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Five years after an intramedullary nailing of a fractured humerus a fistula developed in a dog. The nail was removed and a gross swelling developed 11 weeks later. Osteosarcoma was diagnosed.
A three-year-old girl suffered a T-condylar fracture of the distal humerus. Open reduction and pinning were performed. Three years after injury, there was no functional disturbance or radiographic evidence of avascular necrosis or epiphyseal growth arrest.
The authors reviewed the computed tomography (CT) scans, plain radiographs, and subsequent treatment of 17 patients with complex proximal humeral fractures. CT scans and radiographs were compared in the demonstration of fracture lines, displacement of fracture fragments, rotation of fragments relative to their normal positions, and status of the head and articular surface of the humerus. The impact of CT findings on the decision to treat with surgery versus closed reduction and on the choice of surgical procedure was assessed. Surgery was not performed in nine patients because CT scans showed no significant displacement of fragments previously judged displaced or "indeterminate" on radiographs. Surgery was performed in eight patients; CT demonstrated significant abnormalities not definitely shown with radiography. In six of these eight patients, CT scans demonstrated unsuspected abnormalities that directed the choice of surgical procedure. CT scans provide clinically useful information for the treatment of complex proximal humeral fractures when radiographs provide inadequate or indefinite information.
Seventy patients who had sustained supracondylar fractures of the humerus as children were examined. Loss of carrying angle of the elbow occurred if the fracture was immobilized in a varus position during healing. Varus malalignment could have been obviated if comparative radiographs of the other elbow had been taken and the Baumann angles compared. Rotation and posterior displacement at the fracture had little bearing on the outcome. Immobilization of the fracture in a collar and cuff sling was as effective as more elaborate methods.
Fractures of the humeral shaft in various throwing sports is a well recognized clinical entity. The specific etiology remains uncertain. Competitors engaged in Indian and/or wrist wrestling, a sport receiving increased interest, also are known to sustain humeral fractures. It is thought that these particular fractures are the result of bending moment, axial compression, and torsional forces applied to the humerus. The position of the arm during the match appears to be critical in determining the fracture pattern and location. Closed treatment was successful in all reported cases.
A 41-year-old right-handed woman was involved in a traffic accident and landed on the right arm while the right shoulder was in flexion. She experienced pain and severe impairment of right shoulder motion immediately following the accident. She was misdiagnosed with a fractured proximal humerus with no displacement and was treated conservatively by immobilisation. There was inadequate recovery in range of motion and gradual development of severe pain. Two years and 4 months after the injury, the patient presented to our hospital where a diagnosis of chronic posterior fracture dislocation of the shoulder with split articular surface of the humeral head was made. A humeral head replacement without resection of the greater tuberosity or the coracoid process was performed. Postoperative recovery was uneventful. The patient returned to work as a cook one year later. At 20-month follow-up, the patient had no pain, and her shoulder range of motion was forward flexion 160 degrees, abduction 140 degrees, external rotation 40 degrees, and internal rotation L3.
BACKGROUND: Metastatic disease to the shoulder girdle is a challenging problem because of the potential for pain, pathologic fracture and loss of function of that limb. Management of the bone disease centers around palliation, prevention of further complications and the preservation of residual function. A variety of surgical options exist for managing metastatic disease to the shoulder girdle and our experience with over 90 patients is reported. We focus on a preferred technique of combining rigid intramedullary nailing with cementation. METHODS: Patients with metastatic disease to the shoulder girdle were accrued over a 9 year period from 1996 to 2004. 93 patients were identified with 96 operations being performed. The median age was 63 years (range 33 - 89) and 54% were female. The commonest primary tumor to metastasize was breast, and the proximal and midshaft humerus was involved in 84% of cases. The median survival time was 8 months and at last review 82% of patients had died of their disease RESULTS: Operations performed were intramedullary nailing (n = 51), resection with or without prosthetic reconstruction (n = 34) or plate osteosynthesis (n = 9). The site of the metastasis was a guide to the most appropriate operation. Amputations (n = 2) were not done as the primary procedure. Median post operative hospitalization ranged from 3 to 6 days depending on the type of operation performed. Our preferred technique for diaphyseal lesions (intramedullary nailing plus cementation) achieved excellent results in terms of pain relief, functional restoration and minimal complications. Functional restriction was most notable for proximal humeral prostheses (35% of patients). CONCLUSION: Surgical treatment of metastases to the shoulder girdle can be successful, allowing prompt relief of pain and return to prehospital level of care. Proximal and midshaft humeral metastases are easily amenable to resection and reconstruction or intramedullary nailing with cementation. Relief of pain and preservation of function occurs for the majority of patients.
This paper reports a prospective study of 72 consecutive patients with fractures or fracture-dislocations of the upper end of the humerus, treated during 1981. Most were elderly and treatment was conservative. Of the 72 patients 64 were followed up for a period of six months. Observations were made on the type of fracture, the speed and pattern of recovery of shoulder movements, on the time of commencement of physiotherapy, and on its duration. We found that with conservative treatment alone, 94% of our patients had good or satisfactory results at six months from injury. The criteria for manipulation are discussed and the literature is reviewed.
Ninety-eight children with severely displaced supracondylar fractures of the humerus were treated by straight lateral traction. After a mean follow-up period of 3.5 years there were 90 satisfactory and only eight unsatisfactory results. Cubitus varus was present in only four children, which compares favourably with the results of operative treatment. The indications for straight lateral traction, and the advantages of this method, are discussed.
A simple method of radiological assessment has been used to measure the angle between the long axis of the humeral shaft and the growth plate of the capitellum (the Baumann angle). In the normal arm a significant relationship was found between the Baumann angle and the carrying angle. The Baumann angle was also measured after reduction of supracondylar fractures of the humerus and was found to correlate well with the final carrying angle measured at follow-up. There was no significant difference between the Baumann angle after reduction and that measured at follow-up; and it is suggested that this angle after reduction can be reliably used to predict accurately the final carrying angle.
A new technique for the treatment of displaced fractures of the proximal humerus is described. Twelve fractures in 11 patients were managed by transcutaneous reduction using a Steinmann pin, and external fixation with a Hoffmann-type neutralising bar connected to two half-pins in the humeral head and three half-pins in the shaft. The pins were removed after four weeks. Two patients sustained redisplacement after a further injury, but in the others reduction was maintained. Two cases of pin-track infection resolved after antibiotics, but delayed union resulted. There were no neurovascular injuries and at follow-up of 6 to 12 months no refractures had been seen. The early functional results were excellent or satisfactory in nine cases.
A consecutive series of 31 displaced fractures of the proximal humerus were randomly selected for treatment either by closed manipulation or by transcutaneous reduction and external fixation. Follow-up assessed the quality of reduction and healing as well as the functional outcome. The external fixation method gave better reduction, safer healing and superior function.
We reviewed 57 adult patients at an average of 37 months after early internal fixation for displaced fractures of the distal humerus. Two-thirds had intercondylar (Müller type C) fractures, and one-third had articular comminution (type C3). A chevron olecranon osteotomy was used, with early active movement after fixation. Results were good or excellent in 76% with an average range of movement of 115 degrees. Early stable fixation by an experienced surgeon is recommended for these fractures.
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.
Nonunion of fractures of the olecranon fossa of the humerus presents a difficult surgical problem. The distal fragment is usually small and osteoporotic and stable fixation is not easy to achieve. We describe a modification of the technique of locked nailing by which the distal aspect of the nail is placed in the subchondral region of the trochlea. Good results were obtained in seven out of eight patients with this technique.
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.
Our study describes a posterolateral approach to the distal humerus for open reduction and internal fixation of displaced fractures of the lateral condyle. A total of 20 patients had open reduction and internal fixation over a four-year period using this approach, and at a mean follow-up of 12 months had full union, range of movement and no complications, either clinical or radiological. This approach is well suited to the exact visualisation and accurate reduction of this difficult fracture with minimal dissection of tissues.
We treated 15 patients with atrophic nonunion of a diaphyseal fracture of the humerus with an associated bony defect using an autogenous cancellous bone graft and a plate to bridge the defect. There were nine men and six women with a mean age of 48 years. The mean length of the bony defect was 3 cm. At a mean follow-up of 30 months only one fracture failed to unite. This suggests that, in the presence of a well-vascularised envelope of muscle, the application of an autogenous cancellous bone graft in conjunction with a bridging plate represents a good alternative to more demanding surgical techniques.