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PubMed1999

Pathologic fracture of the humerus due to metastatic cholangiocarcinoma.

Cholangiocarcinoma is a rare tumor of the bile duct system known to frequently metastasize to the axial skeleton, lungs, adrenal glands, brain, and lymphatic system. Spread to the long bones has not previously been reported in the literature partly because of the short life expectancies of patients with this disease. We discuss a case of a pathologic humerus fracture due to metastatic cholangiocarcinoma.

Bile Duct Neoplasms↗
PubMed2004

Treatment of distal humerus fractures in the elderly.

Geriatric patients with osteopenic bone present unique challenges in the treatment of fractures of the distal humerus, and require different strategies from the traditional treatment philosophies. Fracture union, rather than motion, is the first priority, because motion can be restored reliably by subsequent contracture release, if necessary, as long as the fracture heals. Modifications in the surgical technique, combined with newer implants incorporating distal, transcondylar screws into the plate to improve distal fixation, may improve outcomes. The use of massive, tricortical autogenous bone grafts to replace very comminuted segments of the medial and lateral columns also is helpful. Finally, modification of olecranon osteotomy fixation will minimize healing and hardware problems at this site. For fractures that are judged intraoperatively not to be stable enough to commence early motion, the implementation of a short period of immobilization followed by early soft tissue release will avoid exposing the patient to the risk of nonunion, and result in a more predictable functional outcome.

Aged↗
PubMed2005

Fractures of the distal humerus in the elderly: is internal fixation the treatment of choice?

The incidence of osteoporotic fractures of the distal humerus is increasing, and the treatment of these injuries merits closer review. We assessed the results of 28 elderly patients (29 fractures) with a mean age of 85 years (range, 75-100 years). Open reduction and internal fixation was done on 21 elbows, and eight elbows were treated nonoperatively. Orthopaedic Trauma Association grading showed that the group treated with internal fixation had favorable results (three excellent, nine good, seven fair, and two poor) compared with the nonoperatively treated group (zero excellent, two good, three fair, and three poor). Mean loss of extension and mean flexion were better in the surgically treated patients (23.5 degrees and 99 degrees ) than in the nonoperatively treated patients (33.5 degrees and 71 degrees ). Substantial pain relief (mild or no pain) was achieved in a higher proportion (52%) in the surgically treated group than in the nonoperatively treated group (25%). Anatomic restoration of distal humeral tilt and articular congruity also were better in the surgically treated patients. Rates of complications were observed to be comparable to those described in the literature for younger patients. These findings reflect the relevance of surgical fixation of such fractures in this age group highlighting the need for additional clinical studies.

Aged↗
PubMed2005

Supracondylar fractures of the humerus in children.

Supracondylar fractures of the humerus need a precise treatment in order to obtain a satisfactory result because of the low bone remodeling associated with these injuries. It is important to use a systematic procedure for closed reduction and percutaneous fixation. A retrospective review of fractures treated using two K-wires from the lateral side was done in 77 patients with a mean age of 6.7 years (range, 1-13 years). Displacement of the fracture was classified as Gartland Type II in 39 patients (50.6%) and Gartland Type III in 38 patients (49.4%). The results according to Flynn criteria were excellent in 70 patients (90.9%), fair in three patients (3.9%) and poor in four patients (5.2%), with overall satisfactory results in 96.1% of the cases. In four patients there was secondary displacement of the fragments in internal rotation and three of these patients were operated on again, increasing fixation with a third K-wire either from the lateral or medial side. There were two nerve lesions (2.6%), and four patients (5.2%) had a pulseless pink hand that recovered when the fracture was reduced. In three patients (3.9%) infection developed. To obtain satisfactory results using this procedure, enough stability should be achieved, avoiding iatrogenic damage of the ulnar nerve.

Adolescent↗
PubMed2005

Management of distal humerus fractures with minifragment fixation.

Minifragment implants provide several advantages for the stabilization of distal humerus fractures. Compared with small fragment implants, minifragment implants may provide enhanced fracture fixation because a greater number of screws can be placed into the distal fragments. In addition, minifragment plates are easier to contour and less prominent. We describe the surgical technique of minifragment fixation.

Adult↗
PubMed2006

Operative treatment of osteochondral nonunion of the distal humerus.

Three patients with ununited osteochondral fracture fragments of the distal humerus (2 anterior capitellum and trochlea; 1 posterior trochlea) who had debridement and realignment of the nonunion, autogenous cancellous bone graft, and internal fixation an average of 6 (range, 5-8) months after injury were studied. The preoperative arc of elbow flexion was 80 degrees, 35 degrees, and 25 degrees. All 3 fractures healed without implant related complications or osteonecrosis. At 28, 27, and 46 months after the index procedure for nonunion, the patients had 95 degrees, 90 degrees, and 115 degrees arcs of elbow flexion. The scores on the Mayo Elbow Performance Index were 80, 80, and 95 (2 good, 1 excellent). Based on this limited experience, it seems that operative treatment of ununited osteochondral fracture fragments can achieve union without osteonecrosis. Attempts to improve the function of the native elbow rather than salvage the situation with interpositional or prosthetic arthroplasty are worthwhile.

Adult↗
PubMedDate not supplied

Tricortical bone graft for primary reconstruction of comminuted distal humerus fractures.

A tricortical bone graft harvested from the ilium was used to reconstruct a severely comminuted open intra-articular distal humerus fracture in an adult patient. The patient demonstrated a satisfactory functional and radiologic outcome despite loss of the lateral trochlear lip. When the lateral portion of the fractured trochlea cannot be repaired, excision of the fragments and insertion of an autogenous corticocancellous bone graft from the iliac crest can restore satisfactory function, even in the setting of an open fracture provided there is limited contamination and tissue devitalization. Radiocapitellar contact may be essential to good elbow function in this situation, because the corticocancellous bone graft does not restore the important lateral lip of the trochlea.

Adult↗
PubMed2006

Treatment of diaphyseal fractures of the humerus using a functional brace.

OBJECTIVE: To determine humeral diaphyseal fractures at risk for nonunion with functional brace treatment. DESIGN: Retrospective case series. SETTING: A single surgeon's practice. PATIENTS: Forty-nine of 52 consecutive patients treated nonoperatively for an isolated diaphyseal fracture of the humerus during a 6-year period were followed until either union and full or near-full restoration of shoulder and elbow motion, or until 6 months had passed, or until a reconstructive surgery was performed (average follow-up 14 months; range 2 to 50 months). INTERVENTION: Functional fracture brace. MAIN OUTCOME MEASUREMENTS: Radiographic and clinical union. RESULTS: Union was achieved in 44 of 49 patients (90%) with no more than 15-degree loss of shoulder or elbow motion in any patient. Four of 14 proximal-third fractures (29%), one of 22 middle-third fractures (4%), and none of the 13 distal-third fractures failed to heal. CONCLUSIONS: Proximal-third long oblique fractures may be at greater than average risk for nonunion after functional fracture bracing. LEVEL OF EVIDENCE: Level IV (case series).

Adult↗
PubMedDate not supplied

Proximal humerus fractures sustained during the use of restraints in adolescents.

Injuries to skeletally immature individuals sustained during restraints have been rarely documented. The authors report a series of five proximal humerus fractures in skeletally immature patients (average age 15.3 years) that occurred during restraint with handcuffs. A similar mechanism of injury was identified in all of the cases. All five injuries were Salter-Harris type I or II, and three of the five required operative intervention. At short-term follow-up, all patients are doing well without evidence of growth disturbances. To the authors' knowledge, this is a unique mechanism of injury that could be avoided with proper education.

Adolescent↗
PubMed2003

Isolated fractures of the greater tuberosity of the humerus: solutions to recognizing a frequently overlooked fracture.

BACKGROUND: Although isolated fracture of the greater tuberosity of the humerus had been regarded as an easily overlooked fracture, recent literature focusing on its diagnosis is scarce. The purpose of this study was to elucidate the rate of missed diagnosis of isolated humeral greater tuberosity fracture and pitfalls in diagnosis and to ascertain the most effective method for preventing missed diagnosis. METHODS: One hundred sixty-three shoulders, of which diagnosis was made by radiography for all and by proving a localized tenderness on the lateral wall of the greater tuberosity for the acute cases, were retrospectively reviewed. The diagnoses made at the previously visited clinic were analyzed, as was the relationship between missed diagnosis and other pertinent factors such as the extent of fracture and the amount of displacement of the fractured fragment. RESULTS: Fractures were overlooked in 58 of the 99 shoulders (59%) that had been initially examined at other clinics. The rate (64%) of missed diagnosis in one-part fractures was significantly higher than that (27%) in two-part fractures (p < 0.01). Twenty-five (76%) of 33 isolated supraspinatus (SSP) (facet for the SSP), 26 (57%) of 46 SSP + infraspinatus (ISP) (facet for the infraspinatus ISP), and 6 (33%) of 18 SSP + ISP + teres minor (facet for the teres minor) fractures were overlooked at previous clinics. The smaller the fragment, the higher the rate of missed diagnosis (p < 0.05). CONCLUSION: Isolated fracture of the greater tuberosity remains an easily overlooked injury. The likelihood of this missed diagnosis increases with the fracture being limited to the SSP facet and decreases as the fracture extends posteriorly. Confirming the presence of tenderness on the lateral wall of the greater tuberosity is a clinically effective method for preventing missed diagnosis.

Adolescent↗
PubMed1982

Cubitus varus deformity following supracondylar fractures of the humerus in children.

A retrospective study of 63 patients with cubitus varus deformity following supracondylar fracture of the humerus was carried out in order to identify the causes of cubitus varus, to define the best method for prevention, and to evaluate the indications for and results of treatment of the established deformity. There was no evidence of growth disturbance in any of our patients after a mean follow-up of 5 years postfracture. Cubitus varus was found to be secondary to medial tilting of the distal fragment. Failure to recognize this initial or subsequent medial tilt during early treatment of the fracture was the major factor in the development of cubitus varus deformity, thus explaining the average delay in diagnosis of 6 to 10 weeks postfracture. Since all patients regained essentially normal use of the upper extremity after the fracture, cosmesis was the primary indication for corrective surgery. Fifteen supracondylar osteotomies are reported with 33% unsatisfactory results. Prevention of this deformity by careful clinical and radiological evaluation during initial treatment of the supracondylar fracture is emphasized.

Child↗
PubMedDate not supplied

Fractures of the medial condyle of the humerus in children.

Twenty-seven cases of fractures of the medial condyle of the humerus in children were grouped into one of three types, based on displacement of the medial condyle on initial roentgenograms. Results after an average follow-up of 2.2 years showed that children less than 5 years old tended to have undisplaced fractures giving rise to good results. Older children tended to have more severely displaced fractures. Good results were obtained in patients who were seen early after injury and who had adequate reduction of their fractures. In cases seen late, proper reduction and immobilization are necessary to achieve satisfactory results.

Age Factors↗
PubMedDate not supplied

Neurological complications resulting from supracondylar fractures of the humerus in children.

One hundred thirty-eight children with supracondylar fractures of the humerus were reviewed. Seventeen (12%) exhibited neurological deficits. Nine median, four ulnar, and four radial neuropathies were encountered. The neurological deficit was treated expectantly. The osseous injury was treated by a variety of methods. All patients except two recovered spontaneously in an average of 9 weeks. One patient was still improving at 9 months' follow-up. Another patient with radial neuropathy underwent exploration 6 months after injury and was found to have a transected radial nerve. This study demonstrates that neurological deficits from supracondylar humeral fractures remain common, involve all three major nerves of forearm, and, with rare exception, recover with conservative therapy.

Child↗
PubMedDate not supplied

Neurologic complications after K-wire fixation of supracondylar humerus fractures in children.

A retrospective review of 143 supracondylar humerus fractures in children treated with K-wire fixation disclosed four neurologic complications after treatment. There were two late ulnar neuropraxias. One ulnar nerve injury and one radial nerve injury resulted from direct trauma during insertion of a K-wire. All patients regained full neurologic function.

Bone Wires↗
PubMedDate not supplied

Treatment of the displaced supracondylar fracture of the humerus (type III) with closed reduction and percutaneous cross-pin fixation.

Forty-five consecutive patients treated for displaced supracondylar fractures of the humerus, Type III, by means of closed reduction and percutaneous crossed-pin fixation, were studied retrospectively. Thirty-three were available at an average of 33 months post-injury for clinical and radiographic follow-up of the affected and nonaffected extremities. Five additional patients returned radiographs for analysis. Baumann's angle and a lateral humeral capitellar angle were assessed and found to be useful clinical guides for assessing the adequacy of maintenance of fracture reduction. Based upon Flynn's criteria, 31 of 33 patients clinically assessed had a satisfactory result. Closed reduction with percutaneous pin fixation is believed to represent a safe, reliable, and efficient method of managing this difficult fracture.

Adolescent↗
PubMedDate not supplied

Deformity and function in supracondylar fractures of the humerus in children variously treated by closed reduction and splinting, traction, and percutaneous pinning.

The radiographs of 137 patients with supracondylar fractures of the humerus treated by closed reduction and splinting, traction, and closed reduction and percutaneous pinning (CRPP) were reviewed to determine the adequacy of the initial reduction and the maintenance of the reduction. Eighty-four patients were examined for function and deformity. Initially, Baumann's angle was adequate and similar in all patients, but the humerocapitellar angle was better with CRPP. Maintenance of reduction in both planes was superior with CRPP, and significantly better clinical results were achieved by CRPP. Nevertheless, there was no functional loss in any patient, and no parent wanted correction of deformity.

Adolescent↗
PubMedDate not supplied

Supracondylar fractures of the humerus: a prospective study of percutaneous pinning.

In 1981, we designed a protocol to treat displaced supracondylar fractures using a modified technique of closed reduction and percutaneous pinning. After the fracture was internally fixed, intraoperative anteroposterior (AP) radiographs of each distal humerus were compared. The reduction and pinning was accepted only if the radiographs demonstrated that Baumann's angle was < or = 4 degrees of that on the normal side. Seventy-one patients had clinical and radiographic evaluations at an average of 2 years 6 months after the operation. According to Flynn's criteria, the results were satisfactory in 70 patients and unsatisfactory in one. No patient had a cubitus varus deformity at follow-up evaluation.

Bone Nails↗
PubMedDate not supplied

Incidence of anterior interosseous nerve palsy in supracondylar humerus fractures in children.

A retrospective review of 101 supracondylar humerus fractures in children between the ages of 0 and 11 years identified 15 patients with neural lesions. All were associated with displaced fractures, and 10 (66%) required open reduction for definitive fracture management. Six of these lesions were isolated anterior interosseous nerve palsies and four other patients had an anterior interosseous nerve injury in combination with another nerve injury, producing a sensory deficit. Two patients had a complete median nerve palsy. Only three patients had nerve lesions that did not involve the anterior interosseous nerve. The incidence (15%) of neural lesions in this study is similar to that reported elsewhere, but the incidence of anterior interosseous nerve lesions, particularly those occurring as an isolated injury, is much higher than has been reported previously. Because an anterior interosseous nerve palsy results in motor loss only, this injury may be easily overlooked.

Arm↗