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PubMed1996

A regional approach to the classic metaphyseal lesion in abused infants: the proximal humerus.

OBJECTIVE: The purpose of this study was to systematically analyze the spectrum of morphologic alterations of the classic metaphyseal lesion (CML) involving the proximal humerus of abused infants and to identify radiologic features that aid in the diagnosis and assessment of healing. MATERIALS AND METHODS: Thirty-one infants who died with evidence of inflicted skeletal injury were studied with high-detail skeletal surveys, resected specimen radiography, and histologic analysis. In each infant, the number of fractures, the involved portions of the proximal humeral metaphyses, and the age of the lesion were assessed. RESULTS: Seven proximal humeral CMLs were seen in four infants. Radiography of the only infant with an acute injury revealed no fracture; however, evidence of trabecular disruption was found histologically. Radiographic patterns in the six healing injuries included focal corner-fracture appearance, transmetaphyseal radiolucency, irregularity of the metaphyseal margin, and flame-shaped mineralized extensions into the physeal cartilage. Histologically, all CMLs undercut the lateral subperiosteal bone collar, explaining the corner-fracture appearance. Focal and diffuse thickening of the zone of hypertrophic chondrocytes was seen, and peninsulas of primary spongiosa surrounded by hypertrophied cartilage corresponded to the flame-shaped densities revealed radiographically. The fracture morphology was better seen on specimen radiography than on skeletal survey images. CONCLUSION: CML of the proximal humerus has distinctive radiologic and histopathologic characteristics that relate to the anatomy of the region. In our study, changes at the chondroosseous junction revealed by radiography correlated well with histologic evidence of healing. Although the proximal humerus is a less common location for CML than the lower extremity, the proximal humerus should be carefully scrutinized on high-detail radiographs in cases of suspected infant abuse.

Child Abuse↗
PubMed2000

Reconstructive surgery in primary malignant and aggressive benign bone tumor of the proximal humerus.

Primary malignant bone tumors of the proximal humerus have traditionally been treated by forequarter amputation. However, with the increased interest in limb salvage operations, efforts have been made to improve reconstructive surgery and some methods have become available for tumor control and preservation of a useful distal limb. This report describes three reconstructive techniques used for reconstruction of the humerus following primary tumor excision. We followed 11 patients treated by reconstructive surgery following tumor excision for primary malignant and aggressive benign bone tumors in the proximal humerus. The average follow-up period was 35.6 months. The histologic diagnosis included osteosarcoma (9), chondrosarcoma (1) and giant cell tumor (1). The options for reconstructive surgery following tumor excision were six prosthetic arthroplasties with low heat treated autobone, four arthroplasties with Ender nail and bone cement, and one arthroplasty with custom-made tumor prosthesis. We performed a retrospective analysis regarding functional status, as well as local recurrence, distant metastasis and complication. The functional status at final follow-up averaged 16 points (53.3%) overall: 17 points (56.7%) in the six prosthetic arthroplasties with low heat treated autobone; 15 points (50.0%) in two of four arthroplasties with Ender nail and bone cement (the two others died); and 16 points (53.3%) in the one arthroplasty with custom-made tumor prosthesis. Local recurrence was not observed in any of the cases. The complications noted were one nonunion between reimplanted, low heat treated autobone and the normal distal humerus and two metal failures. Each of these techniques for reconstructive surgery resulted in a relatively good outcome, although somewhat better results were found in the case of prosthetic arthroplasty with low heat treated autobone.

Adolescent↗
PubMed2006

Guided bone regeneration with beta-tricalcium phosphate and poly L-lactide-co-glycolide-co-epsilon-caprolactone membrane in partial defects of canine humerus.

This study was performed to evaluate the effect of betatricalcium phosphate and poly L-lactide-co-glycolide-coepsilon- caprolactone (TCP/PLGC) membrane in the repair of partial bone defects in canine proximal humerus. Three adult mixed-breed dogs were used during the experimental period. The length of the defect was quarter of the full length of humerus, and width of the defect was quarter of middle diameter of the lateral aspect of humerus. The humeri of each dog were divided into treatment (TCP/ PLGC) and control groups. The defect was covered with TCP/PLGC membrane in treatment group. To evaluate regeneration of the bone, computerized tomography (CT) and histopathologic examination were performed. The radiopaque lines were appeared at the original defect sites in TCP/PLGC group but below the original site in control at 4th week. Radiopacity and thickness of the defect sites, and radiopaque lines were more increased at 8th week than those of 4th week. Histopathologic findings revealed fibrous connective tissue migration into the defect and the migration inhibited the structure of new cortex to be placed in the original level in control whereas new cortex growth was found in the level of original line in TCP/ PLGC group. However, the new cortical bone in the TCP/ PLGC group was thinner and less organized than the adjacent intact cortex, and the amount of new cancellous bones were also scanty. The result suggested that TCP/ PLGC membrane is a good guided bone regeneration material to restore the original morphology of humerus in partial defect.

Absorbable Implants↗
PubMed1985

The Tikhoff-Linberg procedure: report of ten patients and presentation of a modified technique for tumors of the proximal humerus.

The Tikhoff-Linberg resection is a limb-sparing surgical option to be considered for bony and soft-tissue tumors in and around the proximal humerus and shoulder girdle. Careful selection of patients whose tumor does not involve the neurovascular bundle in the axilla is required. The distal clavicle, upper humerus, and part or all of the scapula are resected. The tumor remains covered by the deltoid muscle plus portions of the muscles that arise from or insert into the resected specimen. In patients with tumors of the proximal humerus a custom prosthesis is used to maintain length and stabilize the distal humerus. Elbow flexion plus stability of the shoulder without the need of an orthosis may be achieved with muscle transfers. Function of the hand and forearm after Tikhoff-Linberg resection should be near normal. Review of results in 10 patients shows no local recurrences and excellent function. The major postoperative problem was nerve palsy. The Tikhoff-Linberg procedure should continue to be used for limb salvage in selected patients with tumors in or around the shoulder girdle.

Adolescent↗
PubMed1988

[En-bloc resection with immediate reconstruction of malignant tumor of the humerus--report of 9 patients].

From March 1966 to June 1985, 9 patients with humerus malignant tumor were treated by en-bloc resection and immediate reconstruction. There were 5 males and 4 females. The ages ranged from 18 to 74 with an average of 38.3 years. These 9 lesions were diagnosed by pathology as malignant giant cell tumor of the bone (2), chondrosarcoma (2), reticulum cell sarcoma (1), osteoblastoma (osteosarcomatous) (1), osteogenic sarcoma (1) and metastatic cancer (1) clear cell cancer and 1 thyroid cancer), located either in the upper or lower end of the humerus. Cutting margin was 4-7 cm from the tumor. The length of resected humerus was 10-18 cm. Simple excision without reconstruction was done only in 1 patient. The bone defect after resection was reconstructed with autogenous fibular graft in 3 patients, replantation of the limb in 2, one of whom was added with prosthesis for reconstruction of the elbow function, humerus prosthesis in 2 and elbow prosthesis in 1. All the patients were followed. Only two had died and 7 are still alive without evidence of disease. The longest survival was 20.5 years and the shortest, 18 months with an average of 10.1 years. The causes of death (1 osteoblastoma and 1 osteogenic sarcoma) were recurrence and lung metastasis. The indication, extent of excision and causes of recurrence are discussed.

Adenocarcinoma↗
PubMed1988

[Assessment of fetal growth using the humerus and femur in ultrasound fetometry].

In a prospective study process curves of fetal development were done for 1618 patients using humerus and femur with at least 5 ultrasound investigations per patient. These prenatal ultrasound values were divided in 7 groups and compared with the postnatal values of newborns to get a reliable statement. Typical curve processes have been demonstrated for low-profile development, mild and severe intrauterine growth-retardation, a macrosomy, and for a diabetic fetopathy. The following results have been gained from ultrasound values of prospective staging of fetal development. From 1618 cases 1263 cases (78.0%) have been staged exactly. 333 cases (20.6%) were not total exact. 22 cases (1.4%) have been evaluated wrong. From 121 cases of IUGR 95 cases (78.5%) have been staged correctly. Humerus and femur values are below the normal range in for IUGR group. 77 cases (62.1%) from the 124 macrosomal newborns have been detected right. Only 2 cases (4.9%) from the 41 cases of diabetic fetopathy have been evaluated lower. Humerus and femur values in severe macrosomia were over the normal range in contrast to the diabetic fetopathy. Our scheme for control of fetal development which use humerus and femur as additional parameters shows higher precision.

Female↗
PubMed1997

[Vascularization of the humerus].

The proximal third of the humerus is fed by the anterior and posterior circumflex arteries of the axillary artery. They construct a fine anastomoses network at the humeral head as well as longitudinal anastomoses to the diaphysis. The middle third of the humerus is maintained by the rami musculoperiostales originating in both the brachial artery and the deep brachial artery. These periosteal vessels are formed both horizontally and vertically. The distal third of the humerus is mainly supplied by the horizontal anastomoses of the collateral arteries. The inner part of the bone is normally penetrated by just one nutrient artery entering the nutrient canal below the middle of the humerus.

Adult↗
PubMed2005

Primary total elbow replacement for fractures of the distal humerus.

OBJECTIVE: Achieving stability and pain-free function for osteoporotic intraarticular multifragmentary fractures of the distal humerus in elderly patients by primary total elbow replacement (TER). INDICATIONS: Non-soft-tissue-attached fragments, poor-quality bone, where stable osteosynthesis is not attainable. Severely comminuted intraarticular closed type C fractures according to the AO classification with multiple small bone/cartilage fragments. In case of degenerative joint diseases and/or previous surgery in rheumatoid patients also type A and B fractures. High compliance, low demand, and old patient > 65 years. CONTRAINDICATIONS: Type II or III Gustilo-Anderson open fractures (primary irrigation and debridement). Preexisting infection, open wounds. Younger, high-demand or noncompliant patient. Paralysis of the biceps muscle. SURGICAL TECHNIQUE: Supine positioning of patient. Triceps-sparing dorsal approach. Elevation of medial aspect of the triceps from posterior aspect of the humerus and capsula, reflecting the triceps in continuity with the ulnar periosteum and the forearm fascia. If removal of distal part of the humerus, the triceps insertion can be left intact. Preparation of humerus: no reconstruction of multifractured condyles; excavate bone from medial and lateral supracondylar ridges with burr. Preparation of ulna: remove tip of olecranon. Cemented humeral and ulnar components. Bone graft interposition behind anterior flange of humeral component. Resection of radial head and coronoid process, if impingement after trial reduction. Triceps reattachment transosseous through olecranon. POSTOPERATIVE MANAGEMENT: No formal physical-therapy sessions. Avoid single-event weight lifting of > 5 kg and repetitive lifting of > 1 kg. Discourage playing racquets sports. RESULTS: 49 acute distal humeral fractures in 48 patients (average age: 67 years) were treated with TER. 43 fractures were followed at an average of 7 years. According to the AO classification, five fractures were type A, five type B, and 33 type C. The average flexion arc at follow-up was 24-131 degrees, the Mayo Elbow Performance Score averaged 93. Data of complications were obtained from records in all 49 patients. 32 of the 49 elbows had neither a complication nor any further surgery from the time of the index arthroplasty to the most recent follow-up evaluation. Ten additional operative procedures, including five revision arthroplasties, were required. The retrospective review supports recommendation for TER for the treatment of an acute distal humeral fracture, when strict inclusion criteria are observed.

Aged↗
PubMed2007

[Management of complications after angularly stable locking proximal humerus plate fixation].

PURPOSE: In this prospective study, complications observed after angularly stable proximal humerus plate fixation (locking proximal humerus plate) were analysed by deriving specific therapies. PATIENTS: Fifty patients (median age 65 years, range 25-84 years, 39 female, 11 male) with displaced proximal humerus fractures (seven single, 36 double, and seven triple fractures) were evaluated 3, 6, and 12 months after angularly stable plate fixation using a standard protocol. RESULTS: Age- and gender-matched median constant scores 12 months postoperatively showed for the three fracture types 86, 87, and 55 points and complication rates of 14, 19, and 100%, respectively. There were seven primary and seven secondary implant displacements, five humeral head necroses, four osseous malalignments, two nonunions, two deep infections, and one heterotopic ossification. Nine reoperations were required in six patients: implant removal (n=3), reosteosynthesis (n=2), revision because of nonunion (n=2), and deep infection (n=2). CONCLUSIONS: Differentiated analysis of complications and the development of specific prevention and therapeutic strategies considering surgical technique, implant, fracture morphology, and humeral head perfusion minimize the rate of complications observed after angularly stable locking proximal humerus plate fixation.

Adult↗
PubMed2003

Hormone replacement therapy and risk for foot, distal forearm, proximal humerus, and pelvis fractures.

This case-control epidemiologic study examines the relationship between hormone replacement therapy (HRT) and risk for fractures of four sites among women 45 years of age and older. From October 1996 to May 2001, incident patients with distal forearm ( n=744), foot ( n=618), proximal humerus ( n=331), and pelvis ( n=109) fractures were recruited from five Kaiser Permanente Medical Centers in northern California. Controls ( n=1617) were selected at random from the same five medical centers over the same time period within strata defined by 5-year age group, gender, and white versus nonwhite or unknown recorded race/ethnicity. Trained interviewers collected information using a standardized questionnaire. Compared with postmenopausal women who never used HRT, postmenopausal women currently using HRT for at least 3 months had a decreased risk of fracture at the distal forearm (adjusted OR=0.55, 95% CI: 0.43, 0.72), proximal humerus (adjusted OR=0.51, 95% CI: 0.36, 0.74), and pelvis (adjusted OR=0.51, 95% CI: 0.27, 0.95), but not the foot (adjusted OR=1.05, 95% CI: 0.81, 1.35). Past use of HRT for more than 7 years also appeared to be associated with a reduced risk of fracture at the distal forearm and proximal humerus. The longer a woman went without HRT after her last menstrual period, the greater her risk of fracture in the distal forearm, proximal humerus, and pelvis. The findings of this study support long-term, current use of HRT for the prevention of osteoporotic fractures, but other risks and benefits also need to be considered.

Aged↗
PubMed2004

Case-control study of risk factors for fractures of the distal radius and proximal humerus among the Japanese population.

We conducted a case-control study to identify risk factors for fractures of the distal radius and proximal humerus. Subjects were selected from women aged 45 and over with distal radius and proximal humerus fractures, resulting from minor trauma. Two age- and gender-matched controls for each case were selected from patients who subsequently visited the same clinic for treatment of conditions other than fractures. Questionnaires including anthropometric data, past and current physical activity, and lifestyle were sent by mail to both subjects and controls. A total of 140 women with distal radius fractures (mean age 67.4 years) and 242 controls were analyzed. Falls during the previous year were a significant risk factor, while futon use (instead of bed use) before fracture was a protective factor for distal radius fractures. A total of 37 women with proximal humerus fractures (mean age 76.3 years) and 67 controls were analyzed. Weight loss was a significant risk factor, while greater frequency of going outside significantly decreased the risk of proximal humerus fracture. There was no significant correlation with eating habits, milk and alcohol consumption, or smoking to the risk of either fracture.

Accidental Falls↗
PubMed1987

Treatment of fractures of the shaft of the humerus accompanied by paralysis of the radial nerve.

This paper reports the results of treatment of 17 patients with fractures of the shaft of the humerus accompanied by paralysis of the radial nerve in a series of 111 patients with fractures of the shaft of the humerus. In early operative explorations in 14 cases the radial nerve appeared undamaged in 13 cases. In cases where spontaneous recovery of the function of the radial nerve failed to occur, no evidence has been found that the delay in exploration influenced eventual motor recovery. The high incidence of undamaged nerves at exploration suggests that a conservative approach by collar and cuff or Sarmiento bracing is justified in such cases of fractures of the shaft of the humerus. Paralysis of the radial nerve associated with fractures of the shaft of the humerus is, in our opinion, not an indication for early operative treatment.

Adolescent↗
PubMed2004

Total elbow anthroplasty and distal humerus elbow fractures.

Palvanen et al in 2003 collected data on osteoporotic fractures of the distal humerus fractures from the Finnish National Hospital Discharge Register. They defined an osteoporotic fracture of the distal humerus as a fracture occurring in persons 60 years of age or older following moderate or minimal trauma. The annual rate of incidence of these types of fractures has increased significantly, with 42 fractures reported in 1970 and 208 fractures in 2000(395% increase). The age-specific incidence rates showed a ninefold increase for women 80 years of age or older (8 in 1970 versus 75 in 2000). In the 60-69-year and 70-79-year age groups, the age adjusted increases were twofold. This presents great challenges for future orthopedists, reinforcing the ongoing need to critically analyze results of treatment for this difficult problem. Many patients over the age of 60 years can do well with traditional open reduction and internal fixation of distal humerus fractures. When patients have poor bone quality, however, preventing stable internal fixation or significant medical comorbidities, TEA should be considered. Encouraging results have been reported using TEA as a primary mode of treatment for carefully selected comminuted distal humerus fractures in elderly patients, particularly if the patient also has significant rheumatoid arthritic changes. A triceps-sparing approach is recommended so that patients may be mobilized early following surgery.

Aged↗
PubMedDate not supplied

Fixed-angle plate fixation in simulated fractures of the proximal humerus: a biomechanical study of a new device.

This study was performed to evaluate the biomechanical properties of a new device for displaced fractures of the proximal humerus. The device is a low-profile, fixed-angle plate specially designed for percutaneous application. With the use of embalmed cadaveric humeri, we simulated both noncomminuted and comminuted 2-part surgical neck fractures of the proximal humerus. Each humerus of a pair was then randomly fixed with either the new experimental device or the Association for the Study of Internal Fixation (ASIF) T-plate and mechanically tested to failure in an axial shear-loading model. The two fixation devices were evaluated in paired humeri with regard to mode of failure, stiffness, displacement at physiologic loads, and displacement, load, and energy at the point of ultimate load before failure. In the noncomminuted fracture trials the experimental device exhibited significantly greater stiffness (P <.001; P =.002 for normalized values) and ultimate load before failure (P =.015) and significantly less displacement at higher physiologic loads (P =.031). In the comminuted fracture trials the experimental device exhibited significantly greater stiffness (P =.048), ultimate load (P <.001) and energy absorbed (P =.048) before failure, and significantly less displacement at higher (P =.004) and lower physiologic loads (P =.011). The study demonstrates improved biomechanical properties for the new experimental device over the T-plate in simulated fractures of the proximal humerus. We extrapolate that these improved biomechanical properties may prove advantageous in future clinical investigation.

Aged↗
PubMed2000

[Intramedullary nailing of humeral shaft fractures--initial experiences with an unreamed humerus nail]].

Interlocking intramedullary nailing has become the preferred method of internal fixation for diaphyseal fractures of the lower extremity. In shaft fractures of the humerus however open reduction and internal fixation with plates and screws is still considered the gold standard for operative treatment. The unreamed humerus nail (UHN) is a new implant for interlocking intramedullary nailing, which allows for stable fixation of humerus shaft fractures and immediate functional after treatment. The UHN could thus become an equal alternative to plate osteosynthesis. From this point of view we analyzed retrospectively 19 shaft fractures of the humerus, which have been treated at our institution with an UHN. Infections and iatrogenic nerve lesions did not occur. One patient with a rotational malalignment of 45 degrees underwent a secondary procedure. In two out of ten fresh fractures the bone healing failed and resulted in a non-union. In all cases of pathological fractures a good palliation could be achieved. With exception of two patients the range of motion of the shoulder and elbow was symmetric. We conclude that the UHN is a real alternative to plate osteosynthesis. Compared with most series of plate osteosynthesis published in the literature the risk for iatrogenic lesions of the radial nerve appears to be lower. Even in this small series we found however a rather high rate of non-unions.

Adult↗
PubMed2004

Displaced fractures of the proximal humerus in children require open/closed reduction and internal fixation.

Fractures of the proximal humerus in children are rare and constitute only 3% of all epiphyseal injuries. From 1992 to 2002 sixteen patients aged 4 - 15 years with a displaced fracture of the proximal humerus were treated at our level I trauma unit. The mean follow-up of the patients was 23.8 months (8 - 72). Ten children had a metaphyseal fracture and six a Salter and Harris Type II injury. Only one metaphyseal fracture was treated conservatively; the other patients underwent surgery (ORIF [= open reduction internal fixation] in ten patients, CRIF [= closed reduction internal fixation] in five patients). Follow-up examination showed no shortening or major angulation of the humerus in any of the sixteen cases. Fifteen children showed excellent and good results. There was only one average result in a polytraumatized child with additional injuries in both upper extremities. Based on the results of this study we suggest performing ORIF/CRIF in displaced fractures of the proximal humerus in children.

Child↗
PubMed1992

Risk factors for fractures of the distal forearm and proximal humerus. The Study of Osteoporotic Fractures Research Group.

The Study of Osteoporotic Fractures is a prospective cohort study begun in 1986 that includes 9,704 women aged 65 years and older from Maryland, Minnesota, Oregon, and Pennsylvania. A total of 171 women suffered fractures of the distal forearm, and 79 women had fractures of the proximal humerus during the first 2.2 years of follow-up. Most fractures at both sites occurred as a result of a fall. Low bone mineral density was a strong predictor of these fractures; comparing those in the lowest quintile of bone mineral density in the distal radius with those in the highest quintile, the rate ratio was 4.1 for fractures of the distal forearm and 7.5 for fractures of the proximal humerus. Other factors associated with an increased rate of distal forearm fracture independently of low bone mineral density included poor visual acuity, number of falls in the year before baseline, and frequent walking. Factors that appeared to be independently associated with an increased rate of fracture of the proximal humerus included a recent decline in health status, insulin-dependent diabetes mellitus, infrequent walking, and several indicators of neuromuscular weakness such as inability to stand with feet in a tandem position for more than a few seconds. These data support the hypothesis that distal forearm fractures often occur as a result of a fall in women with low bone mineral density who are relatively healthy and active and have good neuromuscular function, while fractures of the proximal humerus tend to occur as a result of a fall in women with low bone mineral density who are less healthy and less active than average and who have poor neuromuscular function.

Age Factors↗
PubMed2005

Low incidence of ulnar nerve injury with crossed pin placement for pediatric supracondylar humerus fractures using a mini-open technique.

OBJECTIVES: Several recent studies have suggested that medial pinning in pediatric supracondylar humerus fractures leads to increased rates of ulnar nerve injury. The purpose of this study was to determine the risk of iatrogenic ulnar nerve injury in a consecutive series of supracondylar fractures treated using a standardized technique of crossed pin placement. DESIGN: Single cohort retrospective. SETTING: Metropolitan university tertiary care center. PATIENTS AND PARTICIPANTS: Seventy-one consecutive children with Gartland type II or type III supracondylar humerus were treated surgically by 2 pediatric orthopaedic surgeons at 1 institution between 1995 and 2000 using a medial mini-open and cross-pinning technique. Sixty-five patients were available for follow-up (92%). INTERVENTION: Patients were treated with a combination of medial and lateral pins using a mini-incision technique. MAIN OUTCOME MEASUREMENTS: Outcomes analyzed included ulnar nerve injury and clinical and radiographic evidence of healing. RESULTS: The study group consisted of 65 patients, of whom 29 (45%) presented with Gartland type III fractures, and the remaining 36 (55%) presented with a type II fracture. There were no ulnar nerve motor injuries. One patient was noted to have transient sensory changes in the ulnar nerve distribution postoperatively, which resolved by the 1-week follow-up visit. All patients were noted to have normal ulnar motor and sensory nerve function at final follow-up (average 4.5 months). No cases of nonunion, malunion, or infection were identified during the follow-up period. CONCLUSIONS: The rate of iatrogenic ulnar nerve injury with this specific technique of crossed pin placement for extension-type supracondylar humerus fractures was extremely low in this series. A single case of transient ulnar sensory neuropraxia occurred. Our series demonstrates that crossed pin fixation can be performed safely and reliably and is an appropriate treatment option for unstable supracondylar humerus fractures.

Bone Nails↗