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PubMed2006

Hybrid locked plating of osteoporotic fractures of the humerus.

BACKGROUND: Locked plating techniques recently have gained popularity and offer a different biomechanical approach for fracture fixation compared with traditional compression plating. In certain clinical situations, it may be preferable to employ a "hybrid" construct, in which an unlocked screw is used to assist with reduction and locked screws are subsequently used to protect the initial reduction. In the present study, we used an unstable osteoporotic fracture model of the humerus to determine (1) whether a hybrid construct behaved more like a locked construct or a conventional unlocked construct and (2) whether there was a difference between locked and unlocked constructs. METHODS: Thirty third-generation Sawbones humeri were divided into three groups of ten humeri each. A locking plate with combination holes was applied to each bone with use of either a locked construct, an unlocked construct, or a hybrid construct. To simulate purchase in osteoporotic bone, all screw-holes were drilled to 0.3 mm less than the diameter of the screw used. Each specimen was then osteotomized in the middle part of the shaft, and a 5-mm segment was removed. Oscillating cyclic torsion testing was performed to +/-10 N-m for 1000 cycles, torsional stiffness was determined at periodic cyclic intervals, and the groups were compared. RESULTS: The locked and hybrid constructs demonstrated similar behavior. The initial stiffness was similar in these two groups. At ten cycles, the locked and hybrid constructs retained 96.3% and 95.4% of their initial stiffness, respectively. During the remainder of cycling the stiffness of the locked and hybrid constructs decreased in a linear fashion (R(2) = 0.89 and 0.88, respectively), and at 1000 cycles the stiffness of the locked and hybrid constructs averaged 80.0% and 79.2% of the initial values, respectively (p = 1.0). In contrast, the unlocked constructs initially were significantly less stiff than both the locked and hybrid constructs (p < 0.001). At ten cycles the unlocked constructs retained 80.4% of their initial stiffness, and at 1000 cycles they retained only 22.3% of their initial stiffness. CONCLUSIONS: Hybrid constructs are mechanically similar to locked constructs, and both are significantly more stable than unlocked constructs under torsional cyclic loading. CLINICAL RELEVANCE: Combining screws in the hybrid configuration used in the present study did not compromise the mechanical performance of the construct. Hybrid constructs may decrease cost and may provide additional clinical value when treating fractures in osteoporotic bone.

Bone Plates↗
PubMed2006

Extra-articular distal-third diaphyseal fractures of the humerus. A comparison of functional bracing and plate fixation.

BACKGROUND: There are strong advocates for both operative and nonoperative treatment of distal-third diaphyseal fractures of the humerus, but there are few comparative data. We performed a retrospective comparison of these two treatment methods. METHODS: Fifty-one consecutive patients with a closed, extra-articular fracture of the distal one-third of the humeral diaphysis were identified from an orthopaedic trauma database. Forty patients were followed for at least six months or until healing of the fracture. Eleven patients were excluded because of inadequate follow-up. Nineteen patients had been managed with plate-and-screw fixation, and twenty-one had been managed with functional bracing. RESULTS: Among the operatively treated patients, one had loss of fixation, one had a postoperative infection, and one required tendon transfers for the treatment of a preoperative radial nerve palsy that did not resolve. Three new postoperative radial nerve palsies developed, and one had not resolved when the patient was last evaluated, three months after surgery. All operatively treated fractures healed with <10 degrees of angular deformity, and one patient lost 20 degrees of shoulder or elbow motion. Among the nonoperatively treated fractures, two were converted to plate fixation because of the treating surgeons' concern regarding alignment and radial nerve palsy. Only one patient had >30 degrees of malalignment in any plane. Two patients had development of skin breakdown during treatment and completed treatment in a sling. Two patients lost >/=20 degrees of elbow or shoulder motion. CONCLUSIONS: For extra-articular distal-third diaphyseal humeral fractures, operative treatment achieves more predictable alignment and potentially quicker return of function but risks iatrogenic nerve injury and infection and the need for reoperation. Functional bracing can be associated with skin problems and varying degrees of angular deformity, but function and range of motion are usually excellent.

Adult↗
PubMedDate not supplied

[External fixation war injuries of the proximal humerus].

Nine patients with open fractures of the proximal humerus were treated using an external fixation device. All of them had grade III open fractures resulting from high-velocity missile and explosive injuries with massive foreign body contamination. Radial nerve injury was present in five and two multiply injured patients with thoracic wall and abdominal viscera were present. There were no major arterial injuries. Chronic osteitis with fistula and sequestra developed in one. There were no nonunions and no refractures. Minor painless limitation of shoulder and elbow motion presented in all patient. Upper-third humeral open fractures due to firearms are a unique type of open fractures. They are usually highly comminuted therefore, stable fixation is difficult or impossible to achieve. On the other hand, the risk of infection is high following plate fixation. External fixation allows adequate management of the soft tissue wounds, provides stable bone fixation and allows early mobilization of the shoulder and elbow.

External Fixators↗
PubMed2003

Stress fractures of the tibia and humerus in Thoroughbred racehorses: 99 cases (1992-2000).

OBJECTIVE: To determine clinical characteristics of and outcome in Thoroughbred racehorses with tibial or humeral stress fractures. DESIGN: Retrospective study. ANIMALS: 99 Thoroughbreds with tibial or humeral stress fractures. PROCEDURE: Information obtained from the medical records included history, signalment, and clinical, radiographic, and scintigraphic findings. Outcome was determined by interviewing trainers, performing follow-up examinations, and analyzing race records. RESULTS: Seventy-four tibial stress fractures were identified in 61 Thoroughbreds, and 48 humeral stress fractures were identified in 39 Thoroughbreds (1 horse was included in both groups). Tibial stress fractures occurred most commonly in 2-year-old or unraced horses. Fractures were located in 1 of 3 sites in the tibia (most commonly, the caudolateral cortex of the mid-diaphysis) and 1 of 4 sites in the humerus (most commonly, the caudodistal cortex). Forty-four of 58 (76%) tibial stress fractures and 18 of 32 (56%) humeral stress fractures were identified radiographically. Humeral stress fractures involving the caudodistal cortex were not detected radiographically. Treatment consisted of rest and exercise restriction, and 49 of 61 (80%) horses with tibial stress fractures and 30 of 39 (77%) horses with humeral stress fractures returned to racing. Humeral stress fractures recurred in 6 horses. CONCLUSIONS AND CLINICAL RELEVANCE: Results suggested that in Thoroughbred racehorses, tibial stress fractures occurred most commonly in unraced 2 year olds, whereas humeral fractures occurred most commonly in older horses that had raced previously. The prognosis for racing following treatment was good.

Age Factors↗
PubMed1976

Supracondylar fractures of the humerus in children. A follow-up with particular reference to late results after severely displaced fractures.

A follow-up of 73 cases out of a 10-year material of 90 children with supracondylar fractures of the humerus is described. Forty-three children had fractures with gross displacement, whereas 30 children had undisplaced or slightly displaced fractures. This last group all achieved excellent results after simple conservative treatment. Twenty-three cases among the group with severe displacement were treated with vertical extension, 17 cases with one or more attempts at manipulative reduction and plaster fixation, and three with operation using Kirschner wires. The functional results were approximately the same in the first two groups and were satisfactory in 85-100%. The results with varus derformity were better in the group treated by extension (82% as opposed to 50% in the group treated by manual reposition). We conclude that extension in a vertical direction is the most suitable method of treatment of these often severely displaced fractures.

Adolescent↗
PubMed1978

Reduction of displaced supracondylar fracture of the humerus in children by manipulation in flexion.

Sixty-one children with posteriourly displaced supracondylar fractures of the humerus were treated by minipulation with the elbow flexed 40 degrees-60 degrees. This method proved to be safe, easy to apply and was followed by a high rate of success. The elbow was immobilized using a collar-and-cuff or a broad sling and binding of the arm to the forearm with zinc oxide adhesive plaster. In difficult children, the limb was put under the child's clothing to avoid its being used. Redisplacement occurred in only 8.2 per cent of the patients and in none of these was it severe enough to justify remanipulation.

Adolescent↗
PubMed1978

Supracondylar fracture of the humerus in children. A long-term follow-up study of 107 cases.

A total of 107 cases of supracondylar fracture of the humerus in children were examined after a follow-up period of 8 to 18 years. No serious complications were found. Conservative treatment gave good results, and open reduction was seldom indicated. Rotational displacement and displacement in the frontal or sagittal plane remodelled by the end of the growth period, whereas tilting of the distal fragment into varus or valgus remained. The position of reduction should be checked roentgenologically until bony consolidation occurs, by measuring Baumann's angle or the carrying angle, and rereductions should be performed within 2 weeks.

Adolescent↗
PubMed1982

Displaced supracondylar fractures of the humerus in children.

In a 3-year period, 101 children were admitted to hospital with supracondylar fractures of the humerus. Eight-six were examined an average of 3.7 years after the injury. Forty-seven cases were treated with closed reduction and plaster bandage. After an unsuccessful attempt at closed reduction, 39 cases were treated with percutaneous K-wire pinning and plaster. The cases treated with percutaneous pinning thus include the most severe fractures. Nevertheless, the results at follow-up in these cases easily equalled those obtained by closed reduction for the less displaced fractures. They were also comparable with reported results of extension treatment and, in contrast, required only a few days of hospitalisation.

Child↗
PubMed1984

Closed treatment of fractures of the proximal humerus.

The results of 42 patients with three- or four-part fractures of the proximal humerus treated by closed methods only were reviewed. In 34 three-part fractures, 24 cases were satisfactory and 10 cases unsatisfactory; the satisfactory results tended to be in an older age group. In four-part fractures all eight cases had unsatisfactory results. It is concluded that closed treatment can give satisfactory results in three-part fractures but not in four-part fractures.

Adult↗
PubMed1986

Radial palsy in shaft fracture of the humerus.

Fifty-nine patients with immediate and 16 with secondary radial nerve palsy complicating a fracture of the shaft of the humerus were reviewed. According to the preferences of the surgeon in charge, the palsy was treated either with early exploration of the radial nerve and internal fixation of the fracture or with initial expectance. Of the latter, 12 were later explored. No useful recovery of motor function could be seen in 13/59 patients with immediate and in 2/16 patients with secondary palsy. In patients with immediate palsy treated by early exploration, there were 8/27 nonrecoveries. Among those treated with initial expectance, there were 5/32 nonrecoveries. For secondary palsy, these figures were 2/10 and 0/6, respectively. No support emerged for routine early exploration.

Adolescent↗
PubMed1990

Ulnar nerve palsy after supracondylar humerus fracture.

Six patients with cubitus varus deformity after a supracondylar fracture of the humerus had ulnar nerve palsy 7 (3-14) years following the fracture. All the patients showed anterior dislocation of the ulnar nerve during elbow flexion. In cubitus varus deformity, medial shifting of the triceps muscle occurs, which pushes the ulnar nerve anteriorly and frequently causes ulnar-nerve dislocation. Five of the 6 patients underwent surgery with subsequent improvement.

Electromyography↗
PubMed1986

Randomized trial of oral naproxen or local injection of betamethasone in lateral epicondylitis of the humerus.

A randomized pilot study, comparing oral naproxen and a single betamethasone injection, was carried out in 21 patients suffering from lateral epicondylitis of the humerus ("tennis elbow"). The naproxen dosage was 250 mg per day for two weeks. Six milligrams of betamethasone in a long-acting form was given as a local injection. To achieve "blindness," the patients receiving naproxen were also given an injection of saline into the area of maximal tenderness at the epicondyle, while the patients getting the betamethasone-injection were given oral placebo tablets. At a clinical control after two weeks, five of the ten patients receiving naproxen and five of the 11 patients receiving betamethasone injection were improved. Thus, no apparent difference in effect could be noted at an evaluation after two weeks' treatment. No significant side effects were noted with any of the treatments.

Administration, Oral↗
PubMed1989

Open reduction and internal fixation of three-part fractures of the proximal humerus.

Eleven patients with 12 three-part fractures of the proximal humerus were treated by open reduction and internal fixation using AO/ASIF buttress plating. All of the fractures healed. There were no failures of fixation. Nine of these patients returned for a follow up of more than 2 years and had a satisfactory rating using Neer's shoulder rating system. Five patients who had an acromioplasty at the time of their initial surgery had slightly better function and range of motion than the remaining patients. Successful operative treatment requires accurate definition of the fracture pattern, careful attention to the details of internal fixation, and supervised postoperative rehabilitation.

Adult↗
PubMed1992

Pathologic fractures of the humerus.

Pathologic fractures of the humerus create serious management problems. Impending fractures often can be anticipated. Fixation of impending or established fractures may provide significant benefits: comfort, improved functional ability, and facilitation of nursing care.

Bone Nails↗
PubMed1997

Percutaneous pinning of proximal humerus fractures: a biomechanical study.

Mechanical testing of two-part surgical neck fractures fixed with four different pin configurations was performed. Ten fresh, frozen, unembalmed humeri stripped of all soft tissues were used; the surgical neck was osteotomized perpendicular to the humerus long axis. Terminally threaded 2.5-mm AO pins were used to fix the fracture. Humeri then were tested in both torsion and bending on a custom-made jig using Instron 1331 to assess the rigidity of pinning constructs. In torsion, two lateral pin construct was significantly less rigid than all other pin configurations. The addition of an anterior pin to two lateral pins did not increase bending rigidity, but significantly increased torsional stiffness. The addition of two bicortical tuberosity pins or two bicortical tuberosity pins and one anterior pin to two lateral pins significantly increased rotational and bending rigidity. Results confirm clinical data, and the authors conclude that multiplanar pins are needed to augment torsional stiffness, and that the addition of two bicortical tuberosity pins enhances bending rigidity.

Biomechanical Phenomena↗
PubMed2000

Surgical treatment of comminuted intra-articular fractures of the distal humerus with double tension band osteosynthesis.

Intra-articular fractures of the distal humerus are usually treated with cancellous screws for the condylar metaphysis itself and two Y-shaped plates for fixation of the metaphysis to the shaft. Twenty-four patients with comminuted intra-articular fractures (class C on AO/ASIF classification) were treated with crossed K-wires for the condylar metaphysis and double tension band osteosynthesis for fixation of the metaphysis block to the shaft. Excellent or good results were achieved in 83% of patients. This technique is easier to perform and more cost effective than most other fixation methods. Additionally, it offers good stability and allows for earlier functioning of the elbow. Complication rates are comparable to other methods of internal fixation.

Adult↗
PubMed2006

Quality of reduction versus timing of surgical intervention for pediatric supracondylar humerus fractures.

Recent reports have shown that some displaced supracondylar humerus fractures can be treated in a delayed fashion the day following injury and complication rates will not be increased. This study determined if the quality of the reduction, as determined by restoration of Baumann's angle, is affected by surgical timing. Forty two patients ranging in age from 2 to 12 years were treated. Delayed intervention was defined as > 8 hours post-injury. Acute intervention occurred in 25 patients with a mean age of 5.5 years. Delayed intervention occurred in 17 patients with a mean age of 5.8 years. Baumann's angle was restored to within an average of 2.2 degrees of the contralateral elbow in the acute group and to within 1.2 degrees in the delayed group. Gartland type 2 fractures were more likely to be delayed in this retrospective study and these fractures showed better improvements in Baumann's angle restoration than did type 3 injuries when treated in a delayed fashion. In type 2 injuries and type 3 injuries without neurovascular compromise, delaying operations until the next morning will not compromise the quality of the reduction.

Child↗
PubMed1997

Supracondylar Fractures of the Humerus in Children.

The treatment of type II and type III supracondylar fractures of the humerus in children with closed reduction and percutaneous pinning has dramatically lowered the rate of complications from this injury. The incidence rates of malunion (cubitus varus) and compartment syndrome have both decreased. Nerve injury accompanying this type of fracture (prevalence, 5% to 19%) is usually a neurapraxia, which should be managed conservatively. Vascular insufficiency at presentation (prevalence, 5% to 17%) should be managed initially by rapid closed reduction and pinning without arteriography. Persistent vascular insufficiency necessitates exploration and vascular reconstruction.

Journal Article↗