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Metachronous aneurysmal bone cysts are rare. We report on a 32-year-old man who presented with an aneurysmal bone cyst of the thoracic spine 15 years subsequent to diagnosis of aneurysmal bone cyst of the humerus.
A case of soft tissue recurrence of chondroblastoma after attempted en bloc excision and endoprosthetic replacement is described. This tumor in the proximal humerus recurred after initial curettage and was subsequently treated by attempted en bloc excision with positive microscopic margins. The patient then presented with a large soft tissue recurrence surrounding the endoprosthesis. This periprosthetic recurrence necessitated re-excision and revision of the endoprosthesis. Recurrence is not uncommon following curettage of chondroblastoma. However, less is known about soft tissue recurrence after en bloc resection of this tumor with positive margins. A subset of chondroblastoma may exist with more locally aggressive behavior.
Myxoma of bone, outside of the jaws, is exceptional. We present such a tumor in the humerus and discuss the criteria for the diagnosis of myxoma.
OBJECTIVE: The objective of this study was to compare ultrasonography (US) and plain radiography in the evaluation of the bicipital groove of the humerus and to determine the accuracy of US in measurement of the width and depth of the groove compared to plain radiography. PATIENTS AND METHODS: Visualization of the groove and its abnormalities in 350 consecutive patients by US and on tangential groove radiographs were compared. The groove was measured prospectively in 45 patients on the ultrasound imaging monitor and retrospectively on groove radiographs without knowledge of the US results. RESULTS: The bony anatomy of the groove was adequately seen with US in 90% of patients (314 of 350) and on groove radiographs in 91% (319 of 350). All 24 shallow and 6 tunnel-shaped grooves were diagnosed with both imaging methods, but osteophytes and erosions could not be reliably demonstrated with US. CONCLUSION: Sonography was as accurate for evaluation of the dimensions of the bicipital groove as groove radiographs, and both methods had a similar failure rate. Pathological changes of the walls of the groove could not be reliably evaluated with sonography.
A retrospective study was designed to evaluate the results of closed reduction and percutaneous pinning using threaded pins as a treatment option for fractures of the humeral head. Patients who suffered two- and three-part fractures of the proximal humerus treated by this method of fixation were included. Fifty patients (32 females and 18 males) with an average age of 50 years were clinically evaluated at an average of 2.5 years after this procedure (range 1-4 years). The Constant score was used to evaluate the clinical outcome. Preoperative and postoperative X-rays were also assessed. Out of 50 patients, 18 (36%) obtained excellent results, 17 (34%) good results, eight (16%) fair results and seven (14%) achieved only poor results. The average Constant score was 81 (range 60-100). Fractures confined to the surgical or anatomical neck generally did better than those associated with a greater tuberosity fragment (average score 86 versus 78). Patients who required shaft stabilisation and in addition to reduction and fixation of the greater tuberosity showed a lower average score (68). There were no cases of avascular necrosis, neurovascular complications or deep infections. A significant loss of fracture position due to failure of internal fixation occurred in seven cases, three of these patients underwent revision surgery. Closed reduction and percutaneous pinning offers a good fracture position and stability with minimal soft tissue damage. We recommend that displaced two- and three- part fractures of the humeral head should be treated in this manner. However these patients should be monitored closely for a period of four weeks, since secondary displacement and failure of fixation can occur in this period. Careful patient selection may minimise these complications.
Mixed lytic and sclerotic myeloma are uncommon and occur at an earlier age than multiple myeloma in areas of persistent haemopoiesis. Their characteristic symptoms are pain, swelling and pathological fractures and they are usually detected at an early stage. We report a case of a mixed sclerotic/lytic myeloma of the humerus presenting at an unusually advanced stage and associated with a bilateral progressive demyelinating peripheral sensory and motor polyneuropathy resembling polyradiculitis. The neurological changes partly disappeared after the tumour had been resected which suggests that nerve reconstitution may occur due to reversal of the demyelination.
We present the case of a 12-year-old patient with periosteal osteoblastoma in the distal humerus. The clinical, pathological, and imaging findings are described and discussed.
A series of 33 children with displaced supracondylar fractures of the humerus (SFH) were all treated operatively by open reduction and internal fixation or by closed reduction and percutaneous pinning. A follow-up study was performed on average 29 months (range 3-63 months) after the injury. In 18 per cent of cases primary neurovascular injury was observed and confirmed at operation. Of these patients 32 had open reduction and internal fixation by K-wires; in only one case was closed reduction and percutaneous pinning attempted. If there was preoperative neurological deficit, the nerves were visualized; however nerve suture was not required in our series. In one case we had to reconstruct both the brachial and radial arteries because of intimal lesions totally occluding the vessels. The average hospital stay was 9 days, including pin removal, which was usually performed about 4-5 weeks later, at the time of plaster removal. By Innocenti's criteria, 27 of 30 patients reviewed had an excellent result; three had a good result and three patients were lost to follow-up. There were no complications due to the operation, such as wound healing problems, infections or nerve lesions. In the light of our experience and of the good results, we recommend that displaced SFH be managed by open reduction and internal K-wire fixation. Percutaneous pinning is a good alternative method when closed reduction is successful at the first attempt.
Between 1981 and 1989 22 bicondylar fractures of the distal humerus were operated on. Fractures were classified according to the AO system. Fixation consisted of medial and lateral plates combined to articular screws in 14 cases, one articular screw associated to one medial screw and a lateral plate in four cases, three lag screws in three cases, and in one case the articular screw was associated to one medial screw and one 'Y' plate. Osteotomy of the olecranon was fixed by one intramedullary screw and one wire in 15 cases, other simpler methods (wire or screw alone) were used in seven cases. A scoring system that included pain, range of motion, radiological results and postoperative activity level, was developed to study the results. Two fractures went to nonunion. Results were quoted as excellent in six cases, good in five cases, fair in eight patients and poor in three cases. Younger patients achieved a better range of motion (P = 0.039) and better functional level (P = 0.015), and differences in radiological score (P = 0.029), activity level score (P = 0.048) and total score (P = 0.0031) were observed depending on the anatomical fracture type.
A 22-month-old Saudi child developed a granulomatous lesion of the left humerus following BCG vaccination in the overlying deltoid area 15 days after birth. The clinical picture, investigations and the histopathology reports are presented. The literature regarding BCG vaccine complications and their frequency is reviewed.
This paper describes treating high-tension electrical burns of the upper arms by segmental excision of the necrosed humerus. This is a new surgical method of treating local electrical burns. The authors use modification of traditional surgical method, shorten the course of treatment, and preserve the injured limb. However, this surgical method should not be used to treat all high-tension electrical burns of the upper arm, and should be used only under certain conditions. Therefore, it is important to grasp the operative indications.
BACKGROUND: The objectives of this study were to quantify the indentation strength and modulus of distal humeral cancellous bone, and to identify regional variations. The motivations were to assist in prosthesis development and to optimize screw placement. METHODS: Three consecutive 3mm transverse slices were sectioned from the distal ends of seven fresh-frozen cadaveric specimens. A 3 x 3mm grid was drawn on each slice, providing locations for indentation using a flat cylindrical indenter (diameter=1.6mm) attached to a materials testing machine. The mean indentation modulus and local yield strength were calculated for each site, and pooled into nine anatomically defined regions. FINDINGS: Indentation modulus was found to range from 2.9 to 1041.7 MPa with a mean of 309.8 (242.0)MPa. Local yield strength was found to range from 0.6 to 16.3 MPa, with a mean value of 4.4 (2.5)MPa. The most distal slice had higher modulus values (P<0.05), and the posterior lateral region had lower modulus values (P<0.05). There were no slice or regional differences in strength. INTERPRETATION: The influence of slice depth emphasizes the importance of minimizing the amount of bone removed during prosthetic replacement. Regional variations in indentation modulus suggest that the posterior lateral region should be avoided during fixation of implants or placement of screws. A comparison with proximal tibial cancellous bone properties suggests the distal humerus may carry loads approaching 45% of those at the knee, assuming that bone adapts to stress magnitudes.
The absence of population-specific standards for sex, age and stature estimation for rural Guatemala is problematic for the forensic analysis of skeletal remains recovered from clandestine graves attributed to the recent armed conflict in that country. In order to increase the reliability of the forensic analyses being undertaken in Guatemala, standards for metric determination of sex were developed. Data was collected on several bones; the results for the humerus are presented here. A sample of 118 complete humeri (68 male and 50 female) was studied; maximum length, maximum diameter of the head, circumference at midshaft, maximum diameter at midshaft, minimum diameter at midshaft and epicondylar breadth were measured and subjected to discriminant function analysis. The classification accuracies for the univariate functions range from 76.8% for the maximum diameter at midshaft to 95.5% for the maximum diameter of the head. The classification accuracy for the stepwise procedure was 98.2%.
We report a rare anatomic variation in which the median nerve travels in a bony canal of the distal humerus, separating from the brachial artery. We encountered this during neurolysis for posttraumatic median nerve palsy in a 10-year-old boy. We suggest that this anatomic variation was related strongly to this patient's median nerve palsy.
The purpose of this study was to evaluate predictors of fracture-induced humeral head ischemia. Between February 1998 and December 2001, 100 intracapsular fractures of the proximal humerus, treated by open surgery, were included in a prospective surgical evaluation protocol (mean age, 60 years; minimum, 21 years; maximum, 88 years; 45 men; 57 right shoulders). Fracture morphology was assessed following a structured questionnaire and based on radiographic and intraoperative findings. Perfusion was assessed intraoperatively by observation of backflow after a borehole was drilled into the central part of the head in all shoulders and by intraosseous laser Doppler flowmetry in 46. Good predictors of ischemia were the length of the metaphyseal head extension (accuracy, 0.84 for calcar segments <8 mm), the integrity of the medial hinge (accuracy, 0.79 for disrupted hinge), and the basic fracture pattern (accuracy, 0.7 for combined types 2, 9, 10, 11, and 12). Moderate and poor predictors of ischemia were fractures consisting of four fragments (accuracy, 0.67), angular displacement of the head (accuracy, 0.62 for angulations over 45 degrees ), the amount of displacement of the tuberosities (accuracy, 0.61 for displacement over 10 mm), glenohumeral dislocation (accuracy, 0.49), head-split components (accuracy, 0.49), and fractures consisting of three fragments (accuracy, 0.38). When the above criteria (anatomic neck, short calcar, disrupted hinge) were combined, positive predictive values of up to 97% could be obtained. The most relevant predictors of ischemia were the length of the dorsomedial metaphyseal extension, the integrity of the medial hinge, and the basic fracture type determined with the binary description system.
Cortical thickness and multiple intramedullary canal diameters were measured in sequential axial sections from 27 human cadavers. No age or side differences were identified. The intramedullary humeral canal shape changed along the length of the bone in both male specimens and female specimens. Anteroposterior and male minimal humeral canal diameters increased proximally from the elbow. Male and female medial-lateral humeral diameters decreased proximally from the elbow. All ulnar canal diameters decreased distally in a uniform fashion. The minimal ulnar and humeral canal diameters did not occur in either the sagittal or coronal plane. Humeral and ulnar cortical thickness did not vary within axial sections. Only ulnar cortical thickness changed between sections, decreasing distally. On the basis of these data, a cylindrical humeral stem and an ulnar stem tapering in all planes may be optimal for total elbow arthroplasty stems. The relatively thin cortices of both the humerus and the ulna predispose patients to perforation, periarticular fracture, and complications during revision arthroplasty surgery. Finally, routine frontal and lateral radiographs may overestimate minimal canal size for total elbow arthroplasty components. However, the lateral view appears to approximate the true minimal canal diameter more closely.
BACKGROUND: Smooth-muscle tumors of uncertain malignant potential represent a variant of uterine leiomyoma and remain a dilemma due to their uncertain clinical behavior. Most of these tumors have a benign clinical course, and coagulative tumor cell necrosis has usually been associated with worse outcome. CASE: We present a case of a uterine smooth-muscle tumor (SMT) of uncertain malignant potential without coagulative tumor cell necrosis that has metastasized to the humerus. The metastatic lesion was a high-grade leiomyosarcoma consistent with uterine origin. CONCLUSIONS: Smooth-muscle tumors of uncertain malignant potential that demonstrate a lack of coagulative tumor cell necrosis do not necessarily insure benign clinical outcome. These lesions can recur and metastasize to distant sites, thus requiring long-term follow-up.
Supracondylar fractures of the humerus are the most common fractures in children that require surgery. A significant advancement in the field of pediatric orthopedics has been closed reduction and percutaneous pinning of these fractures. This technique, using high quality fluoroscopic imaging, allows for a near anatomical reduction of fractures without the need for an open surgical procedure or prolonged traction. Supracondylar fractures in children are often associated with neurologic and vascular damage that must be recognized before fracture reduction. Nursing staff members' skill with pediatric patients can greatly aid the surgeon in the timely and safe treatment of these fractures.