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PubMed2005

[Fractures of the distal humerus].

The treatment of fractures of the distal humerus remains challenging due to the complex anatomy of the elbow joint. Satisfactory results can only be attained with the complete recovery of the function and stability of the joint. Open reduction and internal fixation following AO principles, therefore, represents the standard procedure for the treatment of distal humerus fractures. Unfavourable results can, however, not be avoided in all cases, especially if fractures are complicated by concomitant lesions of soft tissues, nerves or vessels.

Fracture Fixation, Internal↗
PubMed1997

[4-fragment fractures of the proximal humerus. Alternative strategies for surgical treatment].

The operative treatment of dislocated fractures of the proximal humerus has been evolving in recent years. Replacement using endoprostheses often results in only moderate functional outcome, and with the high risk of aseptic necrosis with ORIF, new methods of minimally invasive stabilisation have been developed. These methods reduce the opening of the fracture site to a minimum and thereby limit the risk of iatrogenic damage to local vascularity and the rotator cuff. This study reviewed 18 patients operated on with minimal osteosynthesis for dislocated four-part fractures of the proximal humerus from March 1991 to October 1994. Only tension band wiring with resorbable cords from woven polydioxanone was applied. After an average follow-up of 26 months (20-37 months), 72% (n = 13) of the four-part fractures were rated as good and very good results according to the Neer Score. In 16.7%, a complete head necrosis occurred, requiring a prosthetic replacement. Two patients with partial necrosis (11.1%) had a good functional outcome. With regard to these results, we recommend head-preserving tension band wiring with resorbable cords and preservation of the articular surface. At the present time the procedure seems comparable with prosthetic replacement in respect of shoulder function.

Adult↗
PubMed1999

[Fractures of the proximal humerus].

Proximal humeral fractures are common particularly in the elderly. The decision of the optimal treatment is dependent on many factors. On the one hand the biological age of the patient and the bone structure plays a key-role, on the other hand the living conditions and individual needs are of importance. Most fractures with minimal displacement respond satisfactorily to simple conservative treatment including short sling immobilisation and functional aftertreatment under supervision of the physiotherapist. Most recently there is a trend towards more aggressive surgical intervention with percutaneous insertion of cannulated screws also in the slightly displaced fracture situation. This protocol allows for earlier functional and less painful aftertreatment, less risk of displacement of the fracture fragments and better outcome. In severely unstable fractures with marked displacement of the fragments an operative stabilisation is advocated by most surgeons. Again there is a trend from plating towards cannulated screw fixation combined with tension absorbing (resorbable) sutures. In special cases which are described in detail a minimal invasive percutaneous screw technique with less stripping of bone and therefore preservation of the crucial blood supply of the humeral head is recommended. Instead of percutaneous pinning using K-wires only, cannulated screws are inserted today. Plating of proximal humerus joint fractures is the exception in our days, only the subcapital unstable fracture of the elderly would be an indication. LC-condylar plating seems to yield better stability than the conventional T-plate-system. In the most severe fractures of the proximal humerus (4-segment-fractures and dislocation fractures according to Neer, respectively C-2- and C-3-fractures according to the AO-classification) there is still controversy on the best management. Most authors prefer hemiarthroplasty in this situation whereas the other group of orthopaedic surgeons try open reduction and internal fixation particularly in the younger individuals. This stabilisation provides the orthopaedic surgeons with a formidable challenge and requires a lot of experience in this field. Also the understanding of the fracture morphology is needed for optimal results. In spite of good stabilisation techniques often partial or total humeral head necrosis occurs in the most severe fractures. Surprisingly enough results with reasonable function can be obtained even with partial avascular necrosis of the humeral head. A crucial part of the management is team work with the physiotherapist and an individual program for each fracture situation, depending on the stability of the fixation. Close contact between these two professions is of utmost importance. Finally it can be stated that the management of proximal humeral fractures is fairly standardised but it is always dependent on the experience and resources of the attending surgeon and must be tailored to the individual needs of the patient.

Humans↗
PubMed2000

[Proximal and distal humerus fractures in advanced age].

In contrast to distal humeral fractures, humeral head fractures represent a common injury to the old patient. For both fracture localizations osteoporosis and multi-morbidity are of significant importance. The classification for humeral head fractures in one-, two-, three- and four-part fractures is generally accepted. Valgus impacted head fractures as well as head-splitting fractures are considered a separate entity. In none or minimally displaced fractures good functional results are achieved by conservative means. Although numerous therapeutical procedure are offered in the treatment of displaced fractures of the proximal humerus the result are often disappointing. Generally, minimal invasive surgical procedures should be preferred. However, in dislocated multi-part fractures a primary humeral head replacement is often the treatment of choice. In patients with multifarious morbidity a conservative treatment is always to be included into the therapeutical considerations. Distal fractures of the humerus are classified into extraarticular, intraarticular uni-condylar and intraarticular bi-condylar fractures. The therapeutical recommendations, also in the elderly, is relatively homogeneous: primary open reduction and internal fixation (ORIF) should be carried out aiming for an early postoperative functional treatment. Depending from soft tissue conditions and accompanying injuries the functional results are often good or moderate and are generally comparable to those of younger patients. Following a correct indication for surgical intervention the main priority for both distal and proximal humeral fractures is an early definitive surgical treatment.

Aged↗
PubMed2006

Arthroscopic removal of an intramedullary nail in the humerus.

The most frequent criticism of antegrade humeral nailing is its potentially deleterious effect on shoulder function owing to the trauma to the rotator cuff at the insertion point. This problem may also occur when removing an intramedullary nail from the humerus. In an effort to decrease the trauma to the rotator cuff at the nail insertion site during removal of an intramedullary nail from the humerus and to allow recovery of shoulder function as soon as possible after removal, we performed arthroscopic removal of the intramedullary nail and arthroscopic rotator cuff repair. The advantages of this method include the fact that it is a less invasive approach, which causes minimal disruption of the rotator cuff, requires fewer days in hospital, and allows simultaneous arthroscopic correction of the accompanying lesion.

Adult↗
PubMed2006

"Sandwich technique" in the surgical treatment of primary complex fractures of the femur and humerus.

In this prospective study, our aim was to determine the clinical and radiographic outcomes of the surgical treatment of primary complex problem femoral and humeral shaft fractures treated by a new technique called "sandwich technique." A total of 45 patients with comminuted, complex and/or osteopoenic fractures of the femur or humerus (30 femoral and 15 humeral fractures) were treated using this technique. The patients were followed up for a mean of 25 months. In 24 (85.7%) of 28 patients with femoral fractures and in 14 (93.3%) of 15 patients with humeral fractures, union was achieved within 3-6 months of the operation (mean: 4.5 months). The total union rate was 88.4%. The pseudoarthrosis rate was 12%. There was no infection or implant failure seen during the follow-up period. The cortical allograft struts can be used to provide collateral support to weakened osteopoenic/osteoporotic bone. This technique provides a union rate of about 88% in osteoporotic and/or complex primary humerus or femur fractures.

Adolescent↗
PubMed2006

Management of grade III supracondylar fracture of the humerus by straight-arm lateral traction.

Supracondylar fracture of the humerus is a common upper limb fracture in children for which treatment is controversial and often technically difficult, and complications are common. Cubitus varus is the most prevalent complication encountered in such fractures, with a mean incidence rate of 30%. A variety of methods for treating displaced fractures have been recommended. We reviewed 20 cases of severely displaced grade III supracondylar fractures of the humerus in children. There was marked swelling and distorted local anatomy in all these fractures, which were managed conservatively with straight-arm lateral traction. The patients were treated in skin traction for 2 weeks, following which they commenced physiotherapy. The traction was applied with the arm at 90 degrees of abduction and the forearm in supination. None of the patients developed any complication, and all had the full range of movements. None had cubitus varus deformity, and none of these patients required further surgical treatment. There was a complete patient and parent satisfaction. Open or closed reduction with internal fixation is the most common method of treating these injuries, however in some cases this can be very difficult and dangerous. If the local anatomy and swelling do not allow this treatment then non-operative measures have to be adopted. We conclude that straight-arm lateral traction is a safe and effective method of treating these fractures, especially when the local anatomy is disturbed and the swelling makes operative intervention relatively more risky and difficult. Moreover, this method is also appropriate in areas where access to specialised centres in treating these injuries is either difficult or delayed.

Child↗
PubMed2006

Double line sign: a helpful sonographic sign to detect occult fractures of the proximal humerus.

The aim of this study was to describe a new sonographic sign of bone fracture and to determine if it can be helpful in decreasing the number of missed fractures of the proximal humerus. Ultrasound (US) of the shoulder was performed in 57 consecutive patients with shoulder pain and/or disability following trauma. All cases were prospectively reviewed for the presence of a humeral fracture. Sonographic signs of fractures, with special emphasis on what was termed the 'double line sign' (DLS), were assessed. Plain radiography was considered the standard of reference and in equivocal cases magnetic resonance imaging (MRI). Twenty-eight patients had a tuberosity complex fracture, which were all detected at US examination. Sonographic features of a fracture were periosteal elevation, corticol bone discontinuity, step-off deformity or a combination of these findings. This study showed that in 26 (93%) patients an additional sonographic feature, a DLS, could be demonstrated. The DLS is a helpful and probably reliable sonographic sign to indicate a humeral fracture. High-spatial-resolution US substantially increases the detection of fractures of the proximal humerus and should be considered as an alternative diagnostic tool prior to computed tomography (CT), MRI and arthroscopy in patients with persisting shoulder pain and/or disability following trauma.

Adult↗
PubMed2003

Lateral J-plate fixation in comminuted intercondylar fracture of the humerus.

BACKGROUND: Anatomical reduction and rigid internal fixation of the articular surface is key for functional recovery in types C2 and C3 (AO classification) fractures of the distal humerus. Since these fractures are associated with varying degrees of comminution in both the medial and lateral columns, rigid fixation of both columns is necessary for early mobilization of the elbow joint. METHODS: We performed a prospective study of the lateral J-plating technique in 17 patients with comminuted intercondylar fracture of the humerus. There were 9 type C2 and 8 type C3 fractures by the AO/ASIF classification. A lateral J-plate was applied along the lateral aspect of lateral column, and the lag screws were inserted into the medial column through the plate hole. A medial reconstruction plate was selectively applied on the posterior aspect of medial column. RESULTS: All fractures united by 18.7 weeks on average (range 10-28 weeks). Seven patients presented with limitation of motion of the elbow joint, and 5 of them underwent arthrolysis and excision of the heterotopic ossification. The final range of motion of the elbow joint was flexion contracture of 16 deg to further flexion of 121 deg on average. Functional results were excellent in 9 cases, good in 6, fair in 1, and poor in 1 according to Murray's criteria. CONCLUSION: Lateral J-plating with selective augmentation of the medial column provided sufficient rigidity and good clinical results.

Adolescent↗
PubMed2006

Proximal humerus Salter type III physeal injury with posterior dislocation.

Salter type 3 fractures of the proximal humerus are rare injuries. We report the first case of a Salter type 3 physeal fracture with posterior dislocation of the proximal humerus in a 16-year-old boy. The fracture pattern could not be evaluated by simple radiography, but was possible with the aid of MRI. The dislocated humeral head was locked behind the glenoid labrum. Open reduction was mandatory. Sixteen months after the operation, avascular necrosis of the humeral head was detected by simple radiography and MRI. Even though the patient had a full range of motion of the shoulder and no pain, a long-term follow-up is believed necessary.

Adolescent↗
PubMed2006

A combined fracture of the greater and lesser tuberosity with head shaft continuity in the proximal humerus.

We treated a combined fracture of the greater and lesser tuberosity with head shaft continuity in the proximal humerus. This case is impossible to classify in three of the classifications, the Neer classification, AO Müller classification, or Jakob classification. However, this case has been described as fracture types in two different categories in the Codman classification. Based on our experience with this case, we concluded that both the plain radiographs and the CT scans were necessary to make a correct diagnosis and classify the fractures of the proximal humerus.

Bone Screws↗
PubMed2005

Characteristics of an isolated greater tuberosity fracture of the humerus.

BACKGROUND: Most classification systems tend to include isolated greater tuberosity fractures in the group of proximal humeral fractures. The purpose of this study was to elucidate demographic differences between isolated greater tuberosity fractures and the other proximal humeral fractures. METHODS: Altogether, 610 proximal humeral fractures were divided into isolated greater tuberosity fractures of the proximal humerus (group I) and all other proximal humeral fractures (group II). The two groups were analyzed according to their incidence, age and sex distribution, presence of dislocation, and associated chronic medical problems. RESULTS: Group I comprised 18.9% and group II 81.1% off all fractures. The mean age of group I was 42.8 years, and that of group II was 54.2 years. Of the 115 (67.8%) patients in group I, 78 (67.8%) were male. In contrast, most of the group II patients were female (332/495, 67.1%). A higher incidence of glenohumeral dislocation occurred in group I (6.9%) than in group II (3.4%). Of the 495 group II patients, 175 (35.4%) had medical problems, including endocrine, cardiovascular, pulmonary, hepatic, and renal disease, whereas only 15 of the 115 (13%) patients in group I had such problems. CONCLUSIONS: Patients with isolated greater tuberosity fractures of the proximal humerus were different demographically, and their treatment and classification should be considered separately from that for other proximal humeral fractures.

Adolescent↗
PubMed2001

The epidemiology of elbow fracture in children: analysis of 355 fractures, with special reference to supracondylar humerus fractures.

We present a study of the pattern of elbow fractures in children under 15 years of age, during a 5-year period, with special reference to supracondylar humerus fractures. The incidence was 308/100 000 per year; 58% of the children had a fracture in the supracondylar area of the humerus. There were 355 elbow fractures, and there were 164 boys (46%) and 191 girls (54%). The mean age for the entire group was 7.9 years (for boys, 7.2 years; for girls, 8.5 years). Of 209 supracondylar fractures (including 5 combination fractures), 134 were type I, 40 were type II, and 35 were type III (as classified by Gartland). Associated temporary nerve injuries involving the median, radial, and ulnar nerves were seen in 15 patients with type III supracondylar fractures. Associated brachial artery injuries were seen in 6 patients, 5 of whom had type III fractures.

Adolescent↗
PubMed2003

Completely displaced supracondylar humerus fractures in children: results of open reduction versus closed reduction.

This retrospective study was performed to understand the clinical results after closed reduction and open reduction in 35 children (mean age 6.4 years) with completely displaced supracondylar fractures of the distal humerus between 1996 and 2000. Closed reduction (21 cases) was attempted, with open reduction (14 cases) indicated in irreducible cases with or without severe swelling. After an average follow-up of 22 months, according to Flynn's criteria, the results were excellent in 18, good in 12, fair in 2, and poor in 3. The satisfactory results rates were similar for closed and open reduction. The unsatisfactory results were related to the poor initial reduction and redisplacement after operation. The mean Baumann's angle was 8.7 degrees in the closed reduction group and 6.6 degrees in the open reduction group. None of the patients showed restricted elbow motion of more than 10 degrees, even in two cases of hypertrophic scar in the open reduction group. Selective open reduction for displaced supracondylar fractures of the distal humerus produced as good results as closed reduction.

Child↗
PubMed1977

The operative management of the difficult supracondylar fracture of the humerus in the child.

A series of supracondylar fractures of the humerus in children is presented. The majority was reduced by closed manipulation. The difficult fractures were defined as those in which adequate reduction either could not be achieved by manipulation or was not maintained, or those in which neurological or vascular complications occurred. Such cases were treated by open reduction and internal fixation. The results were assessed with regard to loss of elbow movement, deformity and symptoms. The results of the operative series were comparable with those achieved by closed manipulation in the easier cases. No secondary corrective procedures were necessary. It is concluded that closed manipulation should be used routinely as the method of treatment for supracondylar fractures of the humerus in children, except in the difficult case, for which operative treatment should be undertaken. Stiffness or deformity does not follow open reduction and internal fixation.

Adolescent↗
PubMed1992

Electrotherapy and the management of minimally displaced fracture of the neck of the humerus.

A poor outcome arising from a minimally displaced fracture of the neck of the humerus may be the result of a contracture of the capsule of the glenohumoral joint. Pulsed high frequency electromagnetic energy (PHFE) is an electrotherapy to reduce pain and swelling and to enhance healing. If PHFE is effective, early mobilization of the injured shoulder will be possible, reducing the risk of joint capsule contracture. We therefore conducted a double-blind trial of PHFE in minimally displaced fractures of the neck of the humerus. Early physiotherapy produced an excellent outcome in all cases. The functional outcome depended on age rather than time of starting treatment, although a relationship was found between the time of starting treatment and the duration of therapy required. The use of PHFE did not improve the result further.

Adolescent↗
PubMed1995

The management of gunshot fractures of the humerus.

We report 37 patients who were treated for gunshot fractures of the humerus during a 6 month period at the ICRC hospital, Lopiding, on the Sudanese border. Initial treatment followed the established principals for war surgery. The strategy for fracture stabilization however remains controversial. External fixation has been widely used in war surgery. This paper compares the different methods of stabilization for humeral fractures available in a field hospital. Fracture healing was delayed after external fixation and infection persisted longer than with the other methods of immobilization such as skeletal traction, functional bracing and 'collar and cuff' support. In the author's experience, external fixation has no advantage over non-operative methods for comminuted gunshot fractures of the humerus, unlike its use on the lower limb. The best results for fracture healing and final function were achieved by functional bracing.

Adolescent↗