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PubMed2002

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

BACKGROUND: Controversy persists concerning the preferred treatment of displaced fractures of the proximal part of the humerus. The present study was undertaken to evaluate the results of open reduction and internal fixation of three and four-part fractures of the proximal part of the humerus and the functional limitations of patients in whom avascular necrosis of the humeral head develops as a complication of this fracture. METHODS: We assessed the intermediate and long-term results for sixty patients with a three or four-part fracture of the proximal part of the humerus who had undergone open reduction and internal fixation with cerclage wires or a T-plate. The Constant score and a visual analog score for pain were calculated, and radiographs of the proximal part of the humerus were evaluated. RESULTS: After an average of ten years of follow-up, fifty-two patients (87%) had a good or excellent result on the basis of the Constant score whereas eight patients (13%) had a poor result. Fifty-one patients (85%) were satisfied with the result at the time of the most recent examination. Twenty-two patients (37%) had development of avascular necrosis of the humeral head, and seventeen (77%) of these twenty-two patients had a good or excellent Constant score. CONCLUSIONS: Open reduction and internal fixation with cerclage wires or a T-plate yields good functional results in most patients. This option should be considered even for patients with fracture-dislocation patterns that are associated with a high risk for avascular necrosis of the humeral head, as this complication did not preclude a good result.

Adult↗
PubMed2003

[The treatment of displaced supracondylar fractures of the humerus in children (an evaluation of three different treatment methods)].

BACKGROUND: Supracondylar fractures of the humerus are the most common fracture pattern of the elbow in childhood. They require close follow-up subsequent to successful treatment, because of having a great risk of many complications. Many treatment methods have been described for the treatment of displaced supracondylar fractures of the humerus, however it has not been reached a consensus for the choice of the treatment. The purpose of this study is to investigate the late results of three different treatment methods; closed reduction+cast immobilization, skeletal traction+cast immobilization and open reduction+internal fixation by K-wires. We also aimed to compare these methods with the results of current literature. METHODS: Fifty-three (41 boys and 12 girls) displaced supracondylar humerus fractures were treated between January 1986 and March 1999. The average age was 8.0 years. We evaluated the results of patients according to Flynn's criterias. RESULTS: According to the results of the study, we obtained 31 excellent, 9 good, 5 fair and 8 poor results. The ratio of poor results of closed reduction+cast immobilization, skeletal traction+cast immobilization and open reduction+internal fixation by K-wires were 28.6%, 14.3% and 12.8%, respectively. CONCLUSION: The datas in our study show that closed reduction+cast immobilization results in the most poorest outcome in the treatment of displaced supracondylar humerus fractures.

Adolescent↗
PubMedDate not supplied

Outcome of closed reduction and casting in displaced supracondylar fracture of humerus in children.

BACKGROUND: Supracondylar fracture of humerus in children is most common in first decade of life and needs proper management to prevent complications like cubitus varus, elbow stiffness and compartment syndrome. There are various treatment modalities i.e. traction, closed reduction and casting, open reduction and internal fixation and percutaneous pinning. Purpose of the study was to know the outcome of closed reduction and casting in displaced supracondylar fracture of humerus in children while comparing the results with published literature. METHODS: Study was conducted at the Orthopaedics unit of Lady Reading Hospital Peshawar from January 2002 to December 2002 and 25 patients at random, with age range of 04-12 years with displaced supracondylar fracture of humerus were treated with closed reduction and casting. RESULTS: Based on assessment through Flynn's criteria, results were excellent in 04 patients (16%), good in 11 (44%), fair in 03 (12%) and poor in 07 patients (28%). CONCLUSION: Good results can be obtained in displaced supracondylar fracture Gartland type II of humerus in children with closed reduction and casting while the results with Gartland type III fracture were not satisfactory.

Casts, Surgical↗
PubMed1990

[Therapy of humerus fractures of the collum chirurgicum].

From 1978 to 1989 178 patients were treated for humerus fractures of the surgical neck. An examination after an average of 9 months showed in 119 cases of dislocation of the humerus of less than one shaft width no significant differences between conservative and operative treatment. In case of major dislocation of more than one shaft width (n = 59) operative treatment resulted in significantly better functional results in all age groups. A wider indication for operation after 1986 lead to better results even in the elder patients. Younger patients profited by an operative treatment even in case of minor dislocation, especially as regards maximum mobility of the shoulder joint. In most cases percutaneous or open drill-wire osteosynthesis was preferred. It is concluded that in elder patients only humerus fractures of the surgical neck with major dislocations should be operated upon. With younger patients an indication for operative treatment can also be seen in cases with minor dislocation. Nevertheless, the fractures of the proximal humerus, even in case of an increased operative treatment, remain a field of conservative therapy.

Adult↗
PubMed1990

Nonunion of the proximal humerus. A review of 25 cases.

Records of 25 patients with nonunion of the proximal humerus were reviewed retrospectively. The initial fractures included 19 two-part surgical neck fractures and six three-part fractures. Fourteen fractures were treated nonoperatively and 11 surgically. Nine of 11 of the initial internal fixations were unsatisfactory. At the time of fracture 16 patients had one or more significant medical illnesses. Nonunion of the proximal humerus was associated with considerable morbidity. Patients complained of pain, stiffness, and disability in association with shoulder dysfunction. Four treatment groups were evaluated. Patients who declined treatment and patients treated with nonreamed intramedullary nails had limited shoulder motion and pain without union. Patients treated with proximal humeral hemiarthroplasty had relief of pain but limited motion despite rotator cuff reconstruction. The best results of treatment occurred after open reduction with internal fixation and bone grafting. A tension band construction that fixed the rotator cuff and proximal humerus to a plate/shaft composite was used successfully in seven patients. Although satisfactory reconstruction of nonunion of the proximal humerus can be obtained, the results of treatment in this series were only fair. Only 48% (12 of 25 patients) had good results.

Adolescent↗
PubMed1993

Posterior extensile approach to the elbow joint and distal humerus.

Between 1986 and 1990, the authors treated 14 intra-articular fractures of the distal humerus using a posterior extensile approach. This approach, a combination of a triceps-splitting approach and an olecranon osteotomy, allows extensive exposure of the posterior aspect of the elbow joint and distal humerus, facilitating fracture reduction. The extensile approach is advocated for intra-articular fractures of the distal humerus with proximal extension. This approach can be extended proximally to the midshaft of the humerus or distally to expose the radial head and the ulnar shaft. The anatomy of the radial nerve and the innervation of the triceps were noted by studying 10 cadaveric elbow specimens.

Adult↗
PubMed1995

Healing rate of transverse osteotomies of the olecranon used in reconstruction of distal humerus fractures.

To determine the rate of healing of the osteotomy, we studied the cases of 10 patients who had transverse osteotomy of the olecranon for surgical exposure of a complex distal humerus fracture. The average age of the patients was 48 years, and the average follow-up was 24 months. Nine of the fractures were complex supracondylar/intercondylar fractures. All of the humerus fractures were treated with bone plates and screws, and nine of the osteotomies of the ulna were reconstructed with a large lag screw and tension band wire. Smooth pins and a tension band wire were used in 1 patient with osteoporotic bone. Union of the ulnar osteotomy occurred in 7 patients, and 3 of the patients had a nonunion. The average time of healing of the distal humerus fractures was 3.5 months, and the average time of healing of the ulnar osteotomies was 5.2 months. Six of the patients developed a gap at the osteotomy site by displacement or resorption of it, and two of these progressed to a nonunion. The patients whose ulnar osteotomy healed had an average extension lag of 33 degrees, and the average flexion at their elbows was 122 degrees. The patients who had a fibrous nonunion of the ulnar osteotomy had an average extension lag of 27 degrees at the elbow, and all 3 patients had full flexion of the elbow joint. Because of the nonunion rate of 30% in our patients, we no longer use a transverse osteotomy of the olecranon to expose distal humerus fractures at surgery.

Adolescent↗
PubMed2000

A modern human humerus from the early aurignacian of Vogelherdhöhle (Stetten, Germany).

Implicit in much of the discussion of the cultural and population biological dynamics of modern human origins in Europe is the assumption that the Aurignacian, from its very start, was made by fully modern humans. The veracity of this assumption has been challenged in recent years by the association of Neandertal skeletal remains with a possibly Aurignacian assemblage at Vindija Cave (Croatia) and the association of Neandertals with distinctly Upper Paleolithic (but non-Aurignacian) assemblages at Arcy-sur-Cure and St. C¿esaire (France). Ideally we need human fossil material that can be confidently assigned to the early Aurignacian to resolve this issue, yet in reality there is a paucity of well-provenanced human fossils from early Upper Paleolithic contexts. One specimen, a right humerus from the site of Vogelherd (Germany), has been argued, based on its size, robusticity, and muscularity, to possibly represent a Neandertal in an Aurignacian context. The morphological affinities of the Vogelherd humerus were explored by univariate and multivariate comparisons of humeral epiphyseal and diaphyseal shape and strength measures relative to humeri of Neandertals and Early Upper Paleolithic (later Aurignacian and Gravettian) modern humans. On the basis of diaphyseal cross-sectional geometry, deltoid tuberosity morphology, and distal epiphyseal morphology, the specimen falls clearly and consistently with European early modern humans and not with Neandertals. Along with the other Vogelherd human remains, the Vogelherd humerus represents an unequivocal association between the Aurignacian and modern human morphology in Europe.

Animals↗
PubMed1982

The humerus of Aegyptopithecus zeuxis: a primitive anthropoid.

Two complete humeri of Aegyptopithecus zeuxis have been recovered from Oligocene deposits in the Fayum Province of Egypt. These new specimens support previous interpretations of the locomotor adaptations of this species and indicate that A. zeuxis was a robust, slowly moving arboreal quadruped. While the previously described distal articular region of the humerus is virtually identical with the same region in many extant ceboids and the Miocene hominoid Pliopithecus vindobonensis, the more proximal parts of the humerus show many primitive "prosimianlike" features not found the limbs of extant anthropoids. The primitive features include the absence of a distinct deltoid plane, a broad shallow bicipital groove, a large brachialis flange, and an entepicondylar foramen. In most features, the humerus of Aegyptopithecus zeuxis is more primitive than the hypothetical last common ancestor of extant cercopithecoids and hominoids based on neontological comparisons. This supports other lines of evidence indicating that the hominoids from the Egyptian Oligocene are morphologically ancestral to both Old World monkeys and apes.

Animals↗
PubMed1989

Structural adaptations of the femur and humerus to arboreal and terrestrial environments in three species of macaque.

One reason to measure cross-sectional structural properties of primate long bones is to define mechanically relevant complexes of traits that describe the adaptation of bone to different biomechanical environments. This can be effectively accomplished when congeneric species having different postural and locomotor behaviors are compared. This paper compares the cross-sectional geometry of the femur and humerus in three behaviorally different macaque species as a basis for defining such patterns. Cross-sectional moments of inertia in the standard anatomical planes were calculated at five locations along the diaphyses of the femur and humerus in Macaca fascicularis, M. nemestrina, and M. mulatta. The data suggest that the "barrel-shaped" femur is associated with behaviors for which long limbs and small body size are an asset. This may be associated with, but is not restricted to, leaping behaviors. The data also suggest that structural rigidity of the femur and humerus is greater per unit body weight in primates that spend significant amounts of time in terrestrial environments than in those that are more restricted to climbing in arboreal environments.

Analysis of Variance↗
PubMed2003

Lateral arm flap: analysis of its anatomy and modification using a vascularized fragment of the distal humerus.

Soft tissue injuries with associated bone defects are difficult to manage and often require prolonged treatment with repeated interventions. Frequently, a free flap is applied as a first step and bone grafting is carried out in a second procedure. Ideally, these two procedures are combined in one operation, utilizing a soft tissue flap with an attached vascularized bone fragment. The lateral arm flap can provide such an osteoseptocutaneous flap and has been utilized clinically with success; however, the vascular anatomy of the flap, especially the humeral fragment, has not been described in detail previously, and there is broad disagreement concerning its innervation. In this study, the arteries and nerves of 24 fresh cadaver arms were dissected after injection of colored latex. The levels of origin of the periosteal arteries of the humerus were also documented. The lateral arm flap has a consistent arterial supply from three septocutaneous perforating branches that are arranged in a predictable pattern. The lateral supracondylar ridge of the humerus is vascularized by direct branches of the posterior branch of the radial collateral artery and by arteries that arise from muscular branches supplying adjacent muscles. The innervation of the lateral arm flap is by the inferior lateral cutaneous nerve of the arm. Knowledge of the consistent vascular anatomy of the lateral humerus and soft tissue of the donor site allows an osteoseptocutaneous flap to be raised safely with an appropriate technique. We recommend use of the lateral arm flap with a humeral fragment for the treatment of combined soft tissue and bone defects when a single step surgical solution is indicated.

Aged↗
PubMed2001

The treatment of subcapital humerus fracture with dynamic helix wire and the risk of concommitant lesion of the axillary nerve.

Displaced subcapital fractures of the humerus represent a therapeutic challenge for the surgeon, all the more so because of their high incidence among osteoporotic patients. Open surgical repair involves increased risk of avascular necrosis of the humeral head, while percutaneous reduction and fixation often fails as a result of loosening pins. As a possible solution, a minimally invasive technique was developed in which a dynamic titanium wire helix is inserted into the medullary space of the diaphysis of the humerus and then rotated proximally into the head fragment. This new approach for osteosynthesis was performed in 84 patients, most of whom had suffered two- or three-part fractures. Results were evaluated by the Constant Functional Score, indicating an average 87% rehabilitation. An associated anatomical study of 53 human cadavers investigated the position of the main branches of the axillary nerve relative to the surgical placement of the wire helix. In all cases, the distance between the most vulnerable anterior branch of the axillary nerve (ABAN) and the operative site was sufficient, as long as insertion occurs in the distal third of the distance between the head of the humerus and the deltoid tuberosity. Utilization of the titanium helix results in prompt healing of subcapital fractures while offering minimal risk for the elderly osteoporotic patient and does not endanger branches of the axillary nerve.

Aged↗
PubMed2006

Proximal humerus fractures.

Proximal humerus fractures are common injuries. Knowledge of local anatomy is paramount in the evaluation and treatment of these injuries. Information regarding humeral head vascularity, fracture patterns, bone quality, and overall geometry have direct implications for nonoperative treatment, internal fixation, and hemiarthroplasty. The ascending branch of the anterior circumflex artery perfuses most of the humeral head. When fractured, the greater tuberosity tends to displace posterosuperiorly, the lesser tuberosity and the shaft displace medially, and the head may be pulled by the attached tuberosity, impacted into valgus, or in more severe cases dislocated, impacted, or divided. Internal fixation of two-part, three-part, and selected four-part fractures may be compromised by local osteopenia; knowledge of the location of the strongest bone in the proximal humerus combined with the use of fixed-angle devices and occasionally bone graft or substitutes has improved the outcome of osteosynthesis. When the humeral head cannot be preserved, successful hemiarthroplasty requires tuberosity union and anatomic restoration of the overall geometry of the proximal humerus in terms of height, retroversion, and head-tuberosity relationships.

Fracture Fixation, Internal↗
PubMed1995

Intertubercular sulcus of the humerus as an indicator of handedness and humeral length.

Measurements of the maximum width and depth of the intertubercular sulcus (ITS), angles of the medial and lateral walls with the floor of the ITS, as well as the length of the humerus in 100 right and 100 left matched, unpaired dry humeri of 100 adults were statistically analyzed. Since 90-95% of the general population is right handed, on the basis of altered size of the dimensions of the right ITS relative to the left, it is proposed that greater width and smaller angles of the medial and lateral walls of the ITS of one side are indicative of handedness on that side. Handedness can further be deduced by the presence of a < 50 degrees angle of the medial wall and of a supratubercular ridge of Meyer on that side. The length of the humerus correlated with the width and depth of the ITS (P < 0.001). Regression equations of the length of the humerus on width, depth, as well as width and depth of the ITS have been derived.

Adult↗
PubMed2006

Gender differences in the ratio between humerus width and length are established prior to puberty.

SUMMARY: On a sample of 1,317 children aged 9.9 years we developed a novel method of measuring humeral dimensions from total body dual-energy X-ray absorptiometry (DXA) scans and showed that gender differences in the ratio between humeral width and length are established prior to puberty. INTRODUCTION: It is recognised that long bone cross-sectional area is greater in males compared to females, which is thought to reflect more rapid periosteal bone growth in boys. However, it is currently unclear whether these findings reflect gender differences in bone size or shape. In the present study, we investigated whether gender differences exist in the balance between longitudinal and periosteal long bone growth in children, leading to gender differences in bone shape, based on a novel method for evaluating shape of the humerus. We also examined whether these differences are established prior to puberty. METHODS: Length, area and width of the humerus were estimated from total body DXA scans in 1,317 children aged 9.9 +/- 0.33 years, who had participated in a nested case-control study of fractures within the Avon Longitudinal Study of Parents and Children (ALSPAC) (a geographically based birth cohort based in South West England). No differences were observed with respect to parameters of humeral geometry according to fracture history, and so both groups were pooled for further analysis. Aspect ratio (AR) of the humerus was calculated as humeral width divided by length. Total body height and weight were measured at the same time as the DXA scan. Puberty was assessed using self-completion questionnaires. RESULTS: Humeral width and length were positively associated with age and height in boys and girls combined (P<0.001), and with Tanner stage in girls (P<0.002). In contrast, age, height and Tanner stage were not related to humeral AR. We then examined gender differences in humeral shape according to pubertal stage. In prepubertal children (i.e. Tanner stage 1), humeral length was similar in boys and girls, but width (1.92 vs 1.88 cm, P<0.001) and area (47.7 vs 46.9 cm(2), P<0.001) were greater in boys, resulting in a greater AR (7.78 vs 7.53, P<0.001). Similar gender differences were observed in early pubertal children (i.e. Tanner stage 2). CONCLUSION: We conclude that the greater periosteal diameter of boys compared to girls reflects differences in the balance between longitudinal and periosteal bone growth. Interestingly, resulting gender differences in humeral AR are established in prepubertal children.

Absorptiometry, Photon↗
PubMed2001

Quantitative assessment of forearm muscle size, forelimb grip strength, forearm bone mineral density, and forearm bone size in determining humerus breaking strength in 10 inbred strains of mice.

Bone strength is an important clinical endpoint of osteoporosis research. The evaluation of the relative importance of bone and muscle components to bone strength has widespread implications for the understanding and preventing of osteoporosis. The objectives of this study were to understand the interrelationship between the different components of the muscular skeletal system and to determine the effect of forearm muscle size, forelimb grip strength, forearm bone mineral density (BMD), and forearm bone size on the humerus breaking strength among 10 inbred strains of mice. The forearm muscle size was measured using a peripheral quantitative computed tomography (pQCT). The forearm BMD and forearm bone size were measured using a PIXIMUS Densitometer. The forelimb grip strength and humerus breaking strength were measured using an Instron Mechanical Tester. Significant correlations were found among the five regional phenotypes. All variables have a moderately high genetic component with heritability estimates of 0.83 for forelimb grip strength, 0.76 for forearm muscle size, 0.6 for forearm BMD, 0.63 for forearm bone size, and 0.68 for humerus breaking strength. Forward stepwise multiregression analysis showed that the forearm BMD, forelimb grip strength, and forearm bone size were three major determinants of bone strength and explained 61% of the variation in bone breaking strength. These data suggest that evaluation of these three parameters together, rather than BMD alone, is a more effective, noninvasive approach for predicting fracture risk.

Absorptiometry, Photon↗
PubMed1998

Concurrent enchondroma and periosteal chondroma of the humerus mimicking chondrosarcoma.

A case of concurrent enchondroma and periosteal chondroma of the right proximal humerus in a 19-year-old woman is reported. Radiographs and CT scans showed a periosteal lesion with saucerization and spicula-like mineralization of the lateral aspect of the right proximal humerus and an ill-defined irregular lucency with stippled calcifications of the medullary cavity adjacent to it. MRI showed a long intramedullary lesion in addition to the surface lesion. There was no cortical disruption by imaging and gross examination. Histologically, both lesions showed benign cartilaginous tumors; concurrent enchondroma and periosteal chondroma of the humerus was therefore diagnosed. This combination in the same bone in a patient without enchondromatosis is exceedingly rare. Radiographic features may be confused with chondrosarcoma.

Adult↗
PubMed2000

Salvage of the upper extremity in cases of tumorous destruction of the proximal humerus.

Malignant bone tumours or metastasis of the upper humerus may cause significant loss of function especially in those patients with resectional arthroplasty of the shoulder. One method for achieving functional reconstruction of the humerus concerned is replacement with a modular endoprosthesis. Little is known about clinical and radiological results in these rare circumstances. Between 1993 and 1997 we treated 21 patients (22 shoulders) with enlarged osteolytic destructions of the proximal humerus caused by metastatic spread or primary malignant tumours. Patients with additional involvement of the glenoid were excluded from this study. The average follow-up was 3.9 years. Every 3 months all patients were followed-up clinically and radiographically. Prior to surgery, diagnosis was established by incisional biopsy and the outcome determined the therapeutic algorithm (radiotherapy, chemotherapy, surgery). In most cases of metastatic lesions, surgery was the first treatment. According to the regional spread of the tumour, various amount of bone and soft tissues had to be removed. The distal stem of the prosthesis was inserted in a cementless way and secured to bone with two interlocking screws. The length of the diaphyseal part depended on the site of osteotomy. Soft-tissue coverage of the large implant was achieved in all patients. Early complications were lymphogenic oedema and superficial wound dehiscence. One patient developed a deep infection, which had to be managed surgically. According to the functional rating system of the Musculoskeletal Tumour Society for the upper extremity the overall results were inversely proportional to the extent of resection. None of our patients achieved unrestricted motion of the shoulder concerned. The most important finding was a proximal migration of the prosthesis causing a painful subacromial impingement, mainly a consequence of the resection of the deltoid muscle and the rotator cuff. In summary, a modular endoprosthesis cannot be recommended generally as the method of choice. If the muscular balance of the shoulder is too weak to act as a joint centralizer the endoprosthesis has no advantage over a simple diaphyseal spacer.

Adult↗