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Objective: The purpose of this study was to conduct a systematic review and meta-analysis of the effects of acupuncture on humeral fractures., Methods: Randomized controlled trials were searched systematically from inception to January 2020 using the Cochrane Central Register of Controlled Trials, Embase, PubMed, Web of Science, China National Knowledge Infrastructure, and 7 Korean databases. Pain scale and Japanese Orthopaedic Association scores were the primary and secondary measurements. A risk-of-bias assessment and meta-analysis were conducted., Results: Seven randomized controlled trials were included in the systematic review; the quality of the studies was ambiguous. The meta-analysis showed that acupuncture improved the pain severity score compared with conventional therapies (standard mean difference = -4.55, 95% confidence interval, -7.48 to -1.61, I 2  = 98%, P < .00001) but did not improve the Japanese Orthopaedic Association score (standard mean difference = 4.99, 95% confidence interval, -0.31 to 10.30, I 2  = 99%, P < .00001)., Conclusion: Our meta-analysis shows that acupuncture reduced pain after proximal humeral fracture, in addition to common rehabilitative modalities. However, the conclusion of this review should be cautiously applied in clinical practice owing to the low quality of the included studies., (Copyright © 2021. Published by Elsevier Inc.)

Aims: To present a large series of concurrent upper limb and hip fracture in the elderly treated at a United Kingdom major trauma centre., Patients and Methods: Prospective data collection was performed for all elderly patients admitted to a single centre with hip fracture between January 2006 and November 2015. Comparative analysis of concurrent upper limb and hip fracture and an isolated hip fracture was performed., Results: Study cohort included 307 patients that had sustained concurrent upper limb and hip fracture and 6887 with an isolated hip fracture. A concurrent upper limb fracture was associated with increased length of stay (21.7 vs. 18.8 days, p = 0.003) and decreased proportion of patients returning to their own home at discharge (39.2% vs. 49.4%, p = 0.001). No differences in age, Abbreviated Mental Test (AMT), Nottingham Hip Fracture Score (NHFS) and mortality were identified. However, concurrent wrist fracture 365-day mortality was lower than that of isolated hip fracture (20.9% vs 29.2%, p = 0.018). Concurrent humerus fracture was associated with increased inpatient death (13.7% vs 6.4%, p = 0.046) and 365-day mortality (34.7% vs 20.9%, p = 0.014) compared to concurrent wrist fracture. Surgical stabilisation of the concurrent upper limb fracture was performed in 90 wrist (52.3%) and 13 humerus (13.7%) cases. Operative management of the concurrent fracture did not yield significant differences in acute hospital length of stay or rehabilitation requirement. Cox regression analysis of 365-day survival data demonstrated that age, NHFS, AMT, gender and presence of a concurrent upper limb fracture independently influence 365-day mortality rate., Conclusion: There are increased rehabilitation requirements for elderly patients with concurrent upper limb and hip fractures. There is a marked distinction in survivorship outcomes for patients sustaining concurrent wrist and concurrent humerus fractures., Clinical Relevance: Demonstrates increased rehabilitation requirements in concurrent upper limb and hip fracture in the elderly Highlights concurrent humerus fracture as a high risk group., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020. Published by Elsevier Ltd.)

Background: Hip fracture and upper extremity fracture are most important age-related fracture. However, there have been few reports about the analysis of prevalence or risk factors with concomitant hip and upper extremity fractures. This study aimed to describe the prevalence and clinical implications of the concomitant hip and upper extremity fractures in elderly., Methods: We evaluate 1018 patients aged >65 years who were surgically treated for femoral neck or intertrochanteric fractures between March 2008 and December 2018. 35 patients (3.4%) with a hip fracture combined upper extremity fracture. All patients were classified into the isolated hip fracture and the concomitant fracture. We analyzed these patients' characteristics such as age, gender, bone mineral density (BMD), body mass index (BMI), Korean version of Mini-Mental State Examination (MMSE-K), injury mechanism, and length of hospital stay., Results: The most common site of upper extremity fracture was distal radius fracture of 15 patients (42.8%), followed by proximal humeral fracture of 8 (22.8%). Concomitant fractures occurred on the same side in 30 patients (85.7%). The mean age of patients with a concomitant fracture was younger than that of patients with an isolated hip fracture (p < 0.05). Mean preinjury MMSE-K was 22.7 in isolated hip fracture and 25.6 in concomitant fracture patients (p < 0.05). Mean length of hospital stay was statistically significant different between two groups (p < 0.05). According to fracture site of hip, there was no statistically different prevalence of upper extremity fracture in femoral intertrochanteric fracture compared to the neck fracture., Conclusion: We found a 3.4% prevalence of concomitant hip and upper extremity fractures. It was found that the younger the age with preserved cognitive ability in elderly patients with a hip fracture, the higher the prevalence of upper extremity fracture. In addition, it is important to keep in mind that patients with a concomitant fracture have a longer hospital stay and difficulty in rehabilitation., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

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: Supracondylar humeral fractures (SHFs) in children are associated with morbidity due to elbow stiffness. Timely operative management and/or physiotherapy are thought to reduce this complication, but pose challenges in settings with limited resources for health., Methods: This prospective cohort study included 45 pediatric patients with isolated SHF at a large tertiary hospital in Nairobi, Kenya. Patients were managed non-operatively or operatively with varying wait times to surgery, with or without physiotherapy. The measurement of elbow ROM was done up to 12 weeks after removal of Kirshner wires and/or backslab., Results: Elbow ROM increased in the follow-up period, yet residual restricted mobility in the flexion-extension plane was common. Delayed surgical management ≥7 days was associated with reduced elbow ROM in the flexion-extension plane at 12 weeks median IQR 105° 92°-118° vs 120° 108°-124°, p=0.029. Physiotherapy was associated with reduced ROM at 12 weeks p=0.003, possibly due to the use of prolonged immobilization., Conclusion: In this study of pediatric SHFs at a resource-limited hospital, elbow flexion was restricted at 12 weeks follow-up and was associated with major delays in operative management. Quality of orthopedic surgical care and physiotherapy services in low-resource settings deserves further attention., (© 2019 Masumbuko et al.)

Background: This study evaluated the feasibility and reliability of high-resolution ultrasonography (HRUS) of the radial nerve in the early, postoperative period after operative stabilization of humeral shaft fractures., Methods: This study enrolled patients between September 2015 and April 2018 with a humeral shaft fracture who were assessed with HRUS within 2 weeks after surgery. Based on the ultrasound artifacts, the examiners subjectively defined quality of ultrasound as "bad" or "good." The cross-sectional area of the radial and the posterior interosseous nerve was recorded at predefined locations. The radial nerve was scanned axially in the whole course to identify nerve continuity., Results: Of 44 patients who underwent operations for humeral shaft fracture, HRUS was used to assess 15 patients at an average 4.8 ± 2.6 days (range, 2-11 days) after surgery. The examiners defined ultrasound quality as "good" in 13 of 15 patients (~87%). Primary radial nerve palsy (RNP) was identified in 3 of the 15 patients, and 4 sustained secondary RNP. Nerve continuity was demonstrated by HRUS in every patient. In patients with RNP, nerve continuity was secondarily confirmed by surgical exploration or functional and electrophysiological recovery., Conclusion: Early postoperative HRUS of the radial nerve after osteosynthesis of humeral shaft fractures is a feasible and reliable method to identify radial nerve continuity. In case of pathology, this assessment tool can additionally provide valuable information concerning location and etiology of the RNP., (Copyright © 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Introduction: Complicated elbow injuries (elbow injuries with bone and soft tissue injury) with distal biceps tendon ruptures (DBTRs) are not uncommon. There are several treatment modalities in different situations of injuries. In this article, we reported 3 successful individual treatments of delayed DBTR with complicated elbow injuries., Materials and Methods: Three cases of complicated elbow injuries treated between 2010 and 2016 were reviewed. The delayed DBTR cases were summarized and treated. Mayo Elbow Performance Score value, range of motion, and visual analog scale score were used to assess outcomes after a minimum follow-up of 12 months., Results: All 3 patients were male, aged 47 to 54 years (mean, 49.6 years). Patients received surgical treatments. After a mean follow-up of 13.7 months, in cases 1 and 2, Mayo Elbow Performance Score values improved by 50% and 100%, elbow flexion-extension arc were 115 degrees and 110 degrees, pronation-supination arc were 130 degrees and 120 degrees. Arthrodesis case reported pain relief; visual analog scale score for pain was 0 to 1. No postoperative complications were observed, and all patients were satisfied with the results., Conclusions: Individual treatment is advised in DBTR with complicated elbow injuries. Secondary treatment of DBTR can achieve satisfactory results using individual strategies depending on patients' overall condition.

Humeral fractures are not well understood and thus we examined the incidence and outcomes of elderly humeral fractures at a single institution over a 3-year period. We found increasing incidence in humeral fractures with increasing age and negative outcomes comparable to hip fractures., Introduction: In this study, we report the incidence of humeral fractures in the older patient and their outcomes, including new nursing homes discharges and mortality, residing in the metropolitan referral area of a Sydney tertiary referral hospital., Methods: All admissions between 2013 and 2016, of patients aged 65 years or more, presenting to hospital with humeral fractures were reviewed. The data was explored primarily for outcomes (mortality and new admissions to residential aged care facility) and secondarily for clinical association with humeral fractures., Results: Two hundred eighty-one episodes of humeral fracture were identified. Incidence peaked in the above 85-year-old group at 670 per 100,000 persons per year. Proximal fractures were accounted for 84.3% of the cohort. 12.8% received operative management. The in-hospital mortality rate was 3.6%. Gender was a significant predictor for mortality (OR = 5.8, 95% CI 1.3-28.5, p value = 0.0032) with males six times more likely to experience in-hospital mortality compared to females. 17.8% of participants were admitted to a new nursing home. Logistical regression demonstrated age (OR = 1.10, 95% CI 1.04-1.17; p value = 0.001) and Charlson comorbidity index (OR = 1.32, 95% CI 1.04-1.66; p value = 0.02) were predictors of admission to a new nursing home., Conclusion: Humeral fractures are common in the older population and cause a substantial amount of new nursing home admissions and mortality. Further study is required to ascertain appropriate guidelines for treatment and rehabilitation.

The increase in the number of active and independent older adults has, unfortunately, led to an epidemic of musculoskeletal injuries in this population. Chronic pain and functional decline are common sequelae from these injuries and have a major impact on quality of life. Optimizing care for these patients will likely require educating patients about analgesic risks and benefits, promoting physical activity, identifying and addressing the psychological impacts of the injury, and coordinating care between emergency physicians, orthopedists, and primary providers. Active management of acute musculoskeletal pain has the potential to prevent the transition to chronic pain and disability in this vulnerable population., (©2017 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.)

Objective: To investigate the effect of functional exercises at different time and different immobilization positions on the functional recovery of elbow joint with type C distal humeral fractures., Methods: A total of 120 patients with type C distal humeral fractures admitted to the hospital between June 2013 and July 2015 were included in the study. They were randomly allocated to 3 groups, 40 patients in each group. Group A: functional exercises began immediately after the operation; Group B: the affected elbow was fixed at 90° flexion for 1 week and then began functional exercises after 1 week of immobilization; Group C: the affected elbow was fixed at 30° extension for 1 week and then began functional exercises after 1 week of immobilization. There was no significant difference in gender, age, fracture pattern, fracture side, injury time, and surgical approach between groups ( P >0.05)., Results: In groups A and B, 1 case had incision redness and swelling respectively, and the other incisions healed by first intention. Five patients occurred myositis ossificans in group A, 4 cases in group B, and 5 cases in group C. The incidence of complications in groups A, B, and C was 15.0% (6/40), 12.5% (5/40), and 12.5% (5/40), respectively. There was no significant difference between groups ( χ 2 =0.144, P =0.930). All patients were followed up 6-25 months, with an average of 9.8 months. At 2 weeks after operation, the Mayo elbow joint function score of group A was significantly higher than those of groups B and C ( P <0.05), and the visual analogue scale (VAS) of group A was significantly lower than those of groups B and C ( P <0.05). There was no significant difference between groups B and C ( P >0.05). At 6 months after operation, there was no significant difference in Mayo elbow joint function score and VAS score between groups ( P >0.05). At 2 weeks and 6 months after operation, the flexion and extension activities of elbow joint in groups A and C were better than that in group B ( P <0.05), and there was no significant difference between groups A and C ( P >0.05). There was no significant difference in forearm rotation between groups ( P >0.05). All fractures of 3 groups achieved clinical healing, and there was no significant difference in healing time between groups ( P >0.05)., Conclusion: Early functional exercises can relieve pain and obtain better elbow flexion and extesion activities after operation. The elbow joint fixed at 30° extension is better than at 90° flexion in elbow flexion and extension activitis.

The majority of dislocated, intra-articular fractures are treated with an open reduction and internal fixation. In this paper we describe a variety of dorsal approaches to the distal humerus. Beside the dorsal approach through an olecranon osteotomy we also discuss the alternative dorsal approaches without osteotomy and their advantages and drawbacks. Moreover we discuss the preoperative planning and operative procedure. Early functional rehabilitation, without weight bearing, is important to achieve an optimal outcome. Finally we present the results of the last 6 years of patients treated operatively in our clinic with distal humeral fractures.

People with musculoskeletal disorders of the shoulder commonly experience pain, decreased strength, and restricted range of motion (ROM) that limit participation in meaningful occupational activities. The purpose of this systematic review was to evaluate the current evidence for interventions within the occupational therapy scope of practice that address pain reduction and increase participation in functional activities. Seventy-six studies were reviewed for this study-67 of Level I evidence, 7 of Level II evidence, and 2 of Level III evidence. Strong evidence was found that ROM, strengthening exercises, and joint mobilizations can improve function and decrease pain. The evidence to support physical modalities is moderate to mixed, depending on the shoulder disorder. Occupational therapy practitioners can use this evidence to guide daily clinical decision making., (Copyright © 2017 by the American Occupational Therapy Association, Inc.)

Fracture of bilateral capitulum humeri is a very rare injury. We present a case of a 38-year-old woman, affected by a shear fracture of bilateral capitellum after a motorcycle accident. Intervention was carried out through a lateral approach on both sides and direct fixation of the fragment with headless screws. Consolidation was achieved and no signs of avascular necrosis occurred at 24 months of follow-up. The patient returned to her previous activities with no functional limitations. To the best of our knowledge, only four cases are reported describing different types of treatment and postoperative period of cast immobilization. According to our review of the literature regarding capitellar fractures, we preferred an immediate postoperative rehabilitation of the elbow, following the stable osteosynthesis.

Purpose: To describe content validity, concurrent validity, sensitivity to change, internal consistency and the outcome distribution of the Patient Specific Functional Scale (PSFS) in patients with proximal humeral fracture., Method: Fifty-three patients with proximal humeral fracture treated conservatively or surgically with plate and screw or intramedullary nail were recruited 6 weeks (±1 week) post-trauma or post-surgery. The following assessments were used: the PSFS, patient global score, shoulder function assessment, grip strength and Western Ontario Osteoarthritis of the shoulder Index (WOOS), before start of (n = 53) and after (n = 22) 2-3 months of group rehabilitation., Results: In total, 96% of the activities stated in the PSFS was classified in the International Classification of Functioning, Disability and Health activity component and 62% were found in the WOOS. Correlations between measures were low. The PSFS was highly sensitive to change to a period of group rehabilitation. All questions of the PSFS contributed to the total score. Both floor and ceiling effects could be noted., Conclusion: The PSFS shows satisfying measurement properties and may be a useful complement in the evaluation of individual changes during a period of rehabilitation after proximal humeral fracture., Implications for Rehabilitation: The PSFS assesses on activity level in patients with proximal humeral fracture. The PSFS is sensitive to change for group rehabilitation after humeral fracture. The PSFS can be useful for goal-setting, motivating and individually tailoring rehabilitation activities. The PSFS should be used in addition to specific measures of body functions and general health.

We report our experience of performing an elbow hemiarthroplasty in the treatment of comminuted distal humeral fractures in the elderly patients. A cohort of 42 patients (three men and 39 women, mean age 72; 56 to 84) were reviewed at a mean of 34.3 months (24 to 61) after surgery. Functional outcome was measured with the Mayo Elbow Performance Score (MEPS) and range of movement. The disabilities of the arm, shoulder and hand questionnaire (DASH) was used as a patient rated evaluation. Complications and ulnar nerve function were recorded. Plain radiographs were obtained to assess prosthetic loosening, olecranon wear and heterotopic bone formation. The mean extension deficit was 23.5° (0° to 60°) and mean flexion was 126.8° (90° to 145°) giving a mean arc of 105.5° (60° to 145°). The mean MEPS was 90 (50 to 100) and a mean DASH score of 20 (0 to 63). Four patients had additional surgery for limited range of movement and one for partial instability. One elbow was revised due to loosening, two patients had sensory ulnar nerve symptoms, and radiographic signs of mild olecranon wear was noted in five patients. Elbow hemiarthroplasty for comminuted intra-articular distal humeral fractures produces reliable medium-term results with functional outcome and complication rates, comparable with open reduction and internal fixation and total elbow arthroplasty., (©2015 The British Editorial Society of Bone & Joint Surgery.)

Elbow joint stiffness is a common complication following supracondylar humerus fractures. In prospective study, dynamics of establishing a full range of motion in the elbow joint following the treatment of supracondylar humerus fractures were assessed, together with the effects of physical therapy on improvement in the range of motion. Two groups of patients were observed. Physical therapy was administered to the first group, comprised of 25 patients. The second group, comprised of 28 patients, underwent no physical therapy. In the first few months following treatment, the range of motion was significantly greater in the patients who had undergone physical therapy, but after 12 months, the range of motion was almost equal in the two groups. This study has shown that it takes about 12 months to establish a full range of motion after the injury, and that it is not necessary to apply physical therapy in patients with elbow fractures.

Background: Treatment for humeral shaft fractures is restoration of a painless shoulder and elbow with satisfactory function, but achieving good clinical outcomes for fracture healing is difficult, particularly in elderly patients. The aim of the study was to determine if computer-assisted preoperative planning (CAPP) improves clinical outcomes of humeral shaft fractures., Methods: In total, 43 patients were treated for humeral shaft fractures using locking plates with CAPP. The total time needed and total cost for fracture fragments' virtual segmentation/reduction/fixation were recorded. Intra- and inter-observer reliability was analyzed with intraclass correlation coefficients (ICCs). Clinical function was analyzed with Constant Score, Mayo Elbow Performance Score (MEPS), visual analogue scale (VAS) for pain, short-form health survey (SF-36), and radiology., Results: Mean total CAPP time for 12-A, 12-B, and 12-C fractures were 12.78±1.19, 22.07±1.12, and 38.56±2.11 min, respectively. Observer reliability was high (ICC 0.766-0.995). Mean operation time was 76.8±9.2 min. Follow-up (39/43 cases) averaged 36.5 months. Mean Constant Score and MEPS were 85.2±8.1 and 95.7±3.2, respectively. Average VAS was 1.3 points. Mean physical and mental component summary SF-36 scores were 74.3±5.1 and 76.9±5.9, respectively. Two patients had delayed union., Conclusions: The novel CAPP system was efficient and reliable, providing excellent clinical outcomes for treatment of humeral shaft fractures using locking plates., (Copyright © 2014 John Wiley & Sons, Ltd.)

A small proportion of children with Gartland type III supracondylar humeral fracture (SCHF) experience troubling limited or delayed recovery after operative treatment. We hypothesised that the fracture level relative to the isthmus of the humerus would affect the outcome. We retrospectively reviewed 230 children who underwent closed reduction and percutaneous pinning (CRPP) for their Gartland type III SCHFs between March 2003 and December 2012. There were 144 boys and 86 girls, with the mean age of six years (1.1 to 15.2). The clinico-radiological characteristics and surgical outcomes (recovery of the elbow range of movement, post-operative angulation, and the final Flynn grade) were recorded. Multivariate analysis was employed to identify prognostic factors that influenced outcome, including fracture level. Multivariate analysis revealed that a fracture below the humeral isthmus was significantly associated with poor prognosis in terms of the range of elbow movement (p < 0.001), angulation (p = 0.001) and Flynn grade (p = 0.003). Age over ten years was also a poor prognostic factor for recovery of the range of elbow movement (p = 0.027). This is the first study demonstrating a subclassification system of Gartland III fractures with prognostic significance. This will guide surgeons in peri-operative planning and counselling as well as directing future research aimed at improving outcomes., (©2015 The British Editorial Society of Bone & Joint Surgery.)

Reverse shoulder prosthesis has become one of the most often used prosthetic implants in shoulder replacement surgery. It has a wide spectrum of indications, starting from comminuted humeral fractures and posttraumatic arthritis to arthritis caused by the rotator cuff loss. Its application at our hospital began in 2004, at first in few specific cases and with time in ever growing number of patients. Over 8 years, more than 250 reverse shoulder prostheses were implanted at our institution. In addition, our surgeons supervised its application in other hospitals all over Croatia. In the postoperative course, the shoulder was immobilized for 4-6 weeks with a thoracobrachial cast. After removal of the cast, physical therapy was initiated. The length of physical therapy program depended upon many factors. As a rule, immobilization lasted longer in patients that were operated on due to posttraumatic arthritis and those that suffered from deltoid muscle atrophy and shoulder contracture before surgery. Complications included dislocation of the prosthesis shortly after surgery (in the first four weeks) and infection. Infection was a special problem and treatment included even explantation of the prosthesis.

The purpose of this study was to evaluate the clinical and radiographic treatment effects of percutaneous autologous concentrated bone marrow grafting in nonunion cases and to evaluate the effectiveness of this grafting procedure. We enrolled 17 cases those had atrophic changes due to continuous nonunion for over 9 months after injury and had undergone low-intensity pulsed ultrasound treatment for more than 3 months. The site of nonunion was the femur in 10 cases, the tibia in 5 cases, the humerus in 1 case, and the ulna in 1 case. They underwent percutaneous autologous concentrated bone marrow grafting and continued low-intensity pulsed ultrasound stimulation treatment after grafting. Patients were evaluated using the visual analogue scale for pain at immediately before the procedure, 3, 6, and 12 months after grafting. Plain radiographs of the affected site were taken and evaluated about the healing of the nonunion site at each clinical evaluation. As quantitative assessment, CT scans were undertaken before the procedure and 6 months after grafting. The visual analogue scale pain score was reduced consistently after grafting in all patients. About the healing at the nonunion site, 11 and 13 cases of bone union were observed at 6 and 12 months after grafting. The mean volume of callus formation based on CT images was 4,147 (262-27,392) mm3 total between grafting and 6 months. Percutaneous autologous concentrated bone marrow grafting is an effective procedure for the treatment of patients with nonunion.

A 12-yr-old child, with a history of gestational Erb-Duchenne palsy and, later, musculoskeletal injuries in the left arm caused by a car accident, inspired the design of a customized exoskeleton-like device. Such piece, intended for rehabilitation, has one degree of freedom because the exercise routine involves elbow flexion-extension, which was indicated for the damaged muscular group. The device has two functioning modes, passive and assisted, in which the patient can trigger the movement by a biceps contraction, thus promoting the active role of the user in the rehabilitation process. The results were evaluated in terms of qualitative measures of the biceps and the triceps performed by the medical staff and by a questionnaire related to functional activities of the upper limb. A significant improvement in the arm movement and elbow angle was observed after 3 mos of assisted therapy, complementary to conventional exercises. In conclusion, a simple and low-cost device was designed and tested to complement the rehabilitation process of a pediatric patient with physical impairment.

We report the occurrence of a medial supracondylar stress fracture in an adolescent pitcher. To our knowledge, this fracture has not been described in the literature, and awareness of this entity allows initiation of therapy and precludes further unnecessary work-up. The radiographic, computed tomography, and magnetic resonance imaging appearances are reviewed and the mechanism of injury is discussed.

Purpose: Investigate test--retest reliability and validity of five shoulder outcome measures in people during their active rehabilitation after a shoulder fracture., Method: This prospective longitudinal study assessed shoulder function in 20 people (16 women, mean age 68.1 years) with surgical or conservative management at 6, 12 and 13 weeks post proximal humeral fracture using three patient-reported (Disabilities of Arm, Shoulder and Hand; Oxford Shoulder Score; Subjective Shoulder Value) and two clinician-administered (Constant Score; UCLA Shoulder score) outcome measures., Results: Content analysis categorised items into multiple domains of functioning for each outcome measure. Construct validity testing between measures found moderate to strong correlations (r=0.43-0.92). Longitudinal validity (responsiveness), represented by correlations between change scores, was moderate to strong (r=0.44-0.83). Although ICCs2,1 for test-retest reliability ranged from 0.75 to 0.93, Limits of Agreement between measurements were relatively wide (10-23% of available range of scores). Minimal clinically important difference estimates varied between anchor- and distribution-based methods., Conclusions: The five outcome measures assessing shoulder function provided values for reliability and validity that meet measurement requirements for use in groups of people after a proximal humeral fracture. However, the use of these outcome measures might be limited by low absolute agreement between measurements and their content covering multiple domains of functioning. Implications for Rehabilitation Linking the International Classification of Functioning, Disability and Health (ICF) to the content of common shoulder function outcome measures showed that multiple domains of functioning are combined into a single score. This might not be preferred for measurement of the single construct of "shoulder function". Currently available shoulder function outcome measures may not be sufficiently reliable to monitor change in an individual after a proximal humeral fracture during the rehabilitation phase.

Introduction: The study sought to assess the functional results and complications of osteosynthesis using the Lambda(®) plate (Zimmer, Étupes, France) in treating fracture of the distal extremity of the humerus., Materials and Methods: The initial series comprised 115 patients (116 fractures), treated between 1992 and 2008. Forty-one (mainly foreigners) were lost to follow-up. The final series thus comprised 74 patients (75 fractures): 44 female and 30 male, with a mean age of 46±23 years (range, 16-95 years), 22 (29%) being aged 65 years or over. According to AO classification, 22 of the fractures of the distal extremity of the humerus (29%) were diaphyseal-metaphyseal, corresponding to a particular grade of type A2, 12 (16%) were type A2 or A3, six (8%) type B, and 35 (47%) type C. Eight were open fractures: seven grade 1 and one grade IIa on Gustilo's classification. The Lambda(®) plate is an inverted Y shape, with a stem of up to ten holes and sectile arms that can be remodeled to adapt perfectly to the type of fracture and the shape of the distal end of the humerus. A posterior approach was used in all cases: in 26 cases, an extra-articular transolecranal approach and otherwise a transtricipital approach, either vertical for diaphyseal-metaphyseal fracture or inverted V for type-C fracture., Results: Mean follow-up was 115±64 months (range, 24-227 months). There were no cases of infection, non-union of olecranial osteotomy or disassembly of the internal fixation; there was, on the other hand, one case of non-union of the lateral condyle and one of the distal extremity of the humerus, two cases of dysesthesia in the ulnar nerve territory and one in the radial nerve territory (following preoperative paralysis), and four cases of stiffness requiring surgical arthrolysis between 6 and 12 months postoperatively. At follow-up, mean active elbow flexion was 133°±13° (range, 90°-150°) and active extension -12°±14° (range, -45°-0°). Mean elbow flexion range of motion exceeded 100° in 58 patients (77%), was between 50° and 100° in 16 (21%) and was less than 50° in one. Mean Mayo Elbow Performance Score (MEPS) was 97±7 points (range, 40-100), and mean Quick DASH Score (converted as a score out of 100) was 10±18 (range, 0-54). There were 67 excellent results (MEPS, 90-100 points), five good (75-89), two moderate and one poor. The 35 type-C fractures displayed no significant differences from the series as a whole (P=1.24 for MEPS)., Conclusion: Osteosynthesis using the Lambda(®) plate gave excellent medium-term results in terms of both fixation stability and recovery of elbow function after fracture of the distal extremity of the humerus, even in elderly osteoporotic patients., Level of Evidence: Level IV: retrospective study., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Osteoporosis is a skeletal disorder characterized by compromised bone strength predisposing to an increased risk of fracture. The most frequent sites of fragility fractures are the hip, the distal radius, the spine, the proximal humerus, and the ankle. In most cases, a surgical approach with subsequent rehabilitative treatment is required. The general aims of rehabilitation are to increase functioning and improve patients' activities, participation level, and quality of life.

Background: Humeral shaft fractures account for 1-3% of all fractures and 20% of the fractures involving the humerus. The aim of the current study was to compare the outcome after operative and non-operative treatment of humeral shaft fractures, by comparing the time to radiological union and the rates of delayed union and complications., Methods: All patients aged 16 years or over treated for a humeral shaft fracture during a 5-year period were included in this retrospective analysis; periprosthetic and pathological fractures were excluded. Radiographs and medical charts were retrieved and reviewed in order to collect data on fracture classification, time to radiographic consolidation and the occurrence of adverse events., Results: A total of 186 patients were included; 91 were treated non-operatively and 95 were treated operatively. Mean age was 58.7 ± 1.5 years and 57.0% were female. In 83.3% of the patients, only the humerus was affected. A fall from standing height was the most common cause of the fracture (72.0%). Consolidation time varied from a median of 11-28 weeks. The rate of radial nerve palsy in both groups was similar: 8.8% versus 9.5%. In 5.3% of the operatively treated patients, the palsy resulted from the operation. Likewise, delayed union rates were similar in both groups: 18.7% following non-operative treatment versus 18.9% following surgery., Conclusion: The data indicated that consolidation time and complication rates were similar after operative and non-operative treatment. A prospective randomised clinical trial comparing non-operative with operative treatment is needed in order to examine other aspects of outcome, meaning shoulder and elbow function, postoperative infection rates, trauma-related quality of life and patient satisfaction., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Background: Loss of motion is common after intercondylar fracture of the distal humerus despite proper management. The purpose of the current study was to report the results of contracture release for stiffness that developed after open reduction and internal fixation (ORIF) of distal humeral intercondylar fractures., Methods: Twenty-four consecutive patients with a stiff elbow after ORIF of intercondylar fractures (20 AO type C2 and 4 type C3 fractures) were managed with contracture release at a median of 13 months. The surgical indication was total arc of motion of less than 100° despite physical therapy for more than 6 months. Plates and screws for ORIF were removed concomitantly in 16 patients. Each patient was evaluated by final arc of motion and Mayo Elbow Performance Score (MEPS)., Results: The main lesions causing stiffness were heterotopic ossification or excessive callus in 13 patients and capsular fibrosis in 11. The mean total range of motion (ROM) was improved from 60.2° preoperatively to 104.8° postoperatively. At the final follow-up, 17 of the 24 elbows (71.8%) obtained a total ROM of more than 100°. The mean MEPS improved from 69 points preoperatively to 87 points at the final follow-up (P < .05). Refracture occurred during ROM exercise in 4 patients who had undergone concomitant implant removal during the contracture release., Conclusion: Surgical release of a stiff elbow that develops after ORIF of intercondylar fractures can result in satisfactory restoration of ROM in most patients. However, potential risk of refracture after release should be considered when implants are concomitantly removed., (Copyright © 2013 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Fractures of the humeral shaft are common in low-energy and high-energy trauma, and optimal clinical management remains controversial. Nonsurgical management has been supported as the preferred treatment based on high union rates and minimal functional deficit due to a rich vascular supply from overlying muscle and the wide motion available at the glenohumeral joint. Recent studies of nonoperative management have challenged surgeons' understanding of these fractures and the perception of favorable outcomes. Current considerations support expanded operative indications with traditional open-plate fixation and with the use of minimally invasive techniques, implants, and a reconsideration of intramedullary nailing., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Purpose: Complex distal humerus fractures are difficult to fix by conventional methods, especially in comminuted low distal humerus fractures. We propose a technique using small diameter K-wires and a plate on the humeral shaft., Methods: Between May 2007 and March 2009, 19 patients with poor bone quality showing comminuted or low distal humerus fractures involving the articular surface were referred to our institution and were primarily treated by this technique that we called "pin and plate fixation". We have reviewed all the cases treated by this method., Results: The average age was 46 years. All of the patients were followed up for a mean of 12 months and had a good range of motion (the average total arc of flexion-extension was 99°); the average Disabilities of the Arm, Shoulder and Hand (DASH) score was 18 points. The Mayo Elbow Performance Index was measured and the mean score was 88 in our patients., Conclusions: In this study, a technique has been evaluated for the treatment of complex distal humerus fractures. We recommend this technique in comminuted, osteoporotic or low distal humerus fractures in which other fixation methods seem difficult or even impossible.

Background: Although closed reduction and percutaneous pinning is accepted as the treatment of choice for displaced supracondylar fracture of the humerus, there are some debates on the pinning techniques, period of immobilization, elbow range of motion (ROM) exercise, and perceptions on the restoration of elbow ROM. This study was to investigate the consensus and different perspectives on the treatment of supracondylar fractures of the humerus in children., Methods: A questionnaire was designed for this study, which included the choice of pinning technique, methods of elbow motion, and perception on the restoration of elbow ROM. Seventy-six orthopedic surgeons agreed to participate in the study and survey was performed by a direct interview manner in the annual meetings of Korean Pediatric Orthopedic Association and Korean Society for Surgery of the Hand. There were 17 pediatric orthopedic surgeons, 48 hand surgeons, and 11 general orthopedic surgeons., Results: Ninety-six percent of the orthopedic surgeons agreed that closed reduction and percutaneous pinning was the treatment of choice for the displaced supracondylar fracture of the humerus in children. They showed significant difference in the choice of pin entry (lateral vs. crossed pinning, p = 0.017) between the three groups of orthopedic surgeons, but no significant difference was found in the number of pins, all favoring 2 pins over 3 pins. Most of the orthopedic surgeons used a removable splint during the ROM exercise period. Hand surgeons and general orthopedic surgeons tended to be more concerned about elbow stiffness after supracondylar fracture than pediatric orthopedic surgeons, and favored gentle passive ROM exercise as elbow motion. Pediatric orthopedic surgeons most frequently adopted active ROM exercise as the elbow motion method. Pediatric orthopedic surgeons and general orthopedic surgeons acknowledged that the patient's age was the most contributing factor to the restoration of elbow motion, whereas hand surgeons acknowledged the amount of injury to be the most contributing factor., Conclusions: More investigation and communication will be needed to reach a consensus in treating pediatric supracondylar fractures of the humerus between the different subspecialties of orthopedic surgeons, which can minimize malpractice and avoid medicolegal issues.

Background: In the last 40 years, 220 patients with type C distal humeral fractures (AO13-C1-3) were treated at our hospital operatively. Aim of this study is to present results of patients treated by dual plating osteosynthesis in the last decade and to compare them with our previous series (A-C)., Materials and Methods: From 1999 to 2008, 48 distal humeral fractures were treated operatively by perpendicular dual plating osteosynthesis. Twenty-two patients (mean age 43.5 years) were available for follow-up. These patients were allocated on the basis of retrospective evaluation, exploration of their medical history, x-rays based on the AO-classification, and functional outcome using CASSEBAUM, JUPITER, and Quick-DASH (Disabilities of the Arm, Shoulder and Hand) scores., Results: The dominant side was affecting in 42.9%. Transolecranon approach was chosen in 86.4%. Good/excellent results were found in 86.4% (CASSEBAUM) and 81.8% (JUPITER). Mean Quick-DASH was 36.1 ± 28.4. Mean range of motion (ROM) was 0/10.9°/128.2°. Mean hospitalization time was 12.9 days, 22.7% were polytrauma patients. Early mobilization was possible in 81.8%., Conclusion: Early mobilization was possible in the majority of cases, which may be a prerequisite for satisfying functional results. Using new locking plates, early mobilization could be maintained even in an aging population., (Copyright © 2011 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Objective: We conducted a study to evaluate the functional outcomes of elderly patients after open reduction internal fixation of intra-articular distal humerus fractures., Design: Retrospective clinical and radiographic evaluation., Setting: A Level I trauma and tertiary referral center., Patients/participants: We identified 23 eligible patients aged older than 65 years from the center's orthopaedic trauma registry between 1997 and 2005. Fourteen patients were available for follow-up. We had a mean follow-up of 51 months with a range of 20 to 99 months., Intervention: All enrolled patients were acutely treated with open reduction internal fixation of their distal humerus., Main Outcome Measurements: All enrolled patients were contacted and evaluated radiographically and with physical examination. Functional outcome was assessed with the Mayo Elbow Performance, Disabilities of Arm and Shoulder and Hand, and Musculoskeletal Functional Assessment functional questionnaires., Results: All 14 fractures united. The mean Mayo Elbow Performance score was 83. The mean elbow flexion-extension arc was 20° to 120°. There was no significant loss of forearm pronation-supination (P > 0.05) or grip strength (32.6 versus 34.0 lbs, P > 0.05) compared with the contralateral arm. The mean Disabilities of Arm and Shoulder and Hand score was 37.6. Musculoskeletal Functional Assessment scores demonstrated disability with a mean total score of 33.4 (normative 9.3), hand score of 34.7 (normative 3.7), and self-care score of 31.8 (normative 1.7). One patient required reoperation for a disabling flexion contracture., Conclusions: Intra-articular distal humerus fractures are severely disabling injuries, particularly in the elderly population. Good results can be achieved with stable fixation and fracture union. Despite reasonable range of motion, patient-directed questionnaires revealed persistent pain and functional limitations.

Fractures of the distal humerus are rare and count only for a small number of all fractures in mature patients. Due to demographic changes surgeons will be faced with an increasing number of complex multifragmentary fractures with diminished bone quality. As conservative treatment frequently leads to limited and painful elbow function, open reduction and stable internal fixation with early range of motion exercises are considered the gold standard. Detailed knowledge of the complex articular anatomy, the biomechanics, operative approaches and available implants is needed for the proper management of these complex fractures., (© Georg Thieme Verlag KG Stuttgart · New York.)

Hypothesis: Several studies have shown good results with internal fixation of distal humeral fractures; however, few have focused specifically on anatomic parallel plate fixation using the same implant and postoperative regimen. The purpose of this study was to determine the functional outcome after open reduction and internal fixation of these complex fractures using parallel precontoured anatomic plates., Materials and Methods: This was a retrospective single-surgeon series involving 16 patients (12 women, 4 men) treated with a double-column parallel plating technique. Clinical assessment included the Mayo Elbow Performance Score (MEPS) and Disabilities of the Arm, Shoulder and Hand Score (DASH). Mean age was 43 years (range, 20-78 years). Average follow-up was 35 months. Four fractures were AO type A and 12 were AO type C., Results: Union was achieved in all patients. There was no superficial or deep infection or hardware failure. Two patients required removal of plates for pain and prominence but not all screws could be completely removed. The mean flexion was 132 degrees and extension was 29 degrees . The mean DASH score was 46.1. Grip strength was 56% of the uninjured side. Mean flexion and extension force was 72% and 70%, respectively, of the uninjured elbow. The mean MEPS score was 72.3., Discussion: Anatomically precontoured parallel plates are effective in achieving bony union with low implant failure with acceptable functional outcomes. However, screw extraction can be difficult when the implant is removed., (Copyright 2010 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Isolated avulsion fracture of the subscapularis from the lesser tuberosity of the humerus is rare in the pediatric population and only a couple of cases have been described in the literature. In our case, a 13-year-old young man suffered an avulsion of the subscapularis tendon from the lesser tuberosity of the humerus, accompanied by medial dislocation of the biceps tendon with degeneration and tear. The diagnosis was delayed until he completed several weeks of physical therapy. Special tests performed earlier in the primary care clinic or emergency department could have prevented prolonged symptoms and allowed earlier surgical intervention.

Objective: To compare shoulder function, radial nerve palsy and infection after interlocking nailing with plating of fractures of shaft of humerus during 30 weeks of follow-up., Study Design: Experimental study., Place and Duration of Study: Orthopaedic Wards of Combined Military Hospital, Rawalpindi, from November 2006 to November 2008., Methodology: Two groups of 30 patients each were inducted. Group A (n=30) was treated with intramedullary interlocking nailing while Group B (n=30) underwent plating with dynamic compression plate (DCP). Shoulder function using ASES score, radial nerve palsy and infection were observed for 30 weeks., Results: In group A, 11 patients had severe or moderate shoulder dysfunction (ASES score below 39), out of whom 8 (72%) were above 50 years. This age related disability was significant (p=0.003). Transient palsy was observed in 3 patients (10%) and mild wound infection in 2 (6%), which was not associated with age or open fracture. In group B, only 1 patient had severe shoulder dysfunction, the difference was statistically significant between the two groups (p=0.001), especially in patients above 50 years of age. There was no statistical difference in infection and palsy rates between the two groups., Conclusion: Although nailing and plating are effective treatments for fractures of shaft of humerus, ante-grade nailing may not be suitable in elderly patients, as it can cause significant shoulder dysfunction.

Objectives: An effective rehabilitation program is essential to prevent joint stiffness and regain range of motion after surgical treatment of intra-articular fractures of the distal humerus. We evaluated the effect of a physiotherapy program on functional results, that involved passive resistive stretching exercises performed under axillary brachial plexus block after radiographic observation of bone union of intra-articular fractures of the distal humerus treated with open reduction and internal fixation., Methods: The study included 21 patients (7 females, 14 males; mean age 34+/-5 years; range 21 to 57 years) who underwent open reduction and internal fixation for intra-articular fractures of the distal humerus. All the patients had closed fractures. Six patients had AO type C1, six patients had C2, and nine patients had C3 fractures. Surgical treatment consisted of a posterior incision, olecranon osteotomy, and fixation of the metaphyseal fragments using two reconstruction plates placed medially and laterally. Active range of motion exercises were started on the third postoperative day. To prevent early development of heterotopic ossification, passive range of motion exercises were avoided. Active stretching exercises were initiated three weeks after surgery. Upon radiographic observation of bone union, axillary brachial plexus block was performed. The physiotherapy program involved passive stretching exercises during nerve block, and active weight exercises after recovery from motor block. The catheter remained in the axillary region for three months, during which functional rehabilitation was continued 2-3 times a week on an outpatient basis. Functional results were evaluated according to the criteria of Jupiter et al. after a mean follow-up period of 31 months (range 24 to 46 months)., Results: All fractures united within a mean of 11.9 weeks (range 9 to 17 weeks) except for one type C3 fracture. Functional results were excellent in 10 patients (47.6%), good in eight patients (38.1%), moderate in two patients (9.5%), and poor in one patient (4.8%). Two patients with a moderate outcome had associated multiple fractures in the ipsilateral extremity. Distribution of the functional results according to the type of fractures were 4 excellent, 2 good in type C1; 4 excellent, 2 good in C2; and 2 excellent, 4 good, 2 moderate, and 1 poor in C3 fractures. The mean loss of elbow extension was 16 degrees. The mean elbow flexion, pronation, and supination were measured as 131 degrees, 90 degrees, and 75 degrees, respectively. None of the patients had nonunion at the olecranon osteotomy site, superficial or deep infection, or heterotopic ossification. Three patients developed transient ulnar nerve neuropraxia that resolved spontaneously during the follow-up period. There were no complications related to axillary catheterization., Conclusion: Following surgical treatment of intra-articular fractures of the distal humerus, a regular and pain-free physiotherapy program performed under axillary brachial plexus block on an outpatient basis increases patient compliance and enables early return to daily activities.

This is the report of a 33-year-old female patient who was admitted to the Emergency Department with bilateral capitellum humerus fracture after a fall from a height. The patient was surgically treated with open reduction and internal fixation for both elbows, with 3 Kirschner wires on the right elbow and one mini-fragment screw on the left. Surgical intervention was carried out in emergency conditions. Following an early physical rehabilitation programme at the end of the 1st week, the roentgenograms in the 9th week showed acceptable bone union. However, in the 2nd year of follow-up the patient had consistent pain and 35 degrees of flexion loss in her right elbow due to degenerative change. The literature reveals only two reports of such cases. Thus, this rare case of bilateral capitellum humerus showed that early mobilisation after anatomic reduction and stable fixation with a mini-screw provided the optimal outcome.

Treatment of complex distal humeral fractures in older patients with osteopenic bone remains a major surgical challenge. We report the results of 11 patients over 75 years of age who underwent semiconstrained sloppy-hinge total elbow arthroplasty (TEA) due to comminuted intraarticular fractures of the distal humerus. There were 9 women and 2 men with a mean age of 79.6 years. The mean duration of follow up was 2.8 years. According to AO classification, there were 8 type C3 and 3 type C2 fractures. The mean time from injury to operation was 4.3 days and the mean length of hospital stay was 9.8 days. The elbow flexion/extension and forearm pronation/supination arc of motion averaged 107(0) and 121(0) respectively. The mean Mayo Elbow Performance Score (MEPS) was 90 points, equivalent to excellent result. One patient sustained a periprosthetic humeral fracture and signs of non-progressive radiolucency were found in 8 out of the 11 elbows. Our search in the English and International literature revealed 9 other clinical studies describing the results of TEA in 167 patients with 168 distal humeral fractures. The mean age of patients varied from 69 to 84.6 years and the mean follow up from 17.8 months to 7 years. The mean MEPS among the studies was between 85 and 95 points. Wound infection was diagnosed in 9 cases (5.4%) but component removal and subsequent reimplantation was only applied in 3 elbows (1.8%). Partial ulnar nerve lesions were reported in 11 patients (6.5%) and reflex sympathetic dystrophy was developed in 5 patients (3%). In 3 elbows (1.8%) a periprosthetic fracture after a fall was recorded. Radiolucent lines between the cement mantle and bone interface were described in 24 cases (14.3%) but the majority of them (17 cases) were stable and asymptomatic. In conclusion, TEA constitutes a viable treatment option for the complex distal humeral fractures in elderly and medically compromised patients. Careful patient selection and regular follow up evaluation are mandatory for achieving an optimal result and eliminating the risks of mismanagement and early implant failure.

Over a period of 5 years, 63 traumatic and eight pathological diaphyseal humeral fractures were treated with a new modular humeral nail. The nail is cannulated, square in shape--with concave sides--and has two different extensions that can be used with either the antegrade or the retrograde approach. Adequate rotational and axial stability is provided without the need for distal locking screws in the majority of fractures, while the need for proximal locking screws during the antegrade procedure is abolished. This study aims to present the 'Garnavos' nail and the results of its use, along with proposals and guidelines that should be considered whenever intramedullary nailing is selected for the treatment of diaphyseal humeral fractures.

Introduction: The treatment of fractures of the distal humerus is difficult and involves the risk of bad functional results, particularly with articular fractures or impaired bone quality. Anatomical reconstruction and stable fixation allowing early mobilisation of the elbow are the basic prerequisites for good clinical outcomes. The aim of our study was to evaluate whether the Distal Humerus Plate (DHP, Synthes), a novel, perpendicular, fixed-angle plate system, fulfils the requirements for this treatment goal., Methods: From 2004 to 2007, 46 consecutive patients (19 men and 21 women; mean age of 60.5 years) underwent open reduction and internal fixation with the new DHP system. Six patients were lost to follow up. The remaining 40 patients were followed up for 11 months (range 4-24 months). Follow up involved assessment of functional outcome using the Mayo Elbow Performance Score (MEPS) and Liverpool Elbow Score (LES), reduction results and complication rates. Subgroup analyses involved comparisons of younger (<60 years) to elderly (> or =60 years) patients and type C3 injuries versus other fracture patterns., Results: Only six cases received primary internal fixation, whilst 31 patients were temporarily stabilised by either external fixation or cast before ORIF could be performed. Three patients were treated for implant failure (systems other than DHP) after surgery in other hospitals. The mean time from injury to internal fixation was 7 days. Open fractures were present in 10 cases. Olecranon osteotomy was required for reduction in 35 cases. Mean operation time was 215 min. 'Good' or 'excellent' results were observed in 29/40 patients. Median MEPS and LES were 84 and 8.1 points, respectively. Mean ROM was 100 degrees. We found no significant differences in the subgroup analyses; however, there was a tendency towards better functional results in younger patients and injuries without comminution of the articular surface. Complications comprised two superficial wound infections, two cases of heterotopic ossification, one case of delayed union and five cases of transient ulnar neuropathy. Implant failure was observed twice in one patient., Conclusion: Open reduction and internal fixation with the DHP system provides reliable, stable fixation allowing early functional mobilisation of the elbow joint, even in complex fractures and impaired bone quality, resulting in good outcomes for the majority of patients. The complication rate reported here is comparable to that of other implants, but the low number of implant failures is promising and warrants further investigation.

An optimized therapeutic rehabilitation program involved 393 patients with fractured long bones (humeral, radial/ulnar, femoral, crural) admitted to the Orthopedic Department of the Stavropol Regional Children's Clinical Hospital and the Rehabilitation Centre for Handicapped Children and Adolescents. Rehabilitation was performed in three consecutive stages, viz. immobilization, functional recovery and training. The proposed approach ensured rather fast functional recovery of the affected extremity even in cases with compound fractures. The rehabilitation program included polyenzyme therapy with wobenzym during 3-4 weeks after injury or surgical repositioning of bone fragments. Pain and oedema syndromes resolved twice as fast as after traditional treatment. The use of this program permitted to avoid development of contracture and disturbances of locomotary activity; moreover, it improved the quality of life in children with fractures of long tubular bones.

Periprosthetic fractures represent a severe complication after joint replacement. A case of comminuted displaced humeral fracture around the stem of a SMR reverse shoulder prosthesis is reported. The patient was a 81-year-old lady who had had a total shoulder replacement 28 months previously. The surgical solution consisted of a partial revision of the modular implant with conservation not only of the glenoid component but also of the prosthetic humeral body, which was well fixed in the humeral metaphysis. The humeral stem was removed and a long uncemented revision stem was implanted providing fracture stabilisation and allowing early mobilisation.

Fractures of the distal humerus around the elbow joint are most often in supracondylar or condylar lesion. This article described the diagnosis, classification, treatment, progress, side-effect, after-treatment and rehabilitation of fractures of supracondylar, lateral condyle and medial epicondyle of the humerus in child, and also described these of supracondylar, epicondylar fractures of the humerus in adult. Physical therapy should include active and active-assisted exercises for joint mobilization as soon as soft tissue healing permits. To prevent the contracture and the loss of motion of the elbow, rehabilitation of the patient and upper extremity should begin immediately, depending on the fracture and soft tissue stability in these fractures.

Treatment of comminuted intra-articular fractures of the distal humerus in elderly patients remains a challenge in trauma surgery. These fractures are rare, but their frequency increases. Our multicenter studies collected 238 cases of comminuted intra-articular fractures of the distal humerus in patients older than 65: two hundred and five cases for the retrospective study, 33 for the prospective study with a minimum follow-up of six months. The following criterias were studied: age, sex, state of health (with ASA score), functional scores (with Katz score), osteoporosis by the OST score and dual X-ray absorptiometry. The results were evaluated according to the Mayo Elbow Performance Score (Morrey) and the Quick DASH. X-ray studies were performed in order to assess both results for prosthesis and osteosynthesis. The following criteria were studied: bone healing, quality of reduction, signs of arthritis (Broberg-Morrey), prosthetic position, mechanical complications, prosthesis fixation. There were 80% of women in good health according to the ASA score (more than 70% of ASA 1 or 2). Most of them (80%) were self-governing and living at home. Hundred and seventy-two patients had an osteosynthesis and 44 had a prosthetic reconstruction (like Coonrad-Morrey prosthesis). Patients treated with osteosynthesis were younger (mean age was 77) than those treated with prosthetic reconstruction (mean age 81). Mean follow-up was 32 months. Results of osteosynthesis were good and excellent for 77% of the patients. Complications occurred for 20% of patients with a reoperation rate of 13%. Results of prosthetic reconstruction were good and excellent for 83% of the patients with 14% of complications and 6% of reoperation. Prosthetic reconstruction seemed to be better than osteosynthesis according to the Mayo Clinic score (84 points versus 77 points for the retrospective study and 95 points versus 75 points for the prospective study). However, the statistical analysis was not significant. Treatment of these fractures must be discussed according to the physiological status of the patient and the fracture patterns (scan evaluation). In conclusion, osteosynthesis remains the standard treatment when stable fixation is feasible. However, prosthetic reconstruction should be discussed for dependant patients or with comorbidity factors, bad bone quality leading to poor osteosynthesis or complex fracture.

Open reduction and internal fixation is the treatment of choice in distal humerus fractures. The aims of the treatment are to obtain anatomic reconstruction and restoration of the elbow's geometry followed by stable internal fixation that allows immediate rehabilitation. The plates are pre-contoured to fit the natural anatomy of the elbow and in the case of complex fractures they provide a guide for the anatomic restoration of the distal humerus. The two plates are placed parallel with the screws locked together by interdigitation creating a fixed angle in the distal fragments that provides stability to the entire distal humerus. Using this method we obtained good results according to the Mayo Elbow Performance Score (MEPS) and we are able to reduce the incidence of complications. Our experience shows also that it can be useful to obtain an anatomical reduction of distal humeral fractures using the pre-contoured plates in a parallel position recovering the anatomical antiversion of the articular surface.