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Acute shoulder pain lasting less than six months is a common presentation to the primary care office. Shoulder injuries can involve any of the four shoulder joints, rotator cuff, neurovascular structures, clavicle or humerus fractures, and contiguous anatomy. Most acute shoulder injuries are the result of a fall or direct trauma in contact and collision sports. The most common shoulder pathologies seen in primary care are acromioclavicular and glenohumeral joint disease and rotator cuff injury. It is important to conduct a comprehensive history and physical examination to identify the mechanism of injury, localize the injury, and determine if surgical intervention is needed. Most patients with acute shoulder injuries can be treated conservatively using a sling for comfort and participating in a targeted musculoskeletal rehabilitation program. Surgery may be considered for treating middle third clavicle fractures and type III acromioclavicular sprains in active individuals, first-time glenohumeral dislocation in young athletes, and those with full-thickness rotator cuff tears. Surgery is indicated for types IV, V, and VI acromioclavicular joint injuries or displaced or unstable proximal humerus fractures. Urgent surgical referral is indicated for posterior sternoclavicular dislocations.

Outbreaks of humeral fractures in dairy cows have been reported in New Zealand for several years. Gross, histologic, and histomorphometric findings in the humerus from primiparous cows with spontaneous humeral fracture were compared to age-matched control cows. Affected cows had a complete nonarticular spiral fracture of the humerus. Histologically affected humeri had a thicker growth plate with abnormal architecture, thinner cortex with increased abnormal resorption, increased resorption in the distal humerus, decreased trabecular density, abnormal trabecular architecture, presence of growth arrest lines and woven bone formation. Histomorphometry showed reduction in bone volume, trabecular perimeter, and trabecular width. Cows grazed on fodder beet had thicker growth plates with an abnormal appearance compared with cows grazed on pasture, and cows with low/marginal liver copper concentration had more resorption cavities in the distal humerus and thinner cortical bone compared with cows with adequate liver copper concentration. Decreased trabecular density (OR = 249.5), abnormal cortical resorption (OR = 54.2), presence of woven bone formation in the proximal metaphysis (OR = 37.2), and the number of resorption cavities in the distal humerus were significantly associated with a high probability of fracture. Ribs had enlargement of the costochondral junction with fractures in different stages of healing. Histology of the ribs revealed abnormal growth plate appearance, presence of fracture lines, callus tissue, fibrosis, and microfractures. Cows with humeral fracture have osteoporosis due to decreased bone formation and increased bone resorption, likely associated with inadequate feed quality and perhaps copper deficiency leading to a reduction in bone strength and fracture.

The study goal was to evaluate the distances from the radial (RN), the musculocutaneous (MN) and axillary nerves (AN) and the medial neurovascular bundle of the upper arm to a minimally invasive applied plate and to define its relation to the RN during different degrees of malrotation during MIPO. The sample involved ten upper extremities. Application of a PHILOS plate was performed through a Delta-split. Intervals between the AN, MN, RN and the medial vascular bundle were defined at various positions. The humeral shaft was artificially fractured at a height of about the mean of the plate. The distal fragment was brought into 15° and 30° internal (IR) as well as external rotation (ER) and here, the plate's relation to the RN was evaluated. The medial neurovascular bundle intersected the plate at its distal part in two specimens. Regarding the distances from the RN to the plate during different rotation positions the distances became significantly longer during ER, respectively shorter during IR. The medial neurovascular bundle and the RN were identified as the main structures at risk. Care must be taken during distal screw placement and malrotation exceeding 15° must be avoided during MIPO., (© 2022. The Author(s).)

Solitary bone plasmacytoma is an extremely rare entity and is characterized by localized proliferation of monoclonal plasma cells. Plasmacytomas are extremely rare in the pediatric population. The median age at diagnosis is usually the fifth or sixth decade, with axial skeleton being more commonly involved than appendicular. We hereby, report the case of a 13-year-old boy with solitary bone plasmacytoma of the right humerus. Though extremely rare in the pediatric age group, plasmacytomas may be considered as one of the remote differentials in children presenting with solitary bone tumors., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

We hypothesized that postoperative malrotation of humeral shaft fractures can alter the bio-mechanical environment of the shoulder; thus, rotator cuff and cartilage degeneration could be induced. Therefore, we designed an animal experiment to evaluate the impact of malrotation deformities after minimally invasive surgery for humeral fractures on the rotator cuff and cartilage, which has rarely been described in previous studies. Twenty-four New Zealand white rabbits were randomly divided into the sham control group (A), negative control group (B) and malrotated group (C). A sham operation with surgical exposure alone was performed in group A. Humeral shaft osteotomy was performed in Group B and C. In Group B, the fractures were fixed in situ with plate -screw system. While in Group C, iatrogenic rotational deformity was created after the proximal end of the fracture being internally rotated by 20 degrees and then subsequently fixed. The animals with bone healing were sacrificed for pathological and biochemical examination. In group C, the modified Mankin scale for cartilage pathology evaluation and the modified Movin scale for tendon both showed highest score among groups with statistical significance (P < 0.05); Disordered alignment and proportion of collagen I/III of rotator cuff were confirmed with picrosirius red staining; Transmission electron microscopy also showed ultrastructural tendon damage. Immunohistochemistry showed that both MMP-1 and MMP-13 expression were significantly higher in group C than groups A and B(P < 0.05). Minimally invasive techniques for humerus shaft fracture might be cosmetically advantageous, but the consequent postoperative malrotation could increase the risk of rotator cuff and cartilage degeneration. This conclusion is supported here by primary evidence from animal experiments., (© 2021. The Author(s).)

Background: Minimally invasive plate osteosynthesis (MIPO) is one of the generally accepted surgical techniques for the treatment of humeral shaft fractures. However, despite the high bone union rate, a variety of complications are still prevailing. Moreover, the current literature lacks data comparing the anterolateral MIPO approach using dynamic compression plates accommodating different numbers of screws. The aim of this study was to analyze the biomechanical performance of comminuted humeral shaft fractures fixed with dynamic compression plates using either two or three screws per fragment., Methods: Six pairs of fresh-frozen human cadaveric humeri from donors aged 66.8 ± 5.2 years were randomized to two paired study groups for simulation of bridge-plated comminuted shaft fracture type AO/OTA 12-C1/2/3 without interfragmentary bony support, using a dynamic compression plate positioned on the anterolateral surface and fixed with two (group 1) or three (group 2) screws per fragment. All specimens underwent nondestructive quasistatic biomechanical testing under lateral bending, anterior bending, axial bending, and torsion in internal rotation, followed by progressively increasing cyclic torsional loading in internal rotation until failure., Results: Initial stiffness of the plated specimens in lateral bending, anterior bending, axial bending, and torsion was not significantly different between the groups ( P ≥ 0.22). However, cycles to 10°, 15°, and 20° torsional deformation and cycles to construct failure were significantly higher in group 2 compared with group 1 ( P ≤ 0.03)., Conclusions: From a biomechanical perspective, no significant superiority is identified in terms of primary stability when using two or three screws per fragment for bridge compression plating of comminuted humeral shaft fractures. However, three-screw configurations provide better secondary stability and maintain it with a higher resistance towards loss of reduction under dynamic loading. Therefore, the use of a third screw may be justified when such better secondary stability is required., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2021 Guilherme Seva Gomes et al.)

Background: Interest around carbon/PEEK plates and nails has been raising. The elastic modulus close to the bone, the high load-carrying capacity and radiolucency make CFR/PEEK materials a potential breakthrough. In the literature, there are abundant data about CFR/PEEK plates in the treatment of proximal humerus, distal radius and distal fibula fractures. In patients affected by bone metastasis, CFR/PEEK nails were proved effective and safe with 12 months of follow-up. Very little is known about performances of CFR/PEEK nails in patients affected by other pathologies., Purposes: The aim of the study was to evaluate safety and efficacy of CFR/PEEK nails in the treatment of various pathological conditions. It was also investigated whatever radiolucency of this nails could lead to a more objective evaluation of bone callus or disease site., Patients and Methods: In the study group were included 20 patients (22 bone segments) who underwent CFR/PEEK nail implantation (eight humerus, one tibia, nine femur and four knee arthrodesis). They were affected by pathological fractures, and in four cases, they required an arthrodesis of the knee. They were retrospectively evaluated considering nail failures and bone callus or disease progression (RUSH scores). Mean follow-up time was 11 months (min 6.8-max 20.3). In the control group were included patients treated with titanium nails in the same institution for the same pathologies. An interclass correlation coefficient (ICC) analysis was performed in both groups considering RUSH scores by two expert surgeon from two institution to assess whether radiolucency could lead to a more objective evaluation of disease or bone callus site., Results: The ICC of mean values between RUSH scores was 0.882 (IC 95%: 0.702-0.953) in the CFR/PEEK group, while it was 0.778 (IC 95%: 0.41-0.91) in the titanium group. Observers' evaluation showed a significantly higher obscuration by titanium nails than by CFR/PEEK nails. No osteosynthesis failures were reported in both groups., Conclusions: Our results confirm the safety of CFR/PEEK nails in the short-medium term. The radiolucency of these materials led our observers to perform more objective evaluations of bone callus formation or disease progression compared to the titanium group given the higher ICC., Level of Evidence: III Case-control therapeutic study.

Supracondylar humerus (SCH) fractures are reported to be approximately twice as common among boys as among girls. Little is known about sex-associated differences in fracture patterns and complications. We compared the incidence of pediatric SCH fractures, injury mechanism (high-energy or low-energy), fracture subtypes, associated neurologic injuries, and treatment types by patient sex.We reviewed 1231 pediatric SCH fractures treated at 1 center from 2008 to 2017, analyzing sex distributions overall and by year and fracture subtype. We noted patient demographic characteristics, injury mechanisms, neurologic injuries, and treatments (nonoperative or operative). Binomial 2-tailed, chi-squared, and Student's t tests were used for analysis. Multiple logistic regression was performed to assess associations between sex, age, and injury mechanism. Alpha = 0.05.We found no significant difference in the distribution of girls (52%) vs boys (48%) in our sample compared with a binomial distribution (P = .11). Annual percentages of fractures occurring in girls ranged from 46% to 63%, and sex distribution did not change significantly over time. The mean (± standard deviation) age at injury was significantly younger for girls (5.5 ± 2.5 years) than for boys (6.1 ± 2.5 years) (P < .001). High-energy injury mechanism was associated with older age (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.03-1.06) but not male sex (OR, 1.04; 95% CI, 0.98-1.1). The overall incidence of neurologic injury was 9.5% but boys did not have greater odds of sustaining neurologic injury (OR, 1.03; 95% CI, 1.0-1.1). We found no sex-associated differences in the distribution of Gartland fracture subtypes (P = .13) or treatment type (P = .39).Compared with boys, girls sustain SCH fractures at a younger age. SCH fractures were distributed equally among girls and boys in our sample. Patient sex was not associated with fracture subtype, injury mechanism, neurologic injury, or operative treatment. These findings challenge the perception that SCH fracture is more common in boys than girls.Level III, retrospective study.

Background: Incarcerated medial epicondyle fractures in association with elbow trauma are rare and an absolute indication for intervention. Because of the infrequent nature, outcomes following this injury are not well documented. We studied a large cohort of these injuries to determine factors associated with functional outcomes. It was hypothesized that a greater duration between initial presentation and time of surgery would lead to poorer outcomes., Methods: A total of 32 patients aged 18 and under who underwent surgical treatment for an incarcerated medical epicondyle fracture at a level-1 pediatric trauma center from 2003 to 2015 were identified. All patients had a confirmed diagnosis of an incarcerated medial epicondyle at surgery. Medical records and radiographs were reviewed to determine the patient demographics, mechanism of injury, preoperative neurological symptoms, time of primary presentation, time of elbow reduction, and time to surgical intervention. Postoperative outcomes, including pain, range of motion, and ulnar nerve symptoms, were also collected. The Roberts outcome score was determined for each subject., Results: A radiographically confirmed elbow dislocation was identified in 25 subjects. The mean age at injury was 13.2 years (range, 7.3 to 17.8 y). Initial presentation was at a referring institution in 30 patients (94%). First closed reduction attempt of the ulnohumeral joint occurred in the emergency room in 24 subjects (75%); of these 7 subjects (22%) had a first reduction attempted in the emergency room at our institution, 2 patients experienced first elbow reduction during surgical intervention. The median time from first presentation to surgery was 21.9 hours (interquartile range, 15 to 40). Fourteen subjects displayed preoperative ulnar nerve symptoms. Of these, 9 subsequently reported postoperative ulnar nerve symptoms. There was no effect of time to surgical intervention on the Roberts outcome scores at follow-up, nerve symptoms, symptomatic hardware, or need for second surgery to remove hardware. There were 16 subjects with excellent outcomes, 13 with good outcomes, 3 with fair outcomes, and 0 with poor outcomes (based on the Roberts criteria)., Conclusions: Incarcerated medial epicondyle fractures are commonly associated with ulnar nerve symptoms; however, they are not associated with a significant rate of other complications. There was no increased risk of complications in subjects who had a longer duration between initial presentation and surgery. This suggests that, while the presence of an incarcerated medial epicondyle fracture is certainly an indication for timely operative intervention; the injury in isolation does not need to be considered emergent. Other factors including neurovascular status and ability to achieve joint reduction may still necessitate emergency operative care., Level of Evidence: Level IV-therapeutic study, case series.

Background: Surgical treatment of extra-articular distal-third diaphyseal humeral fractures is controversial in terms of surgical approach and position of implant. The aim of this study is to evaluate the clinical and radiological outcomes of a modified application of the proximal humeral internal locking system (PHILOS) plate in extra-articular distal-third diaphyseal humeral fractures., Materials and Methods: A total of 23 patients with extra-articular distal humerus fractures were treated using either open plating or the minimally invasive plate osteosynthesis (MIPO) technique with upside down application of the PHILOS plate. Fracture configuration, number of screws in the distal fragment, and time to union were analysed. Elbow range of motion, Mayo Elbow Performance Score (MEPS), and complications were evaluated at the final follow-up., Results: Fracture union was obtained in all patients at a mean postoperative time of 20.8 ± 2.9 weeks. The mean shortest and longest cortical lengths were 50.7 ± 14.0 mm and 85.2 ± 12.4 mm, respectively. The average number of screws in the distal humeral fragment was 5.6 ± 0.7. No statistically significant correlation was observed between the shortest cortical length and number of screws in the distal fragment (p = 0.224) or between the longest cortical length and the number of screws in the distal humeral fragment (p = 0.956). The average MEPS was 97.6 (range, 75-100). No postoperative complications that required reoperation were occured., Conclusion: A modified anterior application of the PHILOS plate in extra-articular distal-third diaphyseal humeral fracture showed satisfactory outcomes, so it is an alternative when considering the ability to increase plate-screw density with locking screw fixation in a distal humeral fragment., Level of Evidence: Therapeutic level IV, case series., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Optimal treatment of proximal humerus fractures remains controversial. Locking plates offer theoretical advantages but are associated with complications in the clinic. This study aimed to perform parametric design optimisation of proximal humerus plates to enhance their mechanical performance. A finite element (FE) model was developed that simulated a two-part proximal humerus fracture that had been treated with a Spatial Subchondral Support (S3) plate and subjected to varus bending. The FE model was validated against in vitro biomechanical test results. The predicted load required to apply 5 mm cantilever varus bending was only 0.728% lower. The FE model was then used to conduct a parametric optimisation study to determine the orientations of inferomedial plate screws that would yield minimum fracture gap change (i.e. optimal stability). The feasible design space was automatically identified by imposing clinically relevant constraints, and the creation process of each FE model for the design optimisation was automated. Consequently, 538 FE models were generated, from which the obtained optimal model had 4.686% lower fracture gap change (0.156 mm) than that of the manufacturer's standard plate. Whereas its screws were oriented towards the inferomedial region and within the range of neck-shaft angle of a healthy subject. The methodology presented in this study promises future applications in patient-specific design optimisation of implants for other regions of the human body.

Introduction: A pathological fracture appears after a low-energy trauma or minor trauma on bones with a modified histological structure; sometimes, the patient reports shoulder pain antedating the fracture. The most common benign bone tumors that cause pathological fractures in children are simple bone cysts, aneurysmal bone cysts, non-ossifying fibromas and fibrous dysplasia. This type of bone tumors is usually asymptomatic until they reach a large size and cause a pathological fracture after minor trauma. The optimal treatment remains controversial. Our objective was to describe our modern treatment strategies of the large benign osseous tumors of the humerus complicated by pathological humerus fractures and histological aspects in these cases., Patients, Materials and Methods: The study was prospective and included patients who were diagnosed with pathological humeral fractures, which required surgically orthopedic treatment. We selected three cases of pathological fractures of humerus in children each with its particularities, treated in the Department of Pediatric Surgery and Orthopedics, Emergency County Hospital, Arad, Romania. Treatment included curettage of the cyst, sampling for histopathological (HP) examination, bone substitution and titanium elastic nails (TEN) osteosynthesis., Results: No complications and no recurrence were seen in the early postoperative period., Conclusions: Osteosynthesis with TEN and bone substitution is a viable option for treatment of pathological fracture of humerus, secondary to the osseous benign tumors, which required surgically treatment, despite the different HP aspects. By using a combined treatment in these cases, we eliminate the disadvantages of isolated use of the described techniques in the literature.

Background: The purpose of this investigation was to compare the presentation and postoperative results of children treated for open and closed, completely displaced type III supracondylar humerus fractures (SCFs)., Methods: Thirty patients with open and 66 patients with closed, completely displaced type III SCFs were evaluated. Open fractures underwent irrigation and debridement, and all patients were treated by open or closed reduction and pin fixation. Medical records were reviewed to obtain demographic information as well as preoperative and postoperative clinical data regarding mechanism of injury, neurovascular status, associated injuries, postoperative range of motion, infections, and pain. Radiographs were evaluated to quantify displacement, Baumann's angle, humeral capitellar angle, position of the anterior humeral line, and adequacy of reduction. Outcomes were assessed using Flynn criteria. Mean clinical follow-up for the open and closed fracture groups was 8.9 and 5.7 months, respectively., Results: Both groups were similar with respect to age, sex distribution, weight and body mass index, laterality of involvement, and mechanism of injury. At presentation, 35% of closed SCFs and 23% of open SCFs presented with abnormal neurovascular status. There was a higher prevalence of diminished/absent pulses or distal limb ischemia in patients with open injuries (27%) compared with closed fractures (18%). Conversely, severely displaced closed fractures were more commonly associated with nerve injury/palsy at presentation (35%) than those with open fractures (23%). Spontaneous nerve recovery was seen in 87% within 3 to 6 months. Postoperative loss of reduction and malunion were more common in the closed fracture group. However, 84% of patients achieved good-to-excellent results by Flynn criteria, with no appreciable difference based upon open versus closed fractures., Conclusions: With timely wound and fracture treatment, the clinical and radiographic results of children treated for open SCFs is similar to those with closed type III injuries, with little increased risk for infection, malunion, or neurovascular compromise., Level of Evidence: Level III.

Introduction This study investigates the influence of incomplete reduction of supracondylar fractures on the incidence of loss of reduction requiring reoperation Materials and methods A review of 107 consecutive patients presenting with supracondylar fractures treated with closed reduction and Kirschner wire stabilisation, between January 2011 and March 2013, was conducted. The mean age was 5 years (range 10 months to 12 years). Pre-, intra- and postoperative radiographs were reviewed. All patients who had failure of fixation requiring revision surgery were identified. Results Ninety-nine patients had an initial adequate radiographic reduction. Of these, one (1%) required revision surgery. Eight patients had an initial incomplete radiographic reduction and, of these, six (75%) required revision surgery (P < 0.0001). Discussion Supracondylar fractures treated with closed reduction and K wire stabilisation require adequate intraoperative reduction. Incomplete reduction should not be accepted, as despite the bones potential to remodel, the risk of further loss of reduction is high, requiring reoperation.

It is important to conduct timing of injury research analyzing fracture characteristics at known postmortem intervals (PMI) because bone can retain fresh characteristics throughout the PMI. Defleshed pig (Sus scrofa) long bones were fractured weekly in two environments (full sun and shade) over 14 weeks in Central Florida and fracture characteristics were categorized (N = 136) for analysis. Results of analysis of variance (ANOVA) using time in weeks (PMI) as a dependent variable indicate significant relationships between PMI and Fracture Angle (p < 0.001), Fracture Surface (p < 0.001), and Fracture Outline (p < 0.001). Fracture characteristics associated with perimortem trauma (smooth Fracture Surfaces and curved or V-shaped Fracture Outlines) were commonly observed. Analysis of fracture characteristics for each environment demonstrated similar patterns. Overall, the loss of only fresh fracture characteristics for each bone was noted earlier in the PMI for the Central Florida region than previously reported., (© 2016 American Academy of Forensic Sciences.)

The treatment of humeral pallet fractures is mainly based on reconstruction surgery with osteosynthesis. We collected the data of 40 patients with humeral pallet fracture from our archives in the Department of Orthopaedics and Traumatology at the Ibn Sina University Hospital, Rabat from january 2012 to december 2014. The aim of our study was to highlight the clinical, therapeutic and evolutionary features of these fractures as well as the challenges in managing these complex fractures and in evaluating the results. There was a clear male predominance (75% of cases) with an average age of 35 years. Etiologies were dominated by road accidents (56%). All our patients had an emergency hospital admissions and underwent surgery. Type C fracture, according to MÜLLER and ALLGOWER (A.O) classification was the most frequent: 62.5% of cases. Associated lesions were fairly frequent (52.5%) in polytraumas. All our patients underwent surgery (100% of cases), via posterior border in 70% of cases. This procedure included reduction and then osteosynthesis using a Lecestre-type plate in 82.5% of the cases. Our results were good and average in 85.5% of cases, according to literature data. The management of this type of fracture is based on perfect anatomic reduction, a solid assembly which should allow an early reeducation resulting in good functional result., Competing Interests: Les auteurs ne déclarent aucun conflit d’intérêts.

Objective: To investigate the radiographic and clinical assessment for supracondylar humeral fractures resulted from sports in children. Methods: The medical records of 166 patients with displaced supracondylar humerus fractures treated in Shengjing Hospital of China Medical University from January 2015 to December 2015 were reviewed.The etiology of 56 of 166 cases was relevant to the sports.Medical records of 56 of 166 patients were reviewed, incluidng gender, the mean age of patient at the time of surgery, the mean duration of injury, radiographic assessment based on the anteroposterior (AP) and lateral radiographs of the elbow, neurologic injury, the Mayo Elbow Performance Score (MEPS) and the criteria of Flynn. Results: There were 34 boys (34 elbows, 60.7% (34/56)) and 22 girls (22 elbows, 39.3% (22/56)), and 32 patients in left elbow (57.1% (32/56)) and 24 patients in right elbow(42.9% (24/56)). The etiology included football in 16 patients (28.6% (16/56)), basketball in 10 patients (17.9% (10/56)), skating in 10 patients (17.9% (10/56)), skiing in 8 patients (14.3% (8/56)), roller skating in 5 patients (8.8% (5/56)), kick scooter in 3 patients (5.3% (3/56)), riding horse in 2 patients (3.6% (2/56)) and horizontal bar in 2 patients (3.6% (2/56)). The mean age of 56 patients at the time of surgery was 9.5 years ( range from 6 to 13 years). The mean duration of injury was 2.2 days (range from 4 hours to 35 days). The AP and lateral radiographs of the elbow of all 56 patients (56 elbows) were performed, and three dimensional computed tomography(CT) were performed in 23 patients (23 elbows). There were 54 patients in extension type(96.4% (54/56)) and 2 cases in flexion type (3.6% (2/56)) of supracondylar humeral fractures. There were 20 patients (35.7% (20/56)) of Gartland type Ⅱ and 34 patients (60.7% (34/56)) of Gartland type Ⅲ in 54 patients of extension-type. Two cases of flexion type were both Gartland type Ⅱ (3.6% (2/56)). 33 patients (58.9% (33/56)) had posteromedial displacement of the distal fragment, 21 patients (37.5% (21/56)) had posterolateral displacement of the distal fragment, and 2 patients (3.6% (2/56)) had anterolateral displacement of the distal fragment. Three dimensional CT showed the "-" shape and apposite "V" shape in the anterio edge of proximal fragments in 21 patients (91.3% (21/23)) and 2 patients (8.7% (2/23)), respectively.CT showed Gartland type Ⅲ in 5 patients those AP and lateral radiographs of the elbows were Gartland type Ⅱ.The neurologic deficit of radial nerve injury in 2 patients (3.6% (2/56)) resulted from displaced distal fragment.Closed reduction and percutaneous pinning were performed in all 56 patients.The pin configuration included two or three parallel lateral pins in 46 patients (82.1% (46/56)) and two or three divergent lateral pins in 10 patients (17.9% (10/56)). Of the 56 patients, 7 patients were lost to follow-up, leaving a follow-up rate of 87.5% (49/56). The mean length of follow-up was 9.6 months (range from 4 to 14 months). There were no cases of Volkmann's ischaemic contracture, or iatrogenic injury of nerve.There were 25 excellent (44.6% (25/56)), 19 good (33.9% (19/56)), 10 fair results (17.9% (10/56)) and 2 poor results (3.6% (2/56)); the rate of excellent and good outcome was 78.5% (44/56) according to the criteria of Flynn.There were 47 excellent (83.9% (47/56)), 4 good (7.1% (4/56)) and 4 fair results (7.1% (4/56)) and 1 poor result (1.9% (1/56)), and the rate of excellent and good outcome was 91.0% (51/56) according to the MEPS. Conclusions: Sports is the common reason of supracondylar humeral fracture requiring surgical treatment in children.CT is valuable for the diagnosis of supracondylar humeral fracture.Good functional results in the short-term follow-up can be found after closed reduction and percutaneous lateral-entry pinning.

Introduction: Nonunion following closed treatment of humeral shaft fracture is estimated to be 5.5%. Many surgical techniques have been described to address humeral shaft nonunion including: open reduction, internal fixation (ORIF) with compression plating and bone graft, dual plating, cortical strut allograft and autograft, and adding biologic augmentation (BMP). The current standard of care includes ORIF with compression plating and bone grafting, but even this technique has an approximated 10% failure rate. We describe a novel surgical technique using cup and cone reamers, which were originally designed for metatarsophalangeal or metacarpalphalangeal arthrodesis. Cup and cone reamers are the appropriate size for mid-shaft, transverse humeral nonunions to ensure ideal apposition of healthy, bleeding bone., Methods and Patients: We retrospectively reviewed 3 patients with nonunion of the midshaft humerus which were treated with the cup and cone technique and a large fragment LCDC plate. An anterolateral approach was used in 2 cases and a posterior in the other. After exposure of fracture ends, 24-mm hemispherical convex and concave reamers were then used to ream the proximal and distal ends in order to create a "cup and cone" articulation of the fracture ends. All patients were followed for a minimum of 6 months with a mean follow-up of 12 months., Results: All patients treated with this technique achieved union, reported zero pain and full functional outcome. Specifically, patients had a mean age of 36.3 and the mean interval between injury and time to surgery was 11.5 months. Two of the patients presented with nonunions after attempted closed treatment and the other patient had 3 prior surgeries for infected nonunion. Union was achieved at a mean of 12 weeks., Conclusion: To our knowledge, the use of cup and cone reamers for nonunion of the humerus has never been described. We describe a simple and effective technique for humeral shaft nonunions which has been successful in both septic and hypertrophic nonunions, as well as from multiple approaches-both anterolateral and posterior., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Recalcitrant humeral non-union is a disabling condition that is extremely difficult to treat. The use of BMP-7 has been proposed to improve bone healing. This is a report of the results obtained in 12 patients with recalcitrant humeral non-union treated using stable fixation with a long locking compression plate and BMP-7, autologous bone graft and hydroxyapatite pellets applied at the non-union site. Patients had up to three surgical attempts at non-union healing prior to our treatment. The average time from the initial fracture to our surgery was 5.2 years. Average follow-up was 5.3 years. At follow-up, non-union had healed in all patients by an average of 7.3 months. All the patients were very satisfied with their final results, despite a restricted range of motion of the elbow and a moderate muscular atrophy, which was frequently observed. Our study shows that BMP-7 associated with autologous bone grafting and hydroxyapatite pellets after stable fixation is an effective adjuvant to stimulate bone healing in the treatment of recalcitrant humeral non-union., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Achieving quiescence in chronic osteomyelitis remains challenging. Wide resection of all infected and necrotic tissues improves the chances of achieving remission of the disease. Extensive debridement however decreases the already compromised bone stock that increases the complexity of reconstruction. We report on the outcome of eight patients with Cierny and Mader stage IV chronic osteomyelitis of the humerus who underwent debridement followed by bone graft and circular fixator application as a second stage procedure. Resolution of infection and humeral shaft union was achieved in all patients. Our study finds that two-stage reconstruction of stage IV chronic osteomyelitis with the use of circular external fixation is effective in achieving infection control and union in these complex cases., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background: The present objective was to compare medial mini-open and percutaneous treatment of pediatric supracondylar fractures according to fluoroscopy time, duration of surgery, and iatrogenic ulnar nerve injury., Methods: A total of 104 Gartland type III supracondylar humerus fractures were prospectively evaluated between 2011 and 2013. Patients were divided into 2 groups according to type of fixation. In Group A (41 patients), medial pin was inserted with mini-open incision with 2 lateral pins inserted percutaneously. In Group B (63 patients), all pins were inserted percutaneously. Mean follow-up time was 14.1±1.2 months in Group A, and 14.6±2.1 months in Group B. All patients were postoperatively evaluated for nerve injury with both motor and sensory function assessment. Length of surgery, total fluoroscopy time, fluoroscopy time for medial pin insertion, Baumann's angle, humeral capitellum angle, final carrying angle, and range of motion were recorded., Results: Sensorial evaluation showed that Group A had 3 poor, and 1 fair results, and Group B had 2 poor, and 1 fair results. No statistically significant differences were observed, including no differences in either surgery or total fluoroscopy times between groups. However, fluoroscopy time during medial pin placement was significantly lower in the mini-open group., Conclusion: In conclusion, similar results of both techniques were observed, and both carry risk of iatrogenic ulnar nerve injury. Medial pin placement is easier and less demanding when used with mini-open technique.

Aims: To investigate the pathophysiology of humeral fractures in first-lactation dairy heifers in the North Island of New Zealand., Methods: Ten 2-year-old dairy heifers with humeral fractures were subject to euthanasia and the fractured and non-fractured contralateral humeri were collected. Humeri were also collected from 10 unaffected 2-year-old dairy heifers sent for slaughter. Humeri from heifers with and without fractures were examined using computed tomography (CT), and four slices of the diaphysis and lower metaphysis (D1-4) were analysed using the Bone J plug-in for Image J. The humeri were sectioned sagittally and 5 mm bone slabs were processed for histopathology., Results: There were no differences in bone length between the humeri from heifers with or without fractures (p=0.31). Median cortical bone mineral density at D1 was increased in humeri from affected compared with unaffected heifers (810 vs. 783 mg/cm(3); p=0.03), cortical area at D1 was reduced (816 vs. 1,037 mm(2); p=0.04), the median stress strain index, a calculated theoretical measure of bone strength, at D1 was decreased (7,288 vs. 9,072 mm(3); p<0.01), and the median ratio of overall bone volume (BV) to total volume (TV) was decreased (0.32 vs. 0.38; p<0.01). The median periosteal circumference at D1 was also reduced in humeri from affected compared with unaffected heifers (151 vs. 173 mm; p<0.01). Using a binary logistic regression model, BV/TV was the only variable associated with humeral fractures (p=0.03).In nine of 10 fractured humeri the fracture appeared to have started just distal to the head of the humerus and spiralled distally down the diaphysis to end just above the humeral condyles. Histopathological findings included a reduction in the number, and thickness, of trabeculae in the metaphysis; metaphyseal growth arrest lines, and osteoclastic resorption in fractured humeri. Concentrations of copper in serum from four of five animals with fractures were within, and one was below, normal reference ranges, while concentration of copper in the livers of three heifers with fractures were below adequate ranges., Conclusions: The CT and histological findings were consistent with a diagnosis of osteoporosis. We propose that humeral fractures in dairy heifers are associated with osteoporosis, possibly as a result of insufficient deposition of bone during growth because of protein-calorie malnutrition. Increased osteoclastic resorption of bone associated with calcium mobilisation for lactation, and periods of copper deficiency may contribute to bone weakening.

Background: Plate fixation is the gold standard for diaphyseal fracture management, and the anterolateral approach is widely used by reconstructive surgeons. However, the outcomes of humeral shaft fracture fixation using a medial approach are rarely reported. The aim of this study is to explore the management and outcomes of humeral mid-shaft fractures fixed through a medial incision., Methods: Thirty-four patients who sustained a humeral mid-shaft fracture and underwent an open-reduction internal fixation (ORIF) in our department between January 2010 and January 2013 were included in this study. Sixteen patients had an ORIF performed through a medial approach, while the remaining 18 were fixed through an anterolateral approach. Postoperative clinical and radiographic results were reviewed., Results: There were no significant differences in the blood loss and the range of motion of the shoulder and elbow between the anterolateral and medial fixation groups. One patient in the medial group and two patients in the anterolateral group had radial nerve dysfunction that improved after 8, 3 and 6 weeks, respectively. All patients healed radiographically except one from the anterolateral group who underwent grafting and re-fixation for a non-union. No vascular injuries, infections, malunions, broken plates or loose screws were noted in either group., Conclusions: The medial approach to the humerus had equivalent outcomes to anterolateral fixation. It is an available choice for humeral mid-shaft fracture fixation in cases where there is no need to expose the radial nerve. The medial approach does not require a pre-bent plate and creates a large operative exposure. A well-hidden incision can also be designed, improving cosmetic outcomes. However, the medial approach is not suitable to proximal or distal humerus fractures.

Introduction: Implant-related infection is a challenging complication in musculoskeletal trauma surgery. In the present study, we examined the role of implant material and surface topography as influencing factors on the development of infection in an experimental model of plating osteosynthesis in the rabbit., Methods: The implants included in this experimental study were composed of: standard Electropolished Stainless Steel (EPSS), standard titanium (Ti-S), roughened stainless steel (RSS) and surface polished titanium (Ti-P). Construct stability and load-to-failure of Ti-P implants was compared to that of Ti-S implants in a rabbit cadaveric model. In an in vivo study, a rabbit humeral fracture model was used. Each rabbit received one of three Staphylococcus aureus inocula, aimed at determining the infection rate at a low, medium and high dose of bacteria. Outcome measures were quantification of bacteria on the implant and in the surrounding tissues, and determination of the infectious dose 50 (ID50)., Results: No significant differences were observed between Ti-S and Ti-P regarding stiffness or failure load in the cadaver study. Of the 72 rabbits eventually included in the in vivo study, 50 developed an infection. The ID50 was found to be: EPSS 3.89×10(3) colony forming units (CFU); RSS 8.23×10(3) CFU; Ti-S 5.66×10(3) CFU; Ti-P 3.41×10(3) CFU. Significantly lower bacterial counts were found on the Ti-S implants samples compared with RSS implants (p<0.001) at the high inoculum. Similarly, lower bacterial counts were found in the bone samples of animals in the Ti-S group in comparison with both RSS and EPSS groups, again at the high inoculation dose (p<0.005)., Conclusion: No significant differences were seen in susceptibility to infection when comparing titanium and steel implants with conventional or modified topographies. Ti-P implants, which have previously been shown in preclinical studies to reduce complications associated with tissue adherence, do not affect infection rate in this preclinical fracture model. Therefore, Ti-P implants are not expected to affect the infection rate, or influence implant stability in the clinical situation., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

A rare case of a fracture of the anatomical neck of the humerus associated with a posterior dislocation of the shoulder in a 43-year-old man is presented. It was managed by immediate surgery using locking plate osteosynthesis. The shoulder was immobilised for 5 weeks in a Gilchrist brace. The outcome was very good with a full range of motion and a stable shoulder at 1 year after injury, with no signs of avascular necrosis of the humeral head. The aetiology of this injury and possibilities of its treatment are discussed. Key words: shoulder dislocation, humeral fractures.

Background: Elastic stable intramedullary nailing (ESIN) osteosynthesis has been used in our department for the treatment of long-bone fractures in children and adolescents for more than 17 years. During this period we have shown that ESIN has several advantages compared with other methods of treatment. However, as with every other method, ESIN has its drawbacks and complications. These occur primarily if indication criteria are not respected or ESIN technique is inadequate. This paper presents the rate of complications that occurred with this method in our patients, and the means of prevention and treatment of these complications., Patients and Methods: A total of 270 patients treated with ESIN osteosynthesis for fractures of long bones of the extremities completed treatment. The study was conducted at the Department of Child Surgery and Orthopaedics of the Clinical Hospital Centre in Rijeka. All the Nancy Nails used in the study were of the same quality, from one manufacturer and were applied using the standard ESIN technique. In 228 patients (84%), ESIN was the primary treatment, whereas in the remaining 42 patients (16%), ESIN was applied after an attempt at manual reposition and immobilisation of bone fragments. All patients had control radiography at least three times and postoperative monitoring was conducted for at least two years., Results: A total of 35 of the 270 observed patients developed complications; some patients had several complications. There were 53 early intraoperational complications and 29 late postoperative complications. All complications resolved with appropriate therapy. The treatment was satisfactory in all patients except those with an elongation of the extremity (leg) of more than 1cm., Conclusion: Postoperative complications related to the ESIN method of osteosynthesis in the patients in this study were detected by radiological control examinations and long-term clinical monitoring. All the complications of ESIN were relatively easy to treat with current medical methods. The frequency of particular complications is significantly reduced if indication criteria for ESIN are respected and correct ESIN technique is used., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

A fishtail deformity is a well-known complication following pediatric lateral condyle fracture of the humerus. We report a rare case of a medial humeral condyle fracture in a 12-year-old boy who had had a fishtail deformity because of a lateral condyle fracture in childhood. Radiographs showed a longitudinal fracture plane of the medial condyle extending to the articular surface, which is different from the three types of medial condyle fracture classified by Kilfoyle. We present our case and reviewed the literature to clarify the difference in the mechanism of medial humeral condyle fracture after a fishtail deformity.

We report a case of 63-year-old male, who presented with pathological fracture of left distal humerus 3 weeks previously. The radiographic findings showed an ill-defined permeative osteolytic lesion of the left distal humerus. Incisional biopsy and debridement was done; pathological examination revealed a folded cestode larva with calcareous corpuscles in the bone and soft tissue, and increased eosinophils. IgG antibody tests for sparganosis were positive. The patient refused to have surgery for internal fixation and placement of an endoprosthesis.

Background: There is no definite radiographic landmark in plain radiographs for proximal humeral rotation, which is an important parameter for avoiding rotational malalignment during fracture fixation. Here, we used radiographic images of cadaveric humeri to determine whether the landmark of the crest of lesser tuberosity (CoLT) in plain radiographs could be used to determine humeral rotation., Methods: Twenty adult cadaveric humeri were collected and seven consecutive radiographic anteroposterior views (45°, 30°, 15° internal rotation; neutral rotation; and 15°, 30°, 45° external rotation) were obtained for each specimen., Results: The proportional distance (PD) of the CoLT landmark relative to the humeral head was measured and analysed. The mean PDs of the CoLT landmark were 10.2%, 17.9%, 25.6%, 35.9%, 53.4%, and 62.9% of the diameter of the humeral head, corresponding to 45°, 30°, and 15° external rotation, neutral rotation, and 15° and 30° internal rotation, respectively. We found significant differences in the mean PDs with humeral rotation., Conclusion: The projection of the CoLT in plain radiographs can be used as an important landmark to assess humeral head rotation and will be a useful landmark for rotational control of fracture fixation., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Purpose of Review: The present review discusses the relevant anatomy, clinical presentation, and management of medial epicondyle fractures, including diagnostic controversies, the indications for operative and nonoperative management, and outcomes., Recent Findings: Recent studies have highlighted the underestimation of fracture displacement seen on typical radiographic views and have attempted to define the location of the medial epicondyle on radiographs to improve the accuracy of measuring displacement. They have demonstrated variable outcomes following open reduction and internal fixation of medial epicondyle fractures that are associated with intra-articular incarceration. Newer evidence supports the fixation of medial epicondyle fractures in adolescent athletes, to allow return to competitive sports., Summary: Medial epicondyle fractures of the distal humerus account for 12% of pediatric elbow fractures and are frequently associated with intra-articular incarceration of the fracture fragment, elbow dislocation, ulnar nerve injury, and other upper extremity fractures. Recent literature calls into question the accuracy of measuring fracture displacement, and controversy exists regarding optimal management of these fractures. Good outcomes have been achieved with nonoperative treatment for minimally displaced fractures, despite a high rate of nonunion. In patients with displaced fractures, fixation yields stability, functional range of motion, and the ability to return to previous activity levels, including sports. Complications include stiffness, instability, deformity, superficial wound infections, and symptomatic nonunion. Further study is required to standardize the measurement of displacement and to clarify indications for operative treatment in both sedentary and active children.

Background: Humeral fractures with brachial artery injury present a challenge for treating surgeons. Treatment practices vary, including use of vascular shunts, multispecialty teams versus an upper-extremity surgeon, and temporizing external fixation. Our objectives were to describe our treatment approach, to define “absolute ischaemia,” to determine whether to use a vascular shunt, and to identify variables that could improve limb salvage rate., Methods: We conducted a retrospective study of 38 patients with humeral fracture and brachial artery injury from 1999 through 2012 at a level I trauma centre. Demographic and treatment characteristics were compared between blunt and penetrating injuries and between treatment by multispecialty teams and treatment by an upper-extremity surgeon. We investigated other variables of interest, including immediate internal fixation, shunt use, time to brachial artery repair, and flap coverage. This study focused on immediate limb salvage and not on eventual functional outcomes of the limb or patient satisfaction regarding the extremity. The main outcome measure was salvage versus amputation., Results: Thirty-six upper extremities were successfully salvaged, and two underwent eventual amputation. Immediate internal fixation (33 of 38 patients) did not have an adverse effect on the rate of successful limb salvage (p > .05). Shunt use and treatment by an upper-extremity surgeon were not associated with improved salvage rate (p > .05). The need for flap coverage was significantly associated with failed salvage of the extremity (p = .02)., Conclusions: Salvage of the upper extremity with humeral fracture and associated brachial artery injury is not dependent on time to brachial artery repair, shunt use, or specialty of treating surgeon. Immediate internal fixation can be performed without adversely affecting the potential for successful salvage. Flap coverage, which is an indicator of severity of soft-tissue injury, correlates with amputation in these severe injuries., Type of Study/level of Evidence: Therapeutic III.

The patient was an 18-year-old high school baseball pitcher with a chief complaint of right (dominant) arm pain in the region of his right distal humerus that began 8 weeks earlier. Conventional radiographs were obtained, which were interpreted as normal. As a result, magnetic resonance imaging was obtained, which showed a hyperintense bone marrow signal in the distal humerus on fluid-sensitive sequences, which was consistent with a stress reaction of the distal humerus.

Background: Pediatric supracondylar humeral fractures are regularly complicated by vascular compromise. However, the treatment regimen for pulseless hands with good capillary refill time is discussed controversially. The aim of the present study was to present our treatment strategy in a series of children sustaining supracondylar humeral fractures associated with impaired peripheral blood flow., Methods: Medical charts of all children sustaining supracondylar humeral fractures treated between 1995 and 2009 were reviewed. Treatment and the course of patients with impaired peripheral blood flow were evaluated. Patients were invited for a follow-up examination., Results: Forty of 499 patients sustaining a supracondylar humeral fracture presented with peripheral pulselessness. Two children underwent immediate vascular surgery. In the remaining 38 patients, the fracture was reduced, followed by a re-evaluation of the peripheral circulation. Twenty-four of those patients had normal peripheral pulse and capillary refill time, and no further therapy was necessary. Fourteen patients had a persisting absent peripheral pulse after fracture reduction. While in 4 of those patients-including 3 patients with prolonged peripheral capillary refill time-vascular surgery was performed, 10 patients were successfully treated with "watchful waiting." At follow-up of 3.5 years (range, 2-6 years), the performed diagnostic workup including capillary refill time and blood pressure was without pathologic findings in all patients., Conclusion: Our data suggest that blood flow often recovers following reduction of supracondylar fractures with impaired peripheral vascularization. In cases of a "pink pulseless hand" (absent peripheral pulse and good peripheral capillary refill time), "watchful waiting" instead of immediate surgical exploration might be a treatment option. However, further studies with more patients have to be conducted to formulate a recommendation for the treatment of these severe injuries., Level of Evidence: Therapeutic study, level V.

Introduction: The antegrade intramedullary Locking Blade Nail (Marquardt, Germany) is a device aimed at improving purchase in the humeral head and reducing varus displacement by providing medial buttress support and triangular stability within the humeral head. The aim of this study is to measure the relationship of the proximal fixation screws to the axillary nerve., Methods: 13 whole cadavers underwent insertion of an antegrade proximal humeral blade nail via a deltoid split approach to both shoulders. The anatomic proximity of the anterior branch of the axillary nerve to the screws was measured following soft tissue dissection and inspection of the nerve., Results: The mean distance of the nerve from the anterolateral acromion was 62 mm (range 45-81 mm). The nerve lay closest to the distal blade fixation screw 4.9 mm (range 0-19 mm). In three cases the nerve lay directly underneath the washer and in all three cases there was macroscopic evidence of damage to the nerve. In 5 cases the nerve travelled obliquely in a cranial direction to lie 1.8 mm (range 0-3 mm) from the distal blade fixation screw, in 2 of these cases the nerve lay beneath the washer., Conclusion: The anterior branch of the axillary nerve is placed at risk during insertion of the locking screws despite use of protection sleeves and trocars. We advocate that when using antegrade intramedullary nails that incorporate an inferomedial calcar screw an extended anterolateral acromial approach is undertaken., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: Single large-fragment plate constructs currently are the norm for internal fixation of middiaphyseal humerus fractures. In cases where humeral size is limited, however, dual small-fragment locking plate constructs may serve as an alternative. The mechanical effects of different possible plate configurations around the humeral diaphysis may be important, but to our knowledge, have yet to be investigated., Questions/purposes: We used finite element analysis to compare the simulated mechanical performance of five different dual small-fragment locking plate construct configurations for humeral middiaphyseal fracture fixation in terms of (1) stiffness, (2) stress shielding of bone, (3) hardware stresses, and (4) interfragmentary strain., Methods: Middiaphyseal humeral fracture fixation was simulated using the finite element method. Three 90° and two side-by-side seven-hole and nine-hole small-fragment dual locking plate configurations were tested in compression, torsion, and combined loading. The configurations chosen are based on implantation using either a posterior or anterolateral approach., Results: All three of the 90° configurations were more effective in restoring the intact compressive and torsional stiffness as compared with the side-by-side configurations, resulted in less stress shielding and stressed hardware, and showed interfragmentary strains between 5% to 10% in torsion and combined loading., Conclusions: The nine-hole plate anterior and seven-hole plate lateral (90° apart) configuration provided the best fixation. Our findings show the mechanical importance of plate placement with relation to loading in dual-plate fracture-fixation constructs., Clinical Relevance: The results presented provide novel biomechanical information for the orthopaedic surgeon considering different treatment options for middiaphyseal humeral fractures.

Background: Recent advancements in implant technology offer updated options for surgical management that have been rapidly adopted into clinical practice. The objective of this study is to biomechanically test and compare the current fixation options available for surgical fixation of two-part proximal humerus fractures and establish load to failure and stiffness values., Methods: Sixteen match-paired (32 total) fresh-frozen, cadaveric specimens were randomized to receive 1 of 4 fixation constructs following creation of an AO/OTA Type 11A3 (two-part) proximal humerus fractures. Fixation constructs tested consisted of 3.5 mm fixed angle plate (3.5-FAP), 4.5 mm fixed angle plate (4.5-FAP), humeral intramedullary nail (IMN), and a humeral intramedullary nail with a fixed angle blade (IMN-FAB). Specimen bone density was measured to ensure no adequate, non-osteoporotic bone. Constructs were tested for stiffness and ultimate load to failure and compared via one-way ANOVA analysis with subsequent post hoc Tukey HSD multiple group comparison statistical analysis., Results: The IMN-FAB construct was significantly stiffer than the 3.5-FAP construct (123.8 vs. 23.9, p<0.0001), the 4.5-FAP construct (123.8 vs. 33.3, p<0.0001) and the IMN construct (123.8 vs. 60.1, p=0.005). The IMN-FAB construct reported a significantly higher load to failure than the 3.5-FAB construct (4667.3 N vs. 1756.9 N, p<0.0001), and the 4.5-FAP construct (4667.3 N vs. 2829.4 N, p=0.019, Table 2). The IMN construct had a significantly higher load to failure than the 3.5-FAP construct (3946.8 vs. 1756.9, p=0.001, Table 2)., Conclusion: Biomechanical testing of modern fixation options for two-part proximal humerus fracture exhibited that the stiffest and highest load to failure construct was the IMN-FAB followed by the IMN, 3.5-FAP and then the 4.5-FAP constructs. However, prospective clinical trials with longer-term follow-up are required for definitive assessment of the ideal fixation construct for surgical management of two-part proximal humerus fractures., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Background: The current research is a retrospective study that involves the description of a new trochleocapitellar index (TCI), on basis of anteroposterior (AP) radiographs of normal and fractured paediatric elbows. This index may be useful in assessing the alignment of the elbow with a supracondylar fracture., Methods: The index was evaluated to define its normal and pathological range in children between the ages of 1-13 years. A total of 212 elbows in 141 children were radiographically evaluated. 70 children without fracture elbows were evaluated by radiographs taken at the time of trauma. 35 children with unilateral fractures that healed in a normal alignment were compared to 33 patients that had a mal-union and three patients with bilateral elbow fractures. The patients were radiographically assessed at the time of fracture as well as after fracture healing as part of a routine clinical assessment. Treatment included observation, cast or internal fixation as needed., Results: The current study establishes that the normal range of the TCI was 0.25-0.8. The average TCI is 0.45. The lower range correlates with a valgus alignment of the elbow while the higher range indicates a neutral alignment. The TCI in fractured elbows that have healed in a clinically normal alignment is different than the contra-lateral elbow's TCI. This might indicate a sub-clinical remaining deformity., Conclusions: In current practice, paediatric patients with elbow trauma, often undergo bilateral radiographs during emergency room visits. The TCI has high negative and positive predictive values and might be superior to direct angle measurement that is currently in use. The use of the TCI measurement is expected to reduce exposure to irradiation in elbow trauma patients as bilateral comparative films appear to be superfluous when this measurement is used.

Background: Arm wrestling has been recognized as a popular and potentially dangerous competition. Reports on injuries related to arm wrestling are increasing. The most important of these injuries are humeral shaft fractures. The generally accepted theory states that the shoulder joint is actively internally rotated against the opponent while the elbow is fixed in flexion resulting in enormous violent torque forces across the humeral shaft., Methods: The reported fracture morphology seems similar so we theorized that the basis of this fracture type is the bone structure. There is no experimental model of the arm wrestling fracture other than a virtual one. We assess morphology of the humeral bone by means of the bone cutting procedures and to verify the theory that the structure of humeral bone is a basis of the arm-wrestling fracture by means of newly developed model on human bones., Results: Results of the study suggest that the humeral shaft fracture morphology during arm wrestling is based on the spiral structure of the bone combined with the direction of the revolving, rotational force during the match., Conclusion: The safety rules of the arm-wrestling match based on results of our experimental study and the literature metaanalysis are also formulate.

PURPOSE OF THE STUDY Evaluation of outcome after surgical treatment of humerus metastases with a focus on tumour and patient derived factors, timing and strategy of intervention, surgical outcome and complications. MATERIAL AND METHODS Sixty-fie patients with a mean age of 64.3 years (range 25-89) with 66 metastases of the humerus were surgically treated in a 7-year time-period and retrospectively reviewed. RESULTS Renal cell carcinoma and breast cancer were the most abundant types of primary tumour. The mean time from diagnosis of primary tumour to fist metastasis was 14.5 months (range 0-173). The mean time from diagnosis of metastasis to surgery was 21.4 months (range 0-173). 38/28 intramedullary nails/locking plates were used for 58/8 manifest/impending pathological fractures. Mean cumulative survival was 16.3 months and implant failure rate was 6.1% with a mean time from initial surgery to revision of 22.2-20.6 months. CONCLUSIONS Our data indicate that treatment with intramedullary fiation or cement augmented plate osteosynthesis is successful for the vast majority of patients, but thorough clinical evaluation and precise decision making adapted to the patient's estimated life expectancy must be applied to avoid overtreatment or risk of implant failure. Key words: bone metastases, skeletal metastatic disease, humerus metastasis, pathologic fracture, impending fracture.

Background and Purpose: Long term outcome of the treatment of displaced complex fractures of humeral head is rare in the literature especially in greater cohorts. Main purpose of our study was the assessment of long term results of intramedullary nailing of 3-4 part fractures., Patients and Methods: 137 patients with 137 three or four-part fractures of the humeral head treated by intramedullary nailing were reassessed after an average follow-up time of 57 (27-93) months. The whole cohort consisted of 85 three-part fractures, 38 four-part fractures and 14 fracture-dislocations. Radiographic and clinical outcome - absolute Constant score (CS(abs)) and relative Constant score (compared to the contralateral side - CS(rel)) were evaluated. The rate of complications was recorded. Analysis of the influence of quality of achieved reduction on final functional result and on the development of complications was performed., Results: 125 fractures healed uneventfully. Mean long term CS(rel) was 81% of the unaffected side. Mean CS(rel) was 85% in 3-part fractures, 73% in four-part fractures, 80% in three-part fracture-dislocations and 70% in four-part fracture-dislocations. 96 (70%) patients achieved excellent or good results (CS(rel) higher than 80%), 17 (12.4%) satisfactory results and 24 (17.5%) poor results (CS(rel) less than 60%). No significant difference was observed in functional results between different age groups. No incidence of non-union was observed, 4 losses of reduction were encountered. We observed 17 cases of complete humeral head necrosis, 14 of them in the group of 4-part fractures. Reduction quality strongly influenced functional result and development of head necrosis. In the group of excellent reduction mean CS(rel) was 88% and the rate of necrosis was 2%. Moderate reduction quality deteriorated CS(rel) to 70% and head necrosis rate rose up to 28%. If reduction was poor, mean CS(rel) was 52% and the rate of complete necrosis rose to 60%., Conclusion: Long term results confirmed nailing as appropriate treatment strategy for all types of humeral head fractures with limitation of excellent reduction in every age group. Moderate or even poor reduction significantly deteriorates functional results and increases rate of complete necrosis of the humeral head. If good reduction cannot be achieved, treatment strategy should be changed., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Purpose of the Study: The aim of this study was to evaluate comparatively the outcomes of pediatric displaced supracondylar fractures of humerus which were treated with either closed reduction and percutaneous pinning (CRPP) or open reduction and percutaneous pinning (ORPP)., Material and Methods: The study included 100 children with displaced supracondylar fractures of the humerus, who were treated with either CRPP (group 1) or ORPP (group 2); the numbers of subjects in the study groups were equal. The treatment outcomes were assessed clinically and radiologically., Results: Ninety-six percent excellent or good cosmetic results were achieved in both groups, and 94% / 90% excellent or good functional results were achieved in groups 1 and 2 (respectively). There was no signifiant difference between Baumann and humero-capitellar angles of intact and operated sides in both groups, but there was an average carrying angle difference of 2,96 degrees in the group 1 and 1,52 degrees in the group 2 and these differences were statistically signifiant. Five cases (10%) from each group had superfiial pin tract infection. Hypertrophic incision scar occurred in 6 (12%) patients performed ORPP., Conclusion: Both CRPP and ORPP are successful treatment methods in the management of non-complicated and non-comminuted displaced supracondylar fractures of the humerus in pediatric ages and their outcomes are similar. Incision scar and the long duration of operation are the disadvantages of open surgery. For fiing the fracture, placement of two K-wires from the medial and lateral aspects which cross each other is enough to achieve a good stability. In ORPP practices, lateral incision is a simple and reliable approach despite of the dissatisfying scar tissue formation.

Unlabelled: Atrophic nonunion of the distal humerus in children with osteogenesis imperfecta is a vexing and disabling problem. Traditional treatments, including casting, intramedullary nailing, plating and bone grafting have not been universally successful. We report on a case of successful treatment of one atrophic nonunion of the distal humerus in ad 2 year 10 month old child with type III OI who had failed more traditional treatments. The treatment used a combination of telescoping intramedullary nails, locking plate fixation and bone morphogenic protein., Level of Evidence: Level IV.