operating time, length of hospital stay and outcome between two groups of children with displaced supracondylar fractures of the humerus who underwent surgery either within 12 hours of the injury or later. There were 77 children with type-3 supracondylar fractures. Of these, in 43 the fracture was reduced and pinned within 12 hours and in 34 more than 12 hours after injury. Both groups were similar in regard to gender, age and length of follow-up. Bivariate and logistical regression analysis showed no statistical difference between the groups. The number of peri-operative complications was low and did not affect the outcome regardless of the timing of treatment. Our study confirmed that the treatment of uncomplicated displaced supracondylar fractures of the humerus can be early or delayed. In these circumstances operations at night can be avoided

Cubitus varus is the most common complication of supracondylar fracture of the humerus in children. Although function of the elbow is not greatly impaired, the deformity is unsightly. It usually results from malunion, since growth disturbance of the humerus after this fracture is uncommon. The normal carrying angle can be restored by supracondylar osteotomy. This operation was done in 32 patients over a ten-year period, 16 of them using the technique described by French (1959). The results in 27 patients are reviewed in the light of previous reports. French's method proved safe and satisfactory

We present a method of manipulative reduction, immobilisation and fixation using a U-shaped plaster with the elbow in extension for extension-type supracondylar fractures of the humerus in children. When the elbow is in full extension, both the extensor and the flexor muscles are neutralised during manipulative reduction and the carrying angle can be easily assessed thus preventing cubitus varus, the most common complication. In order to evaluate the efficiency of this method, we compared the clinical results of the new method with those of conventional treatment. In a group of 95 children who sustained an extension-type supracondylar fracture of the humerus, 49 were treated by the new method and 46 by the conventional method, reduction and immobilisation in a plaster slab with the elbow in flexion. Reduction and immobilisation were easily achieved and reliably maintained by one manipulation for all the children treated by the new method. In 12 children treated by the conventional method, the initial reduction failed and in seven secondary displacement of the distal fragment occurred during the period of immobilisation in plaster. All required a second or third manipulation. Of the 46 children, 28 (60.9%) had developed cubitus varus at a mean follow-up of 4.6 years when treated by the conventional method. None of the children treated by the new method developed cubitus varus. The mean score, according to the Hospital for Special Surgery (HSS) elbow scoring system, was 91 points using the new method and 78 with the conventional method. The results were statistically significant with regard to the incidence of cubitus varus and the elbow score (p < 0.01) suggesting that the new method is reliable and gives a satisfactory outcome

This study evaluated the effect on movement under load of three different techniques for re-attachment of the tuberosities of the humerus using test sawbones. In the first, the tuberosities were attached both to the shaft and to each other, with one cerclage suture through the anterior hole in the prosthesis. The second technique was identical except for omission of the cerclage suture and in the third the tuberosities were attached to the prosthesis and to the shaft. An orthogonal photogrammetric system allowed all segments to be tracked in a 3D axis system. The humeri were incrementally-loaded in abduction, and the 3D linear and angular movements of all segments were calculated. Displacement between the tuberosities and the shaft was measured. The first and second techniques were the most stable constructs, with the third allowing greater separation of fragments and angular movement. Separation at the midpoint of the tuberosities was significantly greater using the latter technique (p < 0.05). The cerclage suture added no further stability to the fixation

We treated 34 consecutive articular fractures of the proximal humerus in 33 patients with good bone quality by open reduction and internal fixation. Anatomical or nearly anatomical reduction was achieved in 30, at a mean follow-up of 63 months (25 to 131), complete or partial avascular necrosis had occurred in 12 cases (35%). Two patients subsequently underwent arthroplasty and six further patients required additional surgery. The 32 patients who did not require arthroplasty obtained a mean Constant score of 78 points or 89% of an age- and gender-matched normal score (66 points or 76% in the presence and 83 points or 96% in the absence of avascular necrosis (p < 0.0005)); 22 were painfree, and seven had mild pain and three moderate pain. The mean active anterior elevation was 156°. Internal fixation of complex fractures of the proximal humerus restored good shoulder function if avascular necrosis did not develop

Ten patients underwent endoprosthetic replacement of the distal humerus for bone tumours over a period of 30 years. There were eight primary and two secondary tumours in four men and six women with a mean age of 47.5 years (15 to 76). The mean follow-up was eight years (9 months to 31 years). Four patients required further surgery, three having revision for aseptic loosening; two of these and one other later needing a rebushing. There were no cases of postoperative nerve palsy, infection, local recurrence or mechanical failure of the implant. Four patients died from their disease, all with the prosthesis functioning satisfactorily. At follow-up the mean flexion deformity of the elbow was 15° (0 to 35) and the mean range of flexion was 115° (110 to 135). The functional results showed a mean Toronto extremity salvage score of 73% of normal. Endoprosthetic replacement of the distal humerus and elbow is a satisfactory method of treating these rare tumours

Antegrade intramedullary nailing of fractures of the shaft of the humerus is reported to cause impairment of the shoulder joint. We have reviewed 33 patients with such fractures to assess how many had injuries to the ipsilateral shoulder. All had an MR scan of the shoulder within 11 days of injury. The unaffected shoulder was also scanned as a control. There was evidence of abnormality in 21 of the shoulders (63.6%) on the injured side; ten had bursitis of the subacromial space, five evidence of a partial tear of the rotator cuff, one a complete rupture of the supraspinatus tendon, four inflammatory changes in the acromioclavicular joint and one a fracture of the coracoid process. These injuries may contribute to pain and dysfunction of the shoulder following treatment, and their presence indicates that antegrade nailing is only partly, if at all, responsible for these symptoms

Between 1988 and 2006, 18 patients had a custom-made endoprosthetic replacement of the distal humerus for bone tumours at our institution. There were 11 primary malignant neoplasms, six secondary deposits, and one benign aggressive tumour. The mean follow-up was for 4.4 years (1 to 18.2). Complications occurred in nine patients and included aseptic loosening in three (16.6%), local recurrence in two (11%), infection in two (11%), neuropraxia of the radial nerve in one (5.5%) and a peri-prosthetic fracture in one (5.5%). Excision was inadequate in four patients (22%), all of which developed local recurrence and/or metastases. There were seven deaths from the primary disease after a mean of 2.3 years (1 to 5), one of whom had an above-elbow amputation for local recurrence seven months before death. The remaining six had satisfactory elbow function at their last follow-up. The 11 living patients were evaluated using the Musculoskeletal Tumour Society and Toronto Extremity Salvage scoring systems. The mean scores achieved were 76% (67% to 87%) and 73% (59% to 79%), respectively. Overall, 17 of 18 patients had significant improvement in the degree of their pain following operation. Custom-made endoprosthetic reconstruction of the elbow for bone tumours is a viable treatment in carefully selected patients. It maintains satisfactory function and provides good pain relief

We report a case of periosteal chondroma of the proximal humerus with multiple cartilaginous masses extending around two-thirds of the metaphysial circumference. The humerus was short, presumably because the tumour interfered with growth at the epiphysial plate

We undertook a prospective, controlled trial which compared two rehabilitation programmes for 86 patients who sustained two-part fractures of the proximal humerus. Patients were randomised either to receive immediate physiotherapy within one week (group A) or delayed physiotherapy after three weeks of immobilisation in a collar and cuff sling (group B). At 16 weeks after the fracture, patients in group A had less pain (p < 0.01) and had greater shoulder function (p < 0.001) than those in group B. At 52 weeks, the differences between the groups had reduced. Although group A still had greater shoulder function and less pain, there was no statistical difference when compared with group B. By analysis of the area under the curve, an overall measure up to the 52-week period, group A experienced less pain as measured by the SF36 general health questionnaire and had improved shoulder function. Our results show that patients with two-part fractures of the proximal humerus who begin immediate physiotherapy, experience less pain. The gains in shoulder function persist at 52 weeks which suggests that patients do not benefit from immobilisation before beginning physiotherapy

A 16-year-old boy was involved in an agricultural accident in which he sustained a large wound to the right arm and forearm. Radiological examination showed loss of the distal half of the humerus. A posterior splint was applied and after two months there was regeneration of the distal humerus including the articular portion. He was able to use his arm at five months. Twenty years later, he had a painless elbow and a 70° range of movement

This annotation discusses the findings of two papers in the current issue describing the management of the neurovascular complications of supracondylar fractures of the humerus in childhood, with particular reference to the indications for and the timing of exploration of the brachial artery and the affected nerves

Nine children sustained a second fracture of the distal humerus after union of an ipsilateral supracondylar fracture which had healed with cubitus varus. There were eight boys and one girl with a mean age of five years (1 to 8) at the time of the second fracture which occurred at a mean of 1.5 years after the first. In all patients, the second fracture was an epiphyseal injury of the distal humerus, either associated with a fracture of the lateral metaphysis below the site of the previous supracondylar fracture, or a fracture-separation of the entire distal humeral epiphysis. This suggests that the physis and epiphysis tend to be more subject to injury than the metaphysis of the distal humerus in children who have had a previous supracondylar fracture with varus malunion

We retrospectively studied 14 patients with proximal and diaphyseal tumours and disappearing bone (Gorham’s) disease of the humerus treated with wide resection and reconstruction using an allograft-resurfacing composite (ARC). There were ten women and four men, with a mean age of 35 years (8 to 69). At a mean follow-up of 25 months (10 to 89), two patients had a fracture of the allograft. In one of these it was revised with a similar ARC and in the other with an intercalary prosthesis. A further patient had an infection and a fracture of the allograft that was revised with a megaprosthesis. In all patients with an ARC, healing of the ARC-host bone interface was observed. One patient had failure of the locking mechanism of the total elbow replacement. The mean post-operative Musculoskeletal Tumor Society score for the upper extremity was 77% (46.7% to 86.7%), which represents good and excellent results; one patient had a poor result (46.7%). In the short term ARC effectively relieves pain and restores shoulder function in patients with wide resection of the proximal humerus. Fracture and infection remain significant complications

Sixteen patients who underwent a revision operation for nonunion of fractures of the distal humerus following previous internal fixation were reviewed at a mean follow-up of 39 months (8 to 69). The Mayo elbow performance score was excellent in 11, good in two, fair in two and poor in one. In 15 patients union was achieved and in one with an infected nonunion a subsequent bone graft was necessary in order to obtain union. Age, gender, a history of smoking, mechanism of the injury and the AO classification of the initial fracture did not correlate with the development of nonunion. In 12 patients (75%), the initial fixation was assessed as being suboptimal. The primary surgery was regarded as adequate in only three patients. Our findings suggest that the most important determinant of nonunion of a distal humeral fracture after surgery is the adequacy of fixation

Between January 1995 and December 2000, 112 children with a closed displaced supracondylar fracture of the humerus without vascular deficit, were managed by elevated, straight-arm traction for a mean of 22 days. The final outcome was assessed using clinical (flexion-extension arc, carrying angle and residual rotational deformity) and radiographic (metaphyseal-diaphyseal angle and humerocapitellar angle) criteria. Excellent results were achieved in 71 (63%) patients, 33 (29%) had good results, 5 (4.4%) fair, and 3 (2.6%) poor. All patients with fair or poor outcomes were older than ten years of age. Elevated, straight-arm traction is safe and effective in children younger than ten years. It can be effectively used in an environment that can provide ordinary paediatric medical care and general orthopaedic expertise. The outcomes compare with supracondylar fractures treated surgically in specialist centres

The operative treatment of fractures of the proximal humerus can be complicated by poor bone quality. Our aim was to evaluate a new method which allows prediction of the bone quality of the proximal humerus from radiographs. Anteroposterior radiographs were taken of 19 human cadaver humeri. The cortical thickness was measured at two levels of the proximal humeral diaphysis. The bone mineral density (BMD) was determined for the humeral head (HH), the surgical neck (SN), the greater tuberosity (GT) and lesser tuberosity (LT) using dual-energy x-ray absorptiometry. The mean cortical thickness was 4.4 ± 1.0 mm. Specimens aged 70 years or less had a significantly higher cortical thickness than those aged over 70 years. A significant positive correlation was found between cortical thickness and the BMD for each region of interest. The cortical thickness of the proximal diaphysis is a reliable predictor of the bone quality of the proximal humerus

The results of proximal humeral replacement following trauma are substantially worse than for osteoarthritis or rheumatoid arthritis. The stable reattachment of the lesser and greater tuberosity fragments to the rotator cuff and the restoration of shoulder biomechanics are difficult. In 1992 we developed a prosthesis designed to improve fixation of the tuberosity fragments in comminuted fractures of the proximal humerus. The implant enables fixation of the fragments to the shaft of the prosthesis and the diaphyseal fragment using screws, washers and a special toothed plate. Between 1992 and 2003 we used this technique in 50 of 76 patients referred to our institution for shoulder reconstruction after trauma. In the remaining 26, reconstruction with a prosthesis and nonabsorbable sutures was performed, as the tuberosity fragments were too small and too severely damaged to allow the use of screws and the toothed plate. The Constant score two years post-operatively was a mean of 12 points better in the acute trauma group and 11 points better in the late post-traumatic group than in the classical suture group. We recommend this technique in patients where the tuberosity fragments are large enough to allow fixation with screws, washers and a toothed plate

The surgical treatment of three- and four-part fractures of the proximal humerus in osteoporotic bone is difficult and there is no consensus as to which technique leads to the best outcome in elderly patients. Between 1998 and 2004 we treated 76 patients aged over 70 years with three- or four-part fractures by percutaneous reduction and internal fixation using the Humerusblock. A displacement of the tuberosity of > 5 mm and an angulation of > 30° of the head fragment were the indications for surgery. Of the patients 50 (51 fractures) were available for follow-up after a mean of 33.8 months (5.8 to 81). The absolute, age-related and side-related Constant scores were recorded. Of the 51 fractures, 46 (90.2%) healed primarily. Re-displacement of fragments or migration of Kirschner wires was seen in five cases. Necrosis of the humeral head developed in four patients. In three patients a secondary arthroplasty had to be performed, in two because of re-displacement and in one for necrosis of the head. There was one case of deep infection which required a further operation and one of delayed healing. The mean Constant score of the patients with a three-part fracture was 61.2 points (35 to 87) which was 84.9% of the score for the non-injured arm. In four-part fractures it was 49.5 points (18 to 87) or 68.5% of the score for the non-injured arm. The Humerusblock technique can provide a comfortable and mobile shoulder in elderly patients and is a satisfactory alternative to replacement and traditional techniques of internal fixation

Between 1998 and 2002, 37 neuropathies in 32 patients with a displaced supracondylar fracture of the humerus who were referred to a nerve injury unit were identified. There were 19 boys and 13 girls with a mean age of 7.9 years (3.6 to 11.3). A retrospective review of these injuries was performed. The ulnar nerve was injured in 19, the median nerve in ten and the radial nerve in eight cases. Fourteen neuropathies were noted at the initial presentation and 23 were diagnosed after treatment of the fracture. After referral, exploration of the nerve was planned for 13 patients. Surgery was later cancelled in three because of clinical recovery. Six patients underwent neurolysis alone. Excision of neuroma and nerve grafting were performed in four. At follow-up, 26 patients had an excellent, five a good and one a fair outcome

We assessed the inter- and intraobserver variation in classification systems for fractures of the distal humerus. Three orthopaedic trauma consultants, three trauma registrars and three consultant musculoskeletal radiologists independently classified 33 sets of radiographs of such fractures on two occasions, each using three separate systems. For interobserver variation, the Riseborough and Radin system produced ‘moderate’ agreement (kappa = 0.513), but half of the fractures were not classifiable by this system. For the complete AO system, agreement was ‘fair’ (kappa = 0.343), but if only AO type and group or AO type alone was used, agreement improved to ‘moderate’ and ‘substantial’, respectively (kappa = 0.52 and 0.66). Agreement for the system of Jupiter and Mehne was ‘fair’ (kappa = 0.295). Similar levels of intraobserver variation were found. Systems of classification are useful in decision-making and evaluation of outcome only if there is agreement and consistency among observers. Our study casts doubt on these aspects of the systems currently available for fractures of the distal humerus

We randomised prospectively 44 patients with fractures of the shaft of the humerus to open reduction and internal fixation by either an intramedullary nail (IMN) or a dynamic compression plate (DCP). Patients were followed up for a minimum of six months. There were no significant differences in the function of the shoulder and elbow, as determined by the American Shoulder and Elbow Surgeons’ score, the visual analogue pain score, range of movement, or the time taken to return to normal activity. There was a single case of shoulder impingement in the DCP group and six in the IMN group. Of these six, five occurred after antegrade insertion of an IMN. In the DCP group three patients developed complications, compared with 13 in the IMN group. We had to perform secondary surgery on seven patients in the IMN group, but on only one in the DCP group (p = 0.016). Our findings suggest that open reduction and internal fixation with a DCP remains the best treatment for unstable fractures of the shaft of the humerus. Fixation by IMN may be indicated for specific situations, but is technically more demanding and has a higher rate of complications

Over a seven-year period we treated a consecutive series of 58 patients, 20 men and 38 women with a mean age of 66 years (21 to 87) who had an acute complex anterior fracture-dislocation of the proximal humerus. Two patterns of injury are proposed for study based upon a prospective assessment of the pattern of soft-tissue and bony injury and the degree of devascularisation of the humeral head. In 23 patients, the head had retained capsular attachments and arterial back-bleeding (type-I injury), whereas in 35 patients the head was devoid of significant soft-tissue attachments with no active arterial bleeding (type-II injury). Following treatment by open reduction and internal fixation, only two of 23 patients with type-I injuries developed radiological evidence of osteonecrosis of the humeral head, compared with four of seven patients with type-II injuries. A policy of primary treatment by open reduction and internal fixation of type-I injuries is justified, whereas most elderly patients (aged 60 years or over) with type-II injuries are best treated by hemiarthroplasty. The best treatment for younger patients (aged under 60 years) who sustain type-II injuries is controversial and an individualised approach to their management is advocated

Symptoms due to a supracondylar spur of the humerus, although rare, are common enough to make it the subject of routine examination of a patient with pain and disturbance of sensibility of the hand. It can mimic the carpal tunnel syndrome; it may produce ulnar nerve symptoms. Irritation or compression of either the brachial artery or, if there is a high division of it, the ulnar artery, may cause episodes of ischaemic pain in the forearm. The clinical features of a supracondylar spur causing symptoms are: symptoms of median nerve compression; forearm claudication; a palpable spur about two inches above the medial epicondyle; and disappearance of the radial or ulnar pulse on full extension and supination of the forearm

Five cases of fracture-separation of the proximal epiphysis of the humerus are recorded. A method of reduction and immobilisation is described, and the literature is reviewed

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

1. A review of ten cases of T-shaped intercondylar fractures of the humerus treated with a sling and early movement is presented. 2. The method and the results are discussed and some comparison is made with other series. 3. This method of treatment has certain advantages and the results are reasonable in comparison with those of other methods

This study aimed to evaluate the use of pin leverage in the reduction of Gartland type III supracondylar fractures of the humerus in children. The study comprised 95 children, who were split into three groups according to the type of method of reduction used. Group 1, had an open reduction, group 2, had closed reduction and percutaneous pin fixation and group 3, the pin leverage technique. Each group was analysed according to the time to surgery, the duration of the procedure, the incidence of complications, and the clinical and radiological outcome. The mean duration of the operative procedure in groups 1, 2 and 3 was 119 minutes (80 to 235), 57 minutes (20 to 110) and 68 minutes (30 to 90), respectively. At a mean follow-up of 30 months (12 to 63) the clinical results were declared excellent or good in all children and the radiological results intermediate in five patients in group 2. The results of the closed reduction using the pin leverage technique was classified as failure in two children. Our findings lead us to believe that the pin leverage method of reduction gives good results in the treatment of Gartland type III fractures

We assessed the intermediate functional results of eight patients after wide resection of the proximal humerus for malignant bone tumour. We used a free vascularised fibular graft as a functional spacer and a sling procedure to preserve passive scapulohumeral movement. Scapulohumeral arthrodesis was not carried out. Five patients had osteosarcoma, two achondrosarcoma and one a malignant fibrous histiocytoma of the bone. The mean duration of follow-up was 70 months (median, 76) for the seven patients who were still alive at the time of the latest follow-up. One patient died from the disease 12 months after surgery. There were no local recurrences. The functional results were described and graded quantitatively according to the rating system of the Musculoskeletal Tumour Society. Our results were satisfactory with regard to pain, emotional acceptance and manual dexterity. Function and lifting ability were unsatisfactory in two patients. One patient had delayed union between host and graft, but this united after six months without further surgery. Radiographs of the shoulder showed absorption or collapse of the head of the fibula in four of the eight patients and a fracture in another. No functional problems related to absorption or fracture of the head of the fibula were noted. There was no infection or subluxation of the head. We conclude that this is a reasonably effective technique of limb salvage after resection of the proximal humerus

We reviewed 39 patients with displaced three- and four-part fractures of the humerus. In 21 patients (group A) we had used an anatomical prosthesis for the humeral head and in 18 (group B) an implant designed for fractures. When followed up at a mean of 29.3 months after surgery the overall Constant score was 51.9 points; in group A it was 51.5 and in group B 52.4 points. The subjective satisfaction of the patients was assessed using a numerical rating scale and was similar in both groups. In group A complete healing of the tuberosities was found in 29% and 50% in group B. Partial integration was seen in 29% of group A and in only one patient in group B, while resorption was noted in 43% of group A and 44% of group B. The functional outcome was significantly better in patients with complete or partial healing of the tuberosities (p = 0.022). The specific trauma prosthesis did not lead to better healing of the tuberosities. The difference in clinical outcome obtained by the two designs did not reach statistical significance

1. Thirteen cases of non-union of the epiphysis of the lateral condyle of the humerus were studied. Ten followed minor lateral luxations of the epiphysis; three were sequelae of open reduction and soft-tissue suture of major displacements. 2. In three cases in which non-union developed while the patient was under observation, union was secured after bone grafting by a technique described

An elderly woman presented with a pathological fracture of the right humerus. Progressive dissolution of the shaft of this bone took place over six months. No cause could be established and the patient refused biopsy. With only simple splintage for treatment the humeral shaft gradually reformed and re-ossified over a period of two years. The patient has been under review for four and a half years and no further pathology has come to light. The cause of the osteolysis remains obscure

We have undertaken a five-year prospective study of 126 translated two-part fractures of the proximal humerus and present an analysis of the epidemiology and of the factors which affect outcome in elderly patients. The fracture has a unimodal age distribution and rarely affects adults under the age of 50 years. Analysis showed that patients with two-part translated fractures of the surgical neck tended to be independent and relatively fit, despite the fact that their mean age was 72 years. Outcome was determined by the age of each patient and the degree of translation on the initial anteroposterior radiograph. Surgery did not improve the outcome, regardless of the degree of translation

We treated 22 children with a supracondylar fracture of the humerus and an ipsilateral fracture of the forearm by closed reduction and percutaneous fixation. There were four Gartland type-II and 18 Gartland type-III supracondylar fractures of the humerus. There were fractures of both bones of the forearm in 16 and of the radius in six. Both the supracondylar and the distal forearm fractures were treated by closed reduction and percutaneous fixation. The mean follow-up time was 38.6 months. At the latest follow-up there were 21 excellent or good results and one fair result. There were no cases of delayed union, nonunion or malunion. Five nerve injuries were diagnosed on admission and all recovered spontaneously within eight weeks. No patient developed a compartment syndrome

1. Fifty-nine patients with fractures of the medial epicondyle of the humerus have been reviewed, of whom more than one-third also had a dislocation of the elbow. 2. The final disability has been shown to be very slight. Non-union occurs very often with conservative treatment, but gives no disability. Union can be obtained by fixation with a Pidcock pin. 3. Operative treatment is advised only when the fragment is included in the joint. It is suggested that the best position of the elbow in patients treated conservatively is about 60 degrees below the right angle

The treatment of multifragmentary, intra-articular fractures of the distal humerus is difficult, even in young patients with bone of good quality, but is worse in elderly patients who have varying degrees of osteopenia. We have evaluated the functional outcome of primary total elbow replacement (TER) in the treatment of these fractures in ten elderly patients followed for a minimum of one year. There were no complications in regard to the soft tissues, bone or prosthesis. The mean range of flexion obtained was 125° (110 to 140) and loss of extension was 23.5° (0 to 50). The mean Mayo score was 94 points (80 to 100) and patient satisfaction was high. We feel that TER provides an alternative to open reduction and internal fixation in the management of these complicated fractures in the elderly

Existing classifications of fractures of the head of the humerus are inadequate in terms of interobserver reliability and the predictability of the clinical outcome. From a combined study of 73 fracture specimens in museums and 84 CT-three-dimensional reconstructions in patients, we have devised a classification which appears to be more useful clinically. Common patterns of fracture and a plausible mechanism of injury were observed. In 3-D most proximal humeral fractures can be organised into five basic types. These correspond in some degree to the Codman/Neer classification, but differ significantly in regard to the more complex patterns of fracture. We observed a logical progression from simple to complex fractures. An interobserver reliability study was carried out which indicated the improved usefulness of this new 3-D concept in providing a common language among clinicians for classifying these injuries. When surgery is indicated, the 3-D concept is also invaluable in guiding the restitution of anatomy through either open or percutaneous means

We used the Ilizarov circular external fixator to treat 16 patients with persistent nonunion of the diaphysis of the humerus despite surgical treatment. All patients had pain and severe functional impairment of the affected arm. In ten, nonunion followed intramedullary nailing. We successfully treated these by a closed technique. The nail was left in place and the fracture compressed over it. The fractures of the other six patients had previously been fixed by various methods. We explored these nonunions, removed the fixation devices and excised fibrous tissue and dead bone before stabilising with the Ilizarov fixator. In five patients union was achieved. Bone grafting was not required. In the single patient in whom treatment failed, there had been a severely comminuted open fracture. All except one patient had reduction of pain, and all reported an improvement in function

A woman with neurofibromatosis (von Recklinghausen's disease) presented with a giant plexiform neuroma of the arm and chest wall, with dysplastic scoliosis and a pseudarthrosis of the humerus. Her arm resembled that of the "Elephant Man" described by Sir Frederick Treves

Four cases are shown to illustrate remodelling of the lower end of the humerus after supracondylar fractures with displacement in childhood. Remodelling is rapid and will restore almost normal anatomy and good function even with severely displaced fractures. The results are much better than in many cases treated by open reduction

There is a specific type of displaced four-part fracture of the proximal humerus which consists of valgus impaction of the head fragment; this deserves special consideration because the rate of avascular necrosis is lower than that of other displaced four-part fractures. Using either closed reduction or limited open reduction and minimal internal fixation, 74% satisfactory results can be achieved in this injury

We performed an audit of 71 children with consecutive displaced, extension-type supracondylar fractures of the humerus over a period of 30 months. The fractures were classified according to the Wilkins modification of the Gartland system. There were 29 type IIA, 22 type IIB and 20 type III. We assessed the effectiveness of guidelines proposed after a previous four-year review of 83 supracondylar fractures. These recommended that: 1) an experienced surgeon should be responsible for the initial management; 2) closed or open reduction of type-IIB and type-III fractures must be supplemented by stabilisation with Kirschner (K-) wires; and 3) K-wires of adequate thickness (1.6 mm) must be used in a crossed configuration. The guidelines were followed in 52 of the 71 cases. When they were observed there were no reoperations and no malunion. In 19 children in whom they had not been observed more than one-third required further operation and six had a varus deformity. Failure to institute treatment according to the guidelines led to an unsatisfactory result in 11 patients. When they were followed the result of treatment was much better. We have devised a protocol for the management of these difficult injuries

We reviewed 26 patients who had had internal fixation of an open intra-articular supracondylar fracture of the humerus. All operations were performed using a posterior approach, 13 with a triceps split and 13 with an olecranon osteotomy. The outcome was assessed by means of the Mayo Elbow score, the Disability of the Arm, Shoulder and Hand (DASH) score and the SF-36 Physical Function score. Patients with an olecranon osteotomy had less good results

The use of a rotation osteotomy of the humerus in 10 patients with disabling loss of lateral rotation at the shoulder due to brachial plexus birth injuries is described. The operative technique and complications are discussed. Before operation only one patient was independent, but after operation nine of them were. Restoration of lateral rotation at the shoulder can improve the function, the appearance and the independence of these handicapped patients

We carried out extensible endoprosthetic replacement of the proximal or total humerus in 18 children aged between six and 12 years, after resection of primary bone tumours mainly for osteosarcoma and Ewing’s sarcoma. In 11 patients we performed 44 lengthening procedures, with an average of two per child annually and a mean total extension of 29.9 mm per patient. We were able to achieve lengthening of the operated limb with few complications and a mean functional rating of 79.3% according to the Enneking system. Progressive lengthening of these prostheses does not adversely affect the overall function of the arm, and superior subluxation of the head of the prosthesis has not been a problem

We evaluated the biomechanical properties of two different methods of fixation for unstable fractures of the proximal humerus. Biomechanical testing of the two groups, locking plate alone (LP), and locking plate with a fibular strut graft (LPSG), was performed using seven pairs of human cadaveric humeri. Cyclical loads between 10 N and 80 N at 5 Hz were applied for 1 000 000 cycles. Immediately after cycling, an increasing axial load was applied at a rate of displacement of 5 mm/min. The displacement of the construct, maximum failure load, stiffness and mode of failure were compared. The displacement was significantly less in the LPSG group than in the LP group (p = 0.031). All maximum failure loads and measures of stiffness in the LPSG group were significantly higher than those in the LP group (p = 0.024 and p = 0.035, respectively). In the LP group, varus collapse and plate bending were seen. In the LPSG group, the humeral head cut out and the fibular strut grafts fractured. No broken plates or screws were seen in either group. We conclude that strut graft augmentation significantly increases both the maximum failure load and the initial stiffness of this construct compared with a locking plate alone

A case of injury of the axillary artery complicating a closed fracture of the neck of the humerus in a woman of eighty-six is reported. Spasm was not relieved despite repeated instillation of papaverine. Gangrene developed and amputation above the elbow was required

In our practice sequestration of the shafts of long bones in children because of acute osteomyelitis continues to be a problem. Conventional procedures for bone grafting are likely to fail. Vascularised grafts with microvascular anastomosis are technically demanding with a high rate of failure. Transfer of the rib on its vascular pedicle to achieve anterior fusion in the thoracic spine is now well established and the length of the pedicle available is adequate to allow grafting of a diaphyseal defect in the humerus. We describe the successful use of this procedure in two patients