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BACKGROUND Open distal humeral fractures (DHFs) often lead to loss of elbow function, thereby seriously affecting patient quality of life. The aim of this study was to evaluate the treatment outcomes of 2 surgical techniques to determine the better method for repairing open DHFs. Both groups were treated with immediate debridement first, and then group I had only internal fixation (IF), while group II underwent initial external fixation (EF) followed by IF surgery. MATERIAL AND METHODS This retrospective study included 32 patients who had open DHFs between 2013 and 2018. Twelve patients underwent thorough debridement and temporary EF treatment and converted to IF as the ultimate treatment. Twenty patients were treated with immediate open reduction and internal fixation (ORIF). Data of final treatment outcomes were analyzed at the latest follow-up. A comparative analysis of radiological results, function observations, and complications was performed for the 2 surgical groups. RESULTS All DHFs and osteotomized olecranon united after a mean of 5.2±1.21 months. No significant differences were observed in other preoperative demographic data between the 2 groups. Moreover, there was no significant difference in postoperative complications, elbow range of motion, or fracture healing time between the 2 groups. CONCLUSIONS The evidence provided by our study highlights the efficacy of definitive IF in treating open DHFs, which is recommended whenever possible. Furthermore, the combination of EF and ORIF, according to the type of soft tissue damage, may be a promising treatment option with a low revision rate for patients with open DHFs.

Approximately 4.1% of all fractures in the elderly involve the elbow. Most elbow injuries in geriatric patients occur as the result of low-energy mechanisms such as falls from standing height. Elbow injuries in elderly patients present complex challenges because of insufficient bone quality, comminution, articular fragmentation, and preexisting conditions, such as arthritis. Medical comorbidities and baseline level of function must be heavily considered in surgical decision making., Competing Interests: Disclosure All the authors have declared no conflict of interest for this article., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Multiple myeloma (MM) affects the long bones in 25% of patients. The advent of positron-emission tomography/computed tomography (PET/CT) scanners offers the possibility of both metabolic and radiographic information and may help determine fracture risk. To the best of our knowledge, no published study correlates these two factors with long bone fractures., Objectives: To evaluate the impact of PET/CT on fracture risk assessment in multiple myeloma patients., Methods: We identified all bone marrow biopsy proven multiple myeloma patients from 1 January 2010 to 31 January 2015 at a single institution. We prospectively followed patients with long bone lesions using PET/CT scan images., Results: We identified 119 patients (59 males/60 females) with 256 long bone lesions. Mean age at diagnosis was 58 years. The majority of lesions were in the femur (n=150, 59%) and humerus (n=84, 33%); 13 lesions in 10 patients (8%) required surgery for impending (n=4) or actual fracture (n=9). Higher median SUVmax was measured for those with cortical involvement (8.05, range 0-50.8) vs. no involvement (5.0, range 2.1-18.1). SUVmax was found to be a predictor of cortical involvement (odds ratio = 1.17, P = 0.026). No significant correlation was found between SUVmax and pain or fracture (P = 0.43)., Conclusions: Improved medical treatment resulted improvement in 8% of patients with an actual or impending fracture. The orthopedic surgeons commonly use the Mirels classification for long bone fracture prediction. Adding PET/CT imaging to study in myeloma long bone lesions did not predict fracture risk directly but suggested it indirectly by cortical erosion.

The management of upper-limb non-unions can be challenging, especially when infection is existent. Thus, pre-operative detection of infection plays a relevant role in non-union treatment. This study investigated in a large cohort the diagnostic potential of contrast-enhanced ultrasound (CEUS) as stand-alone method for differentiating between aseptic and infected upper-limb non-unions. Osseous perfusion of 50 upper-extremity non-unions (radius/ulna, n = 20; humerus, n = 22; clavicle, n = 8) was prospectively assessed with CEUS before revision surgery. The perfusion was quantified via time-intensity curves and peak enhancement (in arbitrary units). Significant perfusion differences between aseptic and infected non-unions could be detected (peak enhancement, p < 0.001). The sensitivity and specificity for the detection of infected upper-limb non-unions were 80% and 94.3% (cutoff peak enhancement: 130.8 arbitrary units). CEUS reliably differentiates between aseptic and infected upper-limb non-unions. Consequently, CEUS should be integrated into the daily diagnostic routine algorithm to plan non-union revision surgery more precisely as a single- or multi-step procedure., (Copyright © 2020 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All rights reserved.)

Purpose: The debate on the treatment of type IIa supracondylar humerus fractures has yet to be resolved. The purpose of this study was to assess the factors associated with successful closed reduction and immobilization and to assess the efficacy of a novel radiographic "hourglass" angle measurement in the management of type IIa supracondylar humerus fractures within the pediatric population., Methods: An institutional review board-approved retrospective review of all children who underwent closed reduction and casting or splinting of an isolated type IIa supracondylar humerus fractures treated at 2 pediatric hospitals from January 1, 2009 to August 31, 2016. Analyzed radiographic parameters included Baumann angle (BA), humerocondylar angle (HCA), perpendicular distance (PD) from the anterior humeral line to the capitellum, and the hourglass angle (HGA). These parameters were measured on injury radiographs (XR), postreduction XR, and at the first and final follow-up XR. The success of closed reduction was defined as maintenance of an acceptable reduction without a secondary procedure. The interobserver reliability was calculated., Results: There were 77 elbows treated with closed reduction and long-arm cast or splint immobilization. Of those closed reductions, 76.62% of elbows (59/77) maintained their reduction alignment and did not require surgical treatment for percutaneous pinning. In this series, the BA was not significantly different following closed reduction ([INCREMENT]1.04 degrees; P=0.081); however, the PD ([INCREMENT]1.89 mm), HGA ([INCREMENT]7.38 degrees), and HCA ([INCREMENT]5.07 degrees) had significant improvement following closed reduction (P<0.001 for all). The use of procedural sedation during reduction was strongly associated with success, 83.05% (49/59) with sedation compared with 55.56% (10/18) success without sedation (P=0.025). Furthermore, fractures that underwent a secondary procedure had 6.20 degrees less HGA following a closed reduction (P=0.016) and required additional follow-up visits (P=0.0037). The success of type IIa supracondylar humerus fractures did not significantly differ based on sex (P=0.5684), laterality (P=0.6975), mechanism of injury (P>0.9999), location of care-emergency department versus clinic (P=0.1160), or type of fracture immobilization (P=0.7411). The mean HGA in normal elbows was 177.8 degrees. The interobserver reliability for HCA was poor [intraclass correlation coefficient (ICC)=0.342]; fair for BA (ICC=0.458); and excellent for both PD and HGA (ICC=0.769 and 0.805, respectively) (P<0.001 for all)., Conclusions: Improved and acceptable radiographic parameters were achieved by a closed reduction in the majority of minimally displaced type IIa fractures treated by closed reduction and immobilization in this series. HCA upon presentation was significantly greater in successful cases, and failure to improve and maintain HGA and PD following closed reduction was associated with loss of reduction. Procedural sedation during reduction was strongly associated with success. The HGA and PD were consistent parameters used to determine effective management of type IIa fractures. This study adds support for a nonoperative closed reduction under sedation with immobilization of selected type IIa supracondylar humerus fractures.

The open distal humeral fracture associated with the major loss of the articular surface and bony structure is a challenging problem for orthopedic surgeons. In this case report, we describe a case of complete missing lateral column of the distal humerus with severe articular destruction of capitellum and lateral trochlear ridge which was treated with the patient-specific implant created with three-dimensional printing technology. Apart from anatomic replacement of the articular surface, the lateral collateral ligament complex and extensor muscle which are the key soft tissue stabilizers of elbow were repaired by reattaching their bony origins to the impacted iliac crest bone graft inside the implant. Due to the favorable result at 2-year follow-up, this modality is a potentially viable surgical option in treating of the severe open distal humeral fracture associated with entire lateral condylar damage.

Background: To prospectively evaluate a displacement-based classification system and an outcome-derived algorithm in the treatment of children with lateral condyle fractures., Methods: All children with a lateral condyle fracture were prospectively enrolled at our institution between 2013 and 2016. Fractures were classified and treated on the basis of the following classification system: type 1: <2 mm; treated with long arm casting, type II: 2 to 4 mm; treated with closed reduction and percutaneous pinning (CRPP), and type III: >4 mm; open reduction and percutaneous pinning (ORPP). Functional outcomes were assessed at 6 to 12 weeks and at 1-year follow-ups using the Pediatric Outcomes Data Collection Instrument (PODCI)., Results: A total of 55 patients (mean age, 6 y; range 2 to 12 y) were prospectively enrolled. There were 17 (31%) type I fractures treated with a long arm cast, 8 (15%) type II treated with CRPP, and 30 (54%) type III treated with ORPP. Postoperative complications included delayed union (N=5) and pin site infection (N=3). Delayed unions on the basis of fracture type was type I (1/17, 6%), type II (1/8, 13%), and type III (3/30, 10%) (P=0.85). The rate of delayed unions in type II and III fractures fixed with k-wires was 11% (4/38). Four patients required a second operation with screw fixation. No significant differences were found across PODCI domains at 1-year follow-up when comparing our study population with normative data., Conclusions: This is the first prospective study of a treatment protocol for pediatric lateral condyle fractures and validates the use of displacement as a guide for best evidence-based treatment. Children with a lateral condyle fracture can achieve excellent functional outcomes in all classification types with comparable complication rates when radiographic fracture displacement is used to guide surgical and clinical decision making., Level of Evidence: Level II.

Background: Closed reduction and percutaneous pinning in a crossed or lateral configuration is the standard treatment for supracondylar humerus (SCH) fractures. We compared mid-term patient-reported outcomes (PROs), radiographic outcomes, and complication rates between patients treated with crossed versus lateral pinning., Methods: We reviewed 508 pediatric patients treated surgically for Gartland type-III SCH fractures from 2008 to 2017. We included patients aged 5 to 17 years at the time of telephone interviews, who had available radiographs. We excluded those unable to be reached by telephone; those who declined to be surveyed; and those lost to follow-up. Our sample comprised 142 participants (28%) (mean±SD age at surgery, 5.2±2.0 y), 93 (65%) of whom were treated with lateral pinning and 49 (35%) with crossed pinning. Participants' parents completed the Quick Disabilities of the Arm, Shoulder, and Hand and the Patient-Reported Outcomes Measurement Information System Parent Proxy at a mean 4.4 years (range: 2 to 10 y) postoperatively. Postoperative radiographs were reviewed to assess reduction. Bivariate analysis was performed to determine whether outcomes differed by pinning technique (α=0.05)., Results: The proportions of participants achieving complete reduction were not significantly different between pin configuration groups (P=0.71). At follow-up, the 2 groups did not differ significantly in any PRO scores (all, P>0.05)., Conclusion: We found no differences between crossed and lateral pinning of Gartland type-III SCH fractures in terms of radiographic reduction, PROs, or complication rates at mid-term follow-up., Level of Evidence: Level III.

Background: We investigated the overall clinical outcome of the expanded paratricipital approach in complex articular fractures of the distal humerus and the effect of lack of visualization in the surgical field. In addition, we performed a cadaveric study to investigate the expansion or limitation of articular access in the expanded paratricipital approach., Methods: Forty-one AO/OTA type 13C fracture cases treated using the expanded paratricipital approach at a single trauma center from 2013 to 2017 were enrolled in this study. We evaluated the overall clinical outcome and analyzed the effect of lack of visualization in the surgical field with the expanded paratricipital approach by comparing outcomes between 2 groups classified by the location of the main articular fracture (group 1, limited visualization; group 2, without limited visualization). The length of inaccessible and accessible articular segments were analyzed using 40 matched-pair elbows., Results: The average duration of follow-up was 15.1 months. All fractures (type C1 in 11 cases, type C2 in 21, and type C3 in 9) were radiologically healed at 3.2 months after surgery. No cases required additional surgery because of implant irritation. The average Mayo Elbow Performance Score was 90.5. The mean Disabilities of the Arm, Shoulder and Hand score was 18.5. Among the 41 cases, the limited visualization group (group 1, n = 21) had a longer surgical time and higher percentage of nonanatomic reduction than group 2. Although the expanded paratricipital approach allowed more articular exposure than the conventional approach, there was still a 20mm inaccessible articular segment (30% of transepicondylar width) in cadaveric dissection., Conclusions: The expanded paratricipital approach can be used in type C1, type C2, and selective type C3 articular fractures of the distal humerus with favorable results. Relative to surgical times and achieving anatomic reduction, it is more successful in a fracture with a main articular fragment and with good visualization., (Copyright © 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Objective: This study aimed to evaluate the functional outcomes of the surgical treatment performed with a buttress plate for the trochlear and distal capitellum fractures with posterior extension in the humerus., Methods: The data belonging to 6 female and 4 male patients with a mean age of 43.8±11.1 (34-72) years were retrospectively evaluated. The mean follow-up period was 59.6±38.79 (22-127) months. The trochlear extension and posterior comminution of the fractures were assessed through the initial X-rays and computerized tomography images. Ten patients were classified as Dubberley type B. All fractures were treated surgically, with open reduction and internal fixation using a lateral buttress plate, headless cannulated screws, and Kirschner (K)-wires. The passive flexion and extension exercises were initiated at the first postoperative day. The patients were evaluated clinically and radiographically at the final follow-up. The outcomes were quantified using the Mayo Elbow Performance Index (MEPI), visual analog scale (VAS) pain score, and the patient's opinion., Results: At the final follow-up, the mean elbow flexion was 137.5°±3° (132°-140°), extension was -17.9°±9.2° (10°-35°), pronation was 72.2°±2.6° (68°-75°), and supination was 78.9°±4.09 (72°-85°). The mean MEPI score was calculated as 95.5±5.98 (85-100). According to the MEPI score, 8 patients were evaluated as excellent and 2 as good. The mean VAS pain score was 0.8±1.03 (0-2). The subjective patient evaluation was recorded as excellent in 5 patients, good in 3 patients, and moderate in 2 patients. One patient developed avascular necrosis and 2 patients had elbow joint arthrosis. K-wire migration was observed in one patient. Loss of reduction, nonunion, malunion, reflex sympathetic dystrophy, or heterotopic ossification were not encountered., Conclusion: The management of distal humeral fractures is challenging, and favorable outcomes are closely associated with early joint motion. A solid fixation grants early mobilization. An internal fixation using lateral buttress plate, headless cannulated screws, and interfragmentary K-wires provides a solid and secure construction that allows early postoperative joint motion., Level of Evidence: Level IV, Therapeutic study.

We present a rare case of a patient with concurrent fat embolism and pulmonary embolism, in a closed femur fracture with patent foramen ovale (PFO). A 24-year-old man was involved in a motor vehicle accident with a closed left midshaft femur fracture. He developed fat embolism syndrome (FES) on day 3 of admission, and plating was performed. The D-dimer concentration was also high, which raised the suspicion of pulmonary artery embolism. Computed tomography pulmonary angiography (CTPA) revealed right inferior lobar pulmonary artery embolism and FES. A transthoracic echocardiogram (TEE) was performed, which showed a PFO. The presence of a PFO in patients with pulmonary embolism increases the risk of systemic embolism. Therefore, we recommend the routine echocardiogram for patients with pulmonary embolism to exclude any cardiac defect in causing right-to-left shunts, which predisposes the patient to paradoxical embolism.

Purpose: The aim of this paper was to present our experience and the outcomes in 3 elderly patients who underwent combined shoulder and elbow arthroplasty after ipsilateral fractures of the proximal and distal humerus in our center. Also, we evaluate difficulties in their treatment and report their final follow-up., Material and Methods: Three cases of elderly patients who underwent shoulder and elbow arthroplasty after ipsilateral fractures of the proximal and distal humerus were reviewed. Demographic, clinical, and radiological data were analyzed. Also, Constant Shoulder Score, Mayo Elbow Performance Score, Short-Form Health Survey, and four-point Likert scale were evaluated., Results: All patients were females (100%). Mean age was 75 years (range 73-78). Mean follow-up was 36.6 months (SD 11.5). Mean time between injury and surgery was 12 days (SD 7.6). The 3 patients had a displaced and comminuted fracture of the humeral head (4-part, by Neer classification) and a comminuted intraarticular fracture of the distal humerus (13-C3, by AO classification). One patient presented a wound infection that required debridement. Despite the complications, at final follow-up, all patients showed a sufficient capacity to perform comfortably in their daily activities. Radiographs showed good fixation of all components, without evidence of prosthetic loosening or migration. All evaluated scores had good or excellent results., Conclusions: Our study provides further evidence that the shoulder and elbow arthroplasty could be a reliable management for ipsilateral fractures of the proximal and distal humerus in the elderly. In our study, this technique showed in the final follow-up patient's good outcomes.

Background: Cubitus varus deformity is a well-known late complication of supracondylar fractures in children. In this retrospective study, the primary objective was to compare clinical and radiologic outcomes of lateral closing-wedge osteotomy with either internal fixation or external fixation in pediatric patients with cubitus varus deformities., Materials and Methods: From 2010 to 2017, 35 consecutive patients with cubitus varus deformities secondary to supracondylar fractures were included in this study. After corrective osteotomy was performed via a limited lateral approach, the method of definitive fixation was chosen between internal and external. Retrospectively, patients who underwent external fixation on the lateral aspect of the elbow were defined as group I (n = 16) whereas patients with unilateral single-plate fixation were defined as group II (n = 19). The functional outcome was evaluated using the Mayo Elbow Performance Score and Flynn criteria., Results: No significant difference in age was found between the 2 groups (P = .15). Significantly lower costs, a shorter operation duration, smaller scars, and a shorter time for plaster cast use postoperatively were found in group I (P < .001). No nonunion or failure of fixation was found. No significant difference was noted in postoperative elbow range of motion or Mayo Elbow Performance Score (P = .64). Both groups achieved satisfactory functional and cosmetic results., Conclusions: In pediatric patients with cubitus varus, both methods of fixation after lateral closing-wedge corrective osteotomy are reliable, with a low rate of complications and satisfactory functional results. External fixation is more advantageous in terms of easier preoperative planning, shorter operative times, lower costs, and easier postoperative fixation removal., (Copyright © 2019 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Humeral shaft nonunions are challenging to treat, and those that require >1 surgical procedure in order for a nonunion to heal are termed recalcitrant. Most studies on nonunion have evaluated the union rate independent of the number of procedures required to achieve union. The aims of the present study were (1) to compare the healing rates after the index operation for the treatment of a nonunion with conventional versus locked plating with or without graft augmentation, (2) to report the prevalence of recalcitrant nonunion, and (3) to identify risk factors that predict a recalcitrant nonunion., Methods: We performed a retrospective analysis of a prospectively collected database of 125 humeral shaft nonunions treated with open reduction and plate fixation by a single surgeon over 25 years. Univariate and multivariate regression analyses were performed to compare healing rates by type of plate fixation and biological augmentation and to identify demographic, injury, and treatment-related risk factors for the development of a recalcitrant nonunion., Results: One hundred and five patients (84%) had healing after the index procedure for the treatment of nonunion. Twenty patients (16.0%) required secondary procedures and were defined as having a recalcitrant nonunion. Eight of these patients (6.4% of the overall group) healed after the secondary interventions, and 12 (9.6% of the overall group) had a failure to unite. There were no significant differences in healing rates between conventional and locked plates or between the types of bone graft (autogenous or recombinant human bone morphogenetic protein). Risk factors for the development of a recalcitrant nonunion were plate fixation of the acute humeral fracture, a history of deep infection, and ≥2 prior procedures., Conclusions: Plate fixation with bone graft augmentation remains a successful method for the treatment of humeral shaft nonunions. Neither plate type nor graft type reduced the risk of a recalcitrant nonunion. Factors that predicted a recalcitrant nonunion were operative fixation of the acute fracture with a plate, a history of deep infection, and ≥2 surgical procedures., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background: Lateral condyle fractures account for 15% to 20% of pediatric elbow fractures. Among numerous proposed classification systems, the Song classification appears the most comprehensive. The utility of any classification system relies on its ability to be descriptive, reproducible, and to guide prognosis/treatment. We assessed the Song classification by applying it to 736 retrospectively treated patients., Methods: A total of 736 pediatric patients with lateral condyle fractures were identified between 2007 and 2014. In total, 60 patients were selected for a radiographic interclass and intraclass correlation study. Radiographs of the patients were reviewed by 6 observers, who independently measured radiographs for displacement on radiographs and assigned a Song classification. Treatment and outcomes were then reviewed on all 736 patients and evaluated as a successful outcome when achieving a healed fracture at discharge without significant complication or necessitating a change from initial treatment modality., Results: Weighted κ values for intrarater and interrater reliability to assign Song classification indicated excellent agreement. Intraclass correlation coefficients of 6 observers measuring displacement on radiographs in millimeters indicated good to excellent agreement. In total, 106 Song 1 fracture were primarily treated by casting alone and only 5.5% required conversion to operative intervention. Overall, 139 Song 2 fractures were treated by closed treatment (n=114, 82% successful nonoperatively, 16% converted to operative management) or surgical means (n=25, 100% success) without treatment superiority (P>0.999) and both modalities had high success rates. Song 3 fractures (n=17) demonstrated a failure rate of 80% with casting (n=10) and were better managed by closed reduction and percutaneous pinning (n=7, 100% success, P=0.002). Song 4 (n=325) fractures had low success rate (34%) with casting (n=35), but achieved higher success rates (P<0.001) when managed with either closed (n=57) or open reduction (n=233) and pin fixation (89.5% and 92.7% success, respectively, P=0.401). Song 5 fractures (n=149) generally required an open reduction in our series with good success rates (91.2%)., Conclusion: This study validates the Song classification with high interobserver and intraobserver reliability. The Song classification improves on existing classification systems by better distinguishing fractures at risk for failure of nonoperative treatment and guiding treatment outcomes., Level of Evidence: Level IV.

Background: Recent studies investigating fracture development in Germany are not available especially with regard to demographic change. The primary aim of this study was to report trends in fracture development of the upper extremity in Germany between 2002 and 2017 and to evaluate changes over time., Methods: Evaluating inpatient data from the German National Hospital Discharge Registry (International Classification of Diseases, ICD-10) between 2002 and 2017. Total count, incidences and percentage changes of the following fracture localizations were analysed: proximal humerus, distal humerus, proximal ulna, proximal radius, ulna diaphysis (including Monteggia lesion) and distal radius. Ten age groups for men and women were formed: 35-44, 45-54, 55-64, 65-74; 75-84; 85-90, and > 90 (years)., Results: The total count of proximal humeral fractures increased from 40,839 (2002, men/women 9967/30,872) to 59,545 (2017, men/women 14,484/45,061). Distal humeral fractures increased from 5912 (2002, men/women 1559/4353) to 6493 (2017, men/women1840/4653). The total count of forearm fractures increased from 68,636 (2002, men/women 17,186/51,450) to 89,040 (2017, men/women 20,185/68,855). Women were affected in 70-75% of all cases with rising incidences among nearly every age group in female patients., Conclusion: Total count of nearly every evaluated fracture increased. Also, incidences increased especially in the older female age groups. Fracture development already seems to reflect demographic changes in Germany.

Pediatric humeral medial condyle fracture (HMCF) is a rare condition and is difficult to detect, especially in young children. The management of late presentation of HMCF is challenging and lacks consensus. Herein, we reported four cases of HMCF nonunion received open reduction and internal fixation (ORIF) or supracondyle osteotomy from our institution. In addition, 12 cases of ORIF and 4 cases of osteotomy reported in the previous studies were also reviewed. The HMCF nonunion can heal after ORIF, but the indication and the optimal techniques need to be clarified. Supracondylar osteotomy alone is an effective and safe treatment option to improve the functional and cosmetic outcomes of HMCF nonunion.

Objectives: This study aims to present the results of 21 patients with capitellum fractures treated with open reduction and headless screws by a single experienced surgeon., Patients and Methods: Twenty-one patients (13 males, 8 females; mean age 39 years; range, 18 to 63 years) who were admitted to our clinic between June 2011 and January 2018 with the diagnosis of capitellum fracture and followed-up for a mean period of 45 months (range, 12 to 90 months) were included in this retrospective study. The fractures were fixed with headless cannulated screws by a single surgeon., Results: The mean range of motion was 102° (range, 65° to 140°) during flexion-extension and 165° (range, 130° to 180°) during supination-pronation. The mean preoperative visual analog scale (VAS) score was 8.5 (range, 6 to 10), whereas the mean postoperative VAS score was 2.2 (range, 0 to 6). According to the Mayo Elbow Performance score, nine patients were evaluated as excellent, six patients as good, four patients as fair, and two as poor. The mean Quick-Disabilities of the Arm, Shoulder and Hand score was 25.1 (range, 4 to 57). Avascular necrosis developed in three patients (14%) and heterotopic ossification was detected in one patient (4%)., Conclusion: Capitellum fractures are difficult to diagnose and treat, and good results can only be achieved by an accurate diagnosis, careful surgical technique, and stable fixation. Larger and more comprehensive studies are required to establish a generalization and more accurate inferences on this limitedly studied subject.

Background: Occult and missed surgical neck fractures can be found in patients diagnosed with isolated greater tuberosity (GT) fracture during the follow up period. The purpose of this study was to retrospectively assess the incidence rate of occult and missed surgical neck fractures in those initially diagnosed with isolated GT fracture., Methods: Records of patients diagnosed as having an isolated GT fracture were retrieved from a database in a medical center. Two senior orthopedic surgeons blindly reviewed all images of these patients three times to classify GT fracture types (split, avulsion and depression types), and recorded any surgical neck fractures found. Then a meeting was help to confirm the fracture types and presence of surgical neck fracture., Results: Occult surgical neck fractures were found in 5 out of 68 (7.4%) patients, whereas missed surgical neck fractures were found in 3 out of 68 (4.4%) patients. In total, 32 patients had split type GT fracture, 32 had avulsion type and 4 had depression type. For those with occult surgical neck fractures, 7 had the split type GT fracture, while the remaining one had the avulsion type. Although the proportion of occult surgical neck fracture was higher in the split-type GT fracture (21.9%) than in the avulsion-type GT fracture (3.1%), the difference was not statistically significant (p = 0.056)., Conclusion: Occult humeral surgical neck fractures occurred in 7.4% of isolated greater tuberosity fractures after re-evaluation, while missed humeral surgical neck fractures occurred in 4.4%.

Introduction: Efforts to prevent iatrogenic neurovascular injuries with humeral intramedullary nailing lead to design new implants and inside to out distal locking technique using an endopin aims to provide a safer screw application. InSafeLock (TST, Istanbul, Turkey) humeral nail have been recently developed to minimize the possible screw related complications. The anatomical relationship between locking screws and neurovascular structures with the application time were compared between Trigen Humeral Nail (Smith and Nephew, Memphis, USA) and InSafeLock Humeral Nail., Hypothesis: InSafeLock humeral nail would be safer than Trigen Humeral nail in terms of neurovascular injury., Materials and Methods: Seven cadavers were used with both shoulders and surgical application of two nails was performed as the manufacturer guide. An Insafelock humeral nail was used for each right humerus and a Trigen humeral nail was used for each left humerus. Once the nails were placed, proximal and distal region of the nails were dissected to evaluate the relationship between screws and adjacent anatomical structures. The duration of the each screw was assessed via a stopwatch., Results: No significant finding was noted for the relationship between the neurovascular structures and proximal screws in two groups (p<0.05). The distal locking of the InSafeLock humerus nail had a shorter application time and no neurovascular damage was recorded., Discussion: The newly developed Insafelock humerus nails are at least as safe and effective as current humeral nails available on the market. Additional benefits include the preservation of neurovascular structures, as the Insafelock humerus nail does not require the use of an extra incision. Furthermore, surgical time is significantly shorter with using distal endopin., Level of Study: III, controlled laboratory study., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

Introduction: The anterior and anterolateral approaches to the humerus describe splitting brachialis longitudinally, assuming its fibres run parallel to the shaft. Recent improvements in the understanding of brachialis anatomy however have demonstrated it has two distinct heads, with the bulk of its fibres running oblique relative to the humerus. Attempting to split brachialis longitudinally to the extent required for plate osteosynthesis invariably leads to transection of a significant number of muscle fibres. The authors present a less muscle destructive modification to the anterolateral approach (ALA) based on a bicipital brachialis muscle., Method: In order to preserve brachialis muscle fibres, the modified ALA elevates the superficial head from the underlying humerus and longitudinally splits the deep head to allow a fixation device to be tunnelled. Case notes of patients with a humeral shaft fracture fixed via the modified ALA were retrospectively reviewed., Results: Ninteen humeral shaft fractures were fixed via the modified ALA. No post-operative nerve palsies were reported. Of the 19 patients, 14 (73.7%) received clinical and radiological follow-up. All reported being satisfied with their outcome. One developed a superficial wound infection and one (previous diagnosis of spondyloepiphyseal dysplasia tarda) developed a non-union requiring revision surgery. Of the five patients lost to follow-up, two died, and three reported no ongoing orthopaedic issues via telephone., Conclusions: Improved anatomical understanding of brachialis has resulted in the described modification to the ALA which is less muscle destructive and follows a truer inter-nervous plane. This small series demonstrates satisfactory outcomes using this approach.

Low transcondylar fractures of the distal humerus in adults is rarely seen and reported in literatures. It has a bimodal distribution in terms of age, affecting the elderly and younger patients. The fracture is characterized by a very low transverse intra-capsular and extra-articular fracture lines extending from the level of lateral epicondyle to medial epicondyle. Standard elbow plain films and CT scans are crucial and indispensable for diagnosis. Conservative treatment is suitable for undisplaced fractures, patients who are intolerant of anesthesia, or people with advanced dementia. Open reduction and internal fixation (ORIF) is preferred. Parallel and orthogonal plate fixation are widely adopted while some researchers preferred crisscross-type screw fixation or bicolumnar 90-90 plating. In addition, some customized posterolateral plates are specially designed to be able to insert a transverse screw, functioning as lateral support. However, most of the recent researches conducted on low transcondylar fractures of the distal humerus are retrospective studies with relatively lower level of evidence compared to prospective and randomized controlled ones which remain a vacancy in this field. Therefore, further studies comparing the biomechanical properties and clinical prognosis of different configurations of internal fixation or total elbow arthroplasty for the treatment of low transcondylar fractures are needed in the future., Competing Interests: The authors of this article and the planning committee members and staff have no relevant financial relationships with commercial interests to disclose., (Copyright© 2019 by the China Journal of Orthopaedics and Traumatology Press.)

Purpose: The purpose of this video is to present a technique for open reduction and internal fixation of a displaced unstable medial epicondyle avulsion fracture., Method: A 13-year-old boy presented 2 days after injury at our institution after sustaining a medial epicondyle avulsion fracture with incarcerated fragment and posterolateral dislocation of the elbow after a fall off a fence. He described paresthesia in the ulnar nerve distribution and demonstrated slight weakness to intrinsic hand strength on examination. He was urgently reduced under sedation in the emergency department using the Roberts maneuver, a technique consisting of a valgus stress with forearm supination with finger and wrist extension that uses muscle forces to extract the fragment. Successful reduction of the ulna-humeral joint and extraction of the incarcerated medial epicondyle was demonstrated on CT. The patient was then taken in a nonurgent fashion to the operating room for open reduction and internal fixation of the displaced medial epicondyle fracture. Intraoperative examination after fixation demonstrated a congruent and stable elbow. A long-arm cast was then applied., Results: The video is 7-minute, 38-second duration in time and 461 MB in size., Conclusions: Although fixation of medial epicondyle avulsion fractures may be controversial, there are some indications for ORIF including incarcerated epicondylar fragment, suspected entrapment and dysfunction of the ulnar nerve, marked instability of the elbow, and open fracture. Presented in this video is a safe technique for ORIF of the displaced and unstable medial epicondyle avulsion fracture.

The medial condyle fracture of the humerus is-in comparison to the lateral condyle fracture-a very rare Salter-Harrison IV-fracture of the elbow. In this prospective study 14 children were included and reviewed. One child had minimal displacement fracture type I, one child had type II, and 12 children had type III-fractures. One patient was treated conservatively by an upper arm cast; thirteen were surgically treated using open reduction and osteosynthetical treatment. Postoperatively the elbow was immobilized in 90° flexion and neutral position in a long-arm cast for 4-6 weeks. In 11 children the diagnosis was made immediately after trauma, in 3 children the fracture was overlooked initially. Medial condyle fractures may be difficult to diagnose in children younger than 6 years and the lesion may be mistaken for a simple avulsion of the medial epicondyle or even missed. The C-sign is a hint for a medial condyle fracture. The development of nonunion happens in consequence of failure to recognize the fractures. Results after an average follow-up of 36 months showed that children who were diagnosed immediately and received operative stabilization had very good functional and aesthetical results. Three children with delayed diagnosis of the fracture had open surgery with reposition and osteosynthetical fixation. In two of the overlooked cases a slight contracture and angular misalignment persisted. If in this injury the diagnosis is made without delay, an appropriate therapy is implemented and radiographical controls are performed until consolidation, good results can be expected. The main risk in medial condyle fractures of the humerus is to overlook them. This can lead to the development of a nonunion with joint malformations.

Objectives: To evaluate the results obtained using unilateral external fixation as a definitive treatment for humeral shaft fractures and to identify possible predictors of radiographic and functional outcomes., Design: Retrospective study., Setting: One large metropolitan hospital., Patients: A consecutive cohort of 107 patients who underwent external fixation for 109 humeral shaft fractures., Main Outcome Measures: Union rate, time to fracture healing, and functional assessment with disabilities of the arm, shoulder, and hand questionnaire, Constant score, Mayo Elbow Performance Index, and return to prefracture sports activity at a minimum of 2 years after surgery. Comorbidities were evaluated using the Cumulative Illness Rating Scale. Multiple linear regression analysis was used to determine whether any explanatory variables were significantly associated with the outcomes., Results: The union rate in 109 humeral shaft fractures was 97.2% (106/109) at a mean of 99.2 days. Two patients (1.8%) had delayed union, and 1 patient (0.9%) did not achieve union. At the latest follow-up, the mean Constant score, Mayo Elbow Performance Index, and disabilities of the arm, shoulder and hand questionnaire score was 85.6, 97.4, and 7.4 points, respectively. All patients engaged in sports activities before fracture resumed a sport activity. At the multiple linear regression analysis, obesity was directly related to a delayed healing of fracture (P = 0.010) and comorbidity was the most important determinant of the functional outcomes at follow-up (P < 0.001)., Conclusions: These data support the use of unilateral external fixation as an effective therapeutic option in patients with humeral shaft fracture. Comorbidity as assessed by Cumulative Illness Rating Scale score is the most important determinant of functional outcomes., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Objective: Axillosubclavian vessel injury is rare, with most cases occurring after penetrating trauma. A prior database (2002-2006) analysis demonstrated an overall limb loss rate of 2.9%, with no difference between isolated arterial axillosubclavian vessel injury and combined artery/vein axillosubclavian vessel injury. Given increases in advanced vascular surgical techniques, as well as improved multidisciplinary care and expeditious diagnosis with computed tomography angiography, we hypothesized the national rate of limb loss in patients with arterial axillosubclavian vessel injury has decreased. In addition, we attempted to identify current predictors for limb loss in arterial axillosubclavian vessel injury. Finally, we hypothesized that combined artery/vein axillosubclavian vessel injury, as well as associated brachial plexus injury will have a higher risk for limb-loss and mortality compared to isolated arterial axillosubclavian vessel injury., Methods: A retrospective analysis of the National Trauma Data Bank was performed between 2007 and 2015. All patients ≥ 18 years of age with arterial axillosubclavian vessel injury were included. The primary outcome was limb loss. After a univariable logistic regression model identified significant covariates, we performed a multivariable logistic regression for analysis., Results: Of the total 5,494,609 trauma admissions, 3807 patients had arterial axillosubclavian vessel injury (<0.1%). Of these, 3137 (82.4%) had isolated arterial axillosubclavian vessel injury and 670 (17.6%) had combined artery/vein axillosubclavian vessel injury. The overall limb loss rate was 2.4% (from 2.9% in 2006, p = 0.47). After adjusting for covariates, independent risk factors for limb loss included a combined artery/vein axillosubclavian vessel injury (odds ratio = 3.54, confidence interval = 2.06-6.11, p < 0.001), blunt mechanism (odds ratio = 7.81, confidence interval = 4.21-14.48, p < 0.001), open repair (odds ratio = 2.37, confidence interval = 1.47-3.82, p < 0.001), and open proximal humerus fracture (odds ratio = 8.50, confidence interval = 4.97-14.54, p < 0.001). An associated brachial plexus injury was not associated with limb loss ( p = 0.37). Combined artery/vein axillosubclavian vessel injury was associated with higher risk for mortality compared to isolated arterial axillosubclavian vessel injury (odds ratio = 2.17, confidence interval = 1.73-2.71, p < 0.001)., Conclusions: The national rate of limb loss in trauma patients with arterial axillosubclavian vessel injury has not changed in the past decade. A combined artery/vein axillosubclavian vessel injury is an independent risk factor for limb loss, as well as open repair. However, the strongest risk factor is an open proximal humerus fracture. An associated brachial plexus injury is not associated with increased risk of limb loss. Patients with combined artery/vein axillosubclavian vessel injury have a twofold increased risk of death compared to patients with isolated arterial axillosubclavian vessel injury.

Rationale: Osteochondral flap fractures of the elbow are rare in children. To the best of our knowledge, only 12 cases are reported in the literature. Only 1 case was accompanied with lateral condyle fracture classified as Milch I, which was nondisplaced. The mechanism of these injuries is not explained in detail, and the treatment methods are not discussed. Here, we present 3 cases of osteochondral flap fracture of the ulnar coronoid process with accompanying obvious displacement of the lateral condyle fracture., Patient Concerns: All patients fell into one of their outstretched arms, which caused elbow pain and functional limitation., Diagnosis: All 3 patients were diagnosed with lateral condyle fracture of the humerus and osteochondral flap fracture of the ulnar coronoid process., Interventions: All patients underwent open reduction and internal fixation., Outcomes: At 3 months after the operation, they regained full range of motion of the limb and had no elbow instability., Lessons: Osteochondral flap fracture should be considered when there is a bone mass in the elbow space with accompanying displacement of the humeral lateral condyle fracture.

Purpose: Distal metaphyseo-diaphyseal humeral fractures are challenging particularly if open, comminuted, or associated with nerve injury. In cases of open distal complex metaphyseo-diaphyseal humeral fractures inamenable for traditional methods of fixation, retrograde intramedullary locked humeral nail with a new lateral condylar point of entry has been proposed., Methods: Two phases of study were conducted; phase I comprised computerized tomography evaluation of right humeri of 120 adult subjects, while phase II entailed prospective analysis of 18 patients who sustained firearm injuries resulting in open distal metaphyseo-diaphyseal humeral fractures associated with radial nerve injuries. All patients were surgically managed using lateral condylar retrograde humeral nailing with primary radial nerve exploration., Results: Distal sagittal medullary diameter of the humeral medulla was the narrowest in comparison to axial and coronal medullary diameters in phase II, which matched the results of phase I. The mean postoperative disability of the arm, shoulder, and hand score was 11.2 ± 6.4. Only five patients underwent subsequent successful tendon transfer., Conclusions: Lateral condylar retrograde humeral nail with early radial nerve exploration in cases of high-energy distal metaphyseo-diaphyseal humeral fractures yielded good results regarding union and spontaneous radial nerve recovery or later on reconstruction.

Background: Either casting or in situ fixation (to prevent displacement) are recommended for minimally displaced pediatric lateral condyle fractures of indeterminate stability with ≤2 mm lateral displacement and narrowed fracture extension to the epiphyseal articular cartilage. This study compares casting only, acute prophylactic in situ pinning, and surgery if casting fails due to displacement., Methods: In total, 738 fractures at a level 1 trauma center between 2008 and 2014 were reviewed. All fractures were assigned a Song classification and Song 2 fractures followed to union were analyzed. Worsening displacement was defined as an increase in Song stage. Patients were grouped per treatment: (1) cast only; (2) in situ pinning; or (3) closed or open reduction percutaneous pinning after displacement during attempted cast treatment., Results: In total, 139 fractures were included and 45 (32%) underwent surgery. Among 114 fractures intended for casting, only 20 (18%) displaced and needed surgery. This implies 82% of fractures prophylactically pinned in situ may have remained stable in a cast. On average, displaced fractures were noted 6.5 (2 to 13) days after presentation and required 1 extra clinic visit and week of immobilization without increased complications. Surgeons chose open reduction percutaneous pinning more often for displaced fractures., Conclusions: Our data estimate 82% of Song 2 fractures never meaningfully displace in a cast. Meaningful displacements occur in <2 weeks. Benefits of prophylactic pinning include 1 less x-ray and clinic visit in exchange for a clinically insignificant lateral cortex reduction and inherent surgical risks. Compliance, surgical scheduling, and a higher rate of open reduction after displacement should influence early treatment decisions., Level of Evidence: Level III.

Background: Locking plates are the gold standard for treatment of 3-part humeral head fractures, although major complications range from 9% to 36%. Percutaneous techniques may allow vascular supply preservation, maintenance of fracture hematoma, scarce blood loss. Many configurations with Kirschner wires can be performed, generating confusion on result interpretation. We studied the correlation between system configuration, stability, and clinical results in patients with 3-part humeral head fractures treated with the same fixation system but with 2 different biomechanical constructs., Materials and Methods: There were 52 consecutive patients (19 men, 33 women; mean age, 63.1 [standard deviation, 5.6] years; range, 48-82 years) with Hertel 7 humeral head fractures. Two fixation constructs composed of 3 couples (construct A) or 4 couples (construct B) of blocked threaded wires were used in 17 and 35 patients, respectively. At the final follow-up, the individual relative Constant Score (irCS) and visual analog scale were measured. Radiographic evaluation according to the Bahr criteria was performed. Statistical analysis was performed., Results: The mean follow-up was 22 months. The mean irCS at the final follow-up was 89.7%. The mean irCS in patients treated with construct A and construct B was 86% and 93%, respectively (P = .043). One nonunion and 2 superficial infections occurred (6%). The postoperative reduction was excellent in 97% of patients and remained excellent in 89%. The mean postoperative neck shaft angle was 135.0° (construct A: 134.7°; construct B: 135.1°), and the final neck shaft angle was 132.9° (construct A: 131.3°; construct B: 133.8°; P = .047)., Conclusions: The functional and radiologic outcomes obtained with percutaneous fixation or locking plates are similar; however, the percentage of major complications after percutaneous treatment is lower. Results of percutaneous fixation depend on the biomechanical construct., (Copyright © 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Fracture of lateral condyle with dislocation of the elbow joint is rare in pediatric age. Diagnosis and management of these injuries could be a challenge. Delayed presentation of such injuries could be mistaken for a malunited supracondylar fracture of the humerus and treatment of these injuries remains controversial. We present 2 such cases, where the diagnosis of dislocation of elbow was missed at initial presentation and caused diagnostic confusion at late presentation. The problems faced in the diagnosis of these injuries and the management of late presenting cases are discussed.

Rationale: Posteromedial dislocations of the elbow with lateral humeral condylar fractures (LCFs) are uncommon, and only isolated cases have been reported in the English-language literature. Because of the complex radiolucent cartilaginous structures and late-appearing ossification centers, radiological diagnosis of elbow dislocations with LCF in children is challenging., Patient Concerns: We report three children with posteromedial elbow dislocation: two patients with Milch type I and one patient with Milch type II LCF., Diagnoses: In our report, radiographs showed only a small bone fragment, and arthrography or computed tomography were helpful diagnostic aids in cases 1 and 3. In contrast, the patient in case 2 was initially misdiagnosed as having an epiphyseal separation of the distal humerus, and open reduction and internal fixation through the posterior approach revealed Milch type II LCF., Interventions: In case 1 and 3, Milch type I LCFs, open reduction and internal fixation was performed through the posterolateral approach. On the other hand, in case 2, Milch type II LCF, open reduction and internal fixation was performed through the posterior approach., Outcomes: Poor reduction of Milch type I LCFs resulted in incongruity of the articular surface and poor cosmetic results in two patients. In case 2, Milch type II LCF, plain radiographs showed adequate healing without elbow deformity and the clinical result was excellent., Lessons: Because LCFs are intra-articular fractures, anatomical reduction is crucial for satisfactory outcomes. We promote awareness of this injury, especially posteromedial dislocation with Milch type I LCF. Preoperative evaluation is helpful for achieving satisfactory outcomes, and open reduction and internal fixation through an anterolateral approach might be most appropriate for Milch type I LCFs.

To evaluate the clinical outcomes of an anterolateral approach for lateral humeral condylar fractures in children. The patients aged < 15 years undergoing surgery with an anterolateral approach for humeral lateral condylar fractures between April 2005 and March 2014 were investigated. Medical records and radiographs from 15 patients were reviewed. Average patient age at surgery was 6.0 years (range, 3-10 years). Based on Jakob's classification, 12 patients had type II fractures, and 3 patients had type III fractures. Based on Milch classification, 1 elbow was type I, and 14 elbows were type II. The average postoperative follow-up duration was 16.4 months (range, 6-58 months). Postoperative complications, and radiographic and clinical findings, including range of motion and Flynn criteria were evaluated. To evaluate humeral deformity, Baumann angle (BA) and the carrying angle (CA) were calculated on anteroposterior radiographs. There were no postoperative complications, including secondary displacement, deep infection, nonunion, avascular necrosis, or cubitus varus or valgus deformity. In the injured elbow, follow-up radiographs revealed an average BA of 69.1° (range, 57-84°), versus 70.9° (range, 61-83°) on the contralateral side. The average CA on the injured side was 10.3° (range, 4-20°) versus 12.3° (range, 6-24°) on the contralateral side. BA gain and CA loss (affected- compared with contralateral sides) averaged -1.4° (range, -17° to 9°) and 2.3° (range, -2° to 6°), respectively. The mean range of motion in the affected elbow averaged 4.7° (range, 0-15°) in extension and 139.7° (range, 135-140°) in flexion. Over 5° loss of range of motion in the affected elbow compared with the contralateral side was not observed. However, 2 patients experienced over 5° loss of CA in the affected elbow versus the contralateral side. Based on Flynn criteria, clinical results for both cosmetics and function were excellent in 13 patients, and good in 2. The advantages of the anterolateral approach are combining an optimal view of the anterior articular surface of the trochlea and capitellum and a limited risk of devascularization injury. We strongly recommend an anterolateral approach for these fractures in children to prevent postoperative deformity and to achieve anatomical reduction and reliable fixation.

Introduction: Although most humeral shaft fractures can be treated nonoperatively, many patients do benefit significantly from surgical treatment. The anterolateral approach to the humerus provides excellent exposure to the humeral shaft, especially to more proximal aspects. In addition, the approach can be extended both proximally and distally, providing the surgeon a dynamic exposure to the humerus for the treatment of fractures and other pathologies., Methods: This video highlights a clinical case where a mid-shaft humerus fracture was diagnosed and treated with open reduction internal fixation using an 8-hole 4.5-mm limited contact dynamic compression plate through an anterolateral approach., Results: We present indications, anatomic considerations, and surgical techniques used to surgically treat a transverse, mid-shaft humerus fracture through an anterolateral approach. In addition, we demonstrate the use of a push-pull screw to aid in achieving appropriate compression across a fracture site. Using this technique, an anatomic reduction and satisfactory clinical outcome were achieved., Conclusions: The anterolateral approach to the humerus offers excellent exposure to some humeral shaft fractures, particularly those that lie more proximally. However, its use must be weighed carefully against several other approach options, and the surgeon must account for the specific fracture pattern, as well as their own comfort and familiarity with the approach.

Objective: To determine the proximity of neurovascular structures to multiplanar distal interlocking screws and proximal interlocking devices for an antegrade inserted humeral nail., Methods: Humeral nails (Depuy Synthes Humeral Nail-EX, Paoli, PA) were inserted into 10 matched cadavers with 3 distal interlocking trajectories: anterior to posterior (A-P), anterolateral to posteromedial, and anteromedial to posterolateral (AM-PL). The distance of the screw path and screw head to the radial, lateral antebrachial cutaneous nerve (LACN), and median nerves and the brachial artery was measured. Proximally, the distance of spiral blades and/or interlocking screws to the axillary nerve was measured., Results: The median distance of the screw path/screw head inserted (A-P) to the LACN was 0 mm/0 mm in the left arm and 3.5 mm/1.6 mm in the right arm. The median distance of the screw path/screw head inserted AM-PL to the median nerve was 7.08 mm/0 mm in the left arm and 0 mm/0.12 mm in the right arm. The median distance of the screw path/screw head inserted AM-PL to the brachial artery was 4.05 mm/3.83 mm in the left arm and 2.19 mm/2.84 mm in the right arm. The humeral head was radiographically divided into 3 zones. The average distances of the axillary nerve to interlocking devices placed into zone 2 and zone 3 of the humeral head are 14.65 mm and 1.07 mm, respectively., Conclusions: When using the DePuy Synthes Humeral Nail-EX, AM-PL screws may risk the median nerve and brachial artery; thus, this trajectory is not recommended. The LACN may be at risk with A-P and to a lesser degree, anterolateral to posteromedial screws. Proximally, interlocking devices in zone 3 of the humeral head may risk the axillary nerve.

Objective: To compare the outcomes of pediatric supracondylar humerus fractures treated during daytime hours to those treated after-hours., Design: Retrospective., Setting: Academic Level I trauma center., Patients/participants: Two hundred ninety-eight pediatric patients treated with surgical reduction and fixation of closed supracondylar fractures were included., Intervention: Seventy-seven patients underwent surgery during daytime hours (06:00-15:59 on weekdays). One hundred eighty-six patients underwent surgery after-hours (16:00-05:59 on weekdays and any surgery on weekends or holidays)., Main Outcome Measures: Surgeon subspecialty, operative duration, and radiographic and clinical outcomes, including range of motion and carrying angle, were extracted from the patient medical records., Results: There were no patient-related demographic differences between the daytime hours and after-hours groups. Daytime surgery was more likely to be performed by a pediatric orthopaedic surgeon than after-hours surgery. Fractures treated after-hours had more severe injury patterns. After-hours surgery was not independently associated with rate of open reduction, operative times, complications, achievement of functional range of motion, or radiographic alignment. A late-night surgery subgroup analysis demonstrated an increased rate of malunion in patients undergoing surgery between the hours of 23:00 and 05:59., Conclusions: There is no difference in the operative duration or outcomes after surgical treatment of pediatric supracondylar humerus fractures performed after-hours when compared with daytime surgery. However, late-night surgery performed between 23:00 and 05:59 may be associated with a higher rate of malunion. Surgeons can use these data to make better-informed decisions about the timing of surgery in this patient population., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: Distal humerus physeal separations are rare pediatric elbow fractures that are often misdiagnosed and difficult to treat. Adequate reduction is often technically challenging and up to 71% of children develop postoperative cubitus varus. We propose using the medial and lateral humeral lines as an adjunct to elbow arthrography in order to guide intraoperative fixation of distal humerus physeal separations to reduce the incidence of postoperative cubitus varus., Methods: From 2009 to 2014, all pediatric patients under the age of 3 diagnosed with a distal humerus physeal separation and treated surgically at our institution were included for analysis. Two senior pediatric orthopaedic surgeons separately reviewed the preoperative, intraoperative, and postoperative images of all patients and measured the position of the ulnar axis relative to the medial and lateral humeral lines. The medial and lateral humeral shafts were defined as parallel lines drawn along the medial and lateral humeral diaphysis. Adequate reduction was defined by reduction of the ulnar axis within the boundaries of the medial and lateral humeral lines. Patients were assessed at latest follow-up for cubitus varus and any other surgical complications., Results: Thirteen patients fulfilled the inclusion criteria and were on average 1.70 years old, ranging from 0.62 to 3 years old. Intraoperatively and immediately postoperatively, all 13 patients (100%) were noted to have adequate reduction of the ulnar axis within the boundaries medial and lateral humeral lines. None of the patients required intraoperative arthrography (0%). At the date of latest follow-up, 12 patients (92.3%) had no angular deformities compared with the contralateral limb and 1 patient (7.7%) had developed cubitus varus. No surgical complications were noted (0%)., Conclusion: Intraoperative reduction of the ulnar axis within the boundaries of the medial and lateral humeral lines is associated with a lower incidence of postoperative cubitus varus in the treatment of distal humerus physeal separations in children., Level of Evidence: Level IV.

Fractures of the humeral shaft are common injuries with multiple management strategies. Many still regard nonoperative management as the standard of care; however, as the understanding of these injuries increases, treatment recommendations are also evolving. Fracture pattern, fracture location, and identifiable patient risk factors may predict poor outcome with nonoperative management, and earlier operative intervention may be recommended. Operative management includes open reduction and internal fixation through a variety of exposures, intramedullary nail fixation, and external fixation. With increasing rates of shoulder arthroplasty, periprosthetic humeral shaft fractures also deserve special consideration., (Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

The incidence of fragility fractures of the humerus is increasing worldwide. Although clinicians are aware of fractures of hips and wrists, fractures of the shoulder and elbow do not receive much attention. A considerable proportion of the elderly population (estimated at 10-24%) is dependent on walking aids. A well-functioning and pain-free shoulder and elbow is essential for use of these aids. The impact of loss of mobility in the elderly is well known, hence the overall impact of these fractures on the individual can be considerable. This article increases the awareness of these fractures among non-orthopaedic colleagues and provides a brief outline of their management. In the elderly population using walking aids, the shoulder and elbow are effectively weight-bearing joints. Fractures of the shoulder or elbow in the elderly require extra attention to maintain their mobility during this period by physiotherapy to the lower limbs and chest. In patients who mobilize using a frame, the use of a stick on the opposite side of the injury may have to be considered while recovery is in progress.

Background: We compared radiographic and operative results of pediatric patients undergoing surgical treatment of displaced supracondylar humeral fracture (SCHF) according to the surgeon's experience., Methods: During an 11-year period (2006-2016), we reviewed the medical records of 236 patients operated on for Gartland III SCHF in our institution. Operative (operative time, time to implants removal) and radiographic parameters (Baumann and lateral capitellohumeral angles) were assessed. A malalignment was defined if there was a difference in the Baumann angle or lateral capitellohumeral angles >15° or if malrotation existed compared with normative values. We compared surgeon experience and volume (number of patients operated on by year)., Results: In patients operated on by less experienced surgeons (<1 year, n = 69), operative time (61 vs. 41 minutes) and time to implant removal (48 vs. 40 days) were significantly longer (P < .001). Radiographic parameters did not differ between less and more experienced surgeons. Operative parameters improved through the 20 first cases of the younger surgeons. In surgeons managing fewer than 5 patients per year, malalignment and conversion to open reduction were more frequent (all P < .05)., Conclusion: Experience and volume are 2 crucial parameters influencing the quality of management of pediatric patients undergoing surgical treatment for displaced SCHF. They should be taken into account in daily practice, especially when making the decision to operate on these patients out of day time., (Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Objective: The purpose of this retrospective case series was to examine the AO Foundation and Orthopaedic Trauma Association (AO/OTA) 13-C3 distal humeral fractures treated with open reduction-internal fixation (ORIF) in patients older than 70 years., Methods: During an 8-year period, 21 patients older than 70 years with AO/OTA 13-C3 distal humeral fractures were treated with ORIF performed by 2 senior upper extremity traumatologists. There were 16 patients with >1 year of follow-up, with a mean age of 78 (70-84) years., Results: At a mean follow-up of 4 years (1-8 years), all 16 patients demonstrated radiographic signs of bone union. Three patients underwent reoperations, including irrigation and débridement for postoperative infections (n = 2) and removal of implant for symptomatic olecranon intramedullary screw (n = 1). The mean postoperative total arc of ulnohumeral motion was 97° (80°-145°), including a mean flexion of 117° (106°-126°) and flexion contracture of 20° (14°-26°). The mean pronation was 69° (55°-85°), and supination was 78° (74°-9°0). The mean Quick Disabilities of the Arm, Shoulder, and Hand score was 19 (standard deviation, 6.9; confidence interval, 15.4-22.8), and the mean Mayo Elbow Performance Score was 91 (standard deviation, 8.2; confidence interval, 86-95)., Conclusions: ORIF remains a reliable option for treatment of AO/OTA 13-C3 distal humeral fractures in elderly patients. Excellent clinical outcomes can be achieved with preservation of motion and arm function through anatomic reduction, rigid internal fixation, and early mobilization., (Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Previous randomized controlled studies and meta-analyses have failed to collectively favor either open reduction-internal fixation (ORIF) or intramedullary nailing (IMN) fixation. The purpose of our investigation was to elucidate the optimal decision between ORIF and IMN for acute traumatic operative humeral shaft fractures through an expected value decision analysis., Methods: We performed an expected value decision analysis and sensitivity analysis to elucidate the difference between ORIF and IMN fixation for patients with acute traumatic humeral shaft fractures. We surveyed 100 consecutive, randomly selected volunteers for their outcome preferences. Outcomes included union, delayed union, major complications, minor complications, and infection. A literature review was used to establish probabilities for each of these respective outcomes. A decision tree was constructed and a fold-back analysis was performed to find an expected patient value for each treatment option., Results: The overall patient expected values for ORIF and IMN were 12.7 and 11.2, respectively. Despite artificially decreasing the rates of major complications, infection, delayed union, and nonunion each to 0% for IMN fixation (sensitivity analysis), ORIF continued to maintain a greater overall patient expected value (12.7 vs. 11.4, 11.2, 11.2, and 12.1, respectively). Only if the rate of nonunion after ORIF was increased from 6.1% to 16.8% did the overall expected outcome after ORIF equal that of IMN (11.2)., Conclusion: Our expected value decision analysis demonstrates that patients favor ORIF over IMN as the optimal treatment decision for an acute traumatic humeral shaft fracture., (Published by Elsevier Inc.)

PURPOSE OF THE STUDY Olecranon fractures in skeletally immature patients are rather rare and represent up to 7% of elbow skeletal injuries. Although the majority of olecranon fractures is constituted by undisplaced fractures treated conservatively with good outcomes, a few of them require surgery. The aim of the study was to compare two different approaches of surgical treatment - the open reduction with tension band wiring - cerclage (ORCe) and the closed reduction and percutaneous pinning (CRPP). MATERIAL AND METHODS 37 patients (28 boys, 9 girls) were included in the retrospective multicentric study. The patients were treated at two different institutions (the Clinic of Paediatric Surgery, Orthopaedics and Traumatology, the University Hospital Brno and the Department of Paediatric Surgery and Traumatology, the University Hospital Hradec Králové, Czech Republic). 17 patients underwent the ORCe procedure, while 20 patients were treated using the CRPP method. Different parameters were statistically compared in the groups (demographic data, data concerning the course of the therapy, outcome of the therapy in terms of movements' restrictions and complications such as osteosynthesis failure and infection). RESULTS Both the groups were comparable in terms of demographic data because no statistically significant difference was observed in terms of the age (p = 0.082), the affected site (p = 1.000) and the gender (p = 0.462). Statistically significant difference between these two groups was found in the interval between the implementation and the removal of the osteosynthetic material (p < 0.001) and in the length of cast immobilisation (p = 0.047). The number of patients with movement restriction up to 10° was statistically significantly higher in patients who underwent the CRPP procedure (p = 0.040), but no statistically significant difference was seen between these two groups in terms of movement restriction more than 10° (p = 0.609). One revision surgery was performed in the CRPP group, however with no statistical significance (p = 0.350). DISCUSSION The multicentric study included 37 children, who underwent surgical treatment of a displaced olecranon fracture. Compared to the studies dealing with this topic the number of patients included in this study is relatively high. It advocates the possibility of using the CRPP method as a good alternative to the gold-standard ORCe technique because no difference in terms of the number of revision surgeries and the clinically important movement restriction of more than 10° were seen. It also brings along advantages such as a simple surgical technique, good functional and cosmetic effects, reducing the risk of ischemic insult of growth plate and the possibility of osteosynthetic material removal at an outpatient department with no need for general anaesthesia. The risk of a higher radiation exposure of both the patient and the surgical team should be considered as a disadvantage of the closed method. CONCLUSIONS The mini-invasive CRPP appears to be a good alternative option to the ORCe method for the treatment of isolated olecranon fractures in children offering the advantages such as avoiding extensive open procedure and simple implants removal. Key words:children, olecranon, fracture, tension band wiring - cerclage, percutaneous pinning, elbow.

Objectives: To assess the presence of fracture site gross motion on physical examination to predict humeral shaft fracture progression to nonunion in patients managed nonoperatively., Design: Retrospective cohort study., Setting: Single trauma level 1 institutional center., Patients: Eighty-four consecutive patients undergoing nonoperative treatment of a diaphyseal humeral shaft fracture were identified. The average age of the population was 48.3 years, and 50% of the cohort was men., Intervention: Clinical examination for fracture stability was routinely performed on patients by the treating physicians and documented it in the medical record. Patients were followed until union or surgery for persistent fracture mobility., Main Outcome Measurements: Stability was graded if there was motion at the site (1: motion of any kind and 0: moved as a unit)., Results: Seventy-three patients (87%) healed their fracture within our study cohort by 6 months postfracture. Of the remaining 11 patients, after discussion with their treating physicians about the option of surgical intervention, 8 chose to undergo open reduction internal fixation at an average of 8 months, 1 proceeded nonsurgical interventions, and 2 were lost of follow-up. If the humeral shaft fracture site was mobile at 6 weeks follow-up visit, it identified future fracture nonunion with 82% sensitivity and 99% specificity (only 1 patient with motion at 6 weeks proceeded to fracture union)., Conclusion: With a high negative predictive value, clinical examination of fracture motion at 6 weeks should be assessed in every patient to determine which patients should obtain closer follow-up for the risk of nonunion progression. Knowledge of gross fracture motion can be used in the shared decision-making model in counseling about early surgical options., Level of Evidence: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background  Supracondylar humerus fractures are usual in children but their recent trends are unclear. Material and Methods  A population-based study was performed to determine the epidemiology of childhood supracondylar humerus fractures during the decade, 2000 to 2009, in a geographic area of Oulu, Finland. Altogether, 565 extension-type supracondylar humerus fractures were included. The fractures and their treatment were analyzed according to the Gartland classification. Results  Fracture incidence increased by 28%, from 50.9 to 65.2 per 100,000 during 2000 to 2009 (β = 1.03, p  < 0.001). The increase was from 41.3 to 57.6 per 100,000 in girls (β = 1.9, p  < 0.001). Trampoline-related fractures in particular increased in girls. Type II fractures increased twofold from 7.1 to 16.3 per 100,000 (β = 1.1, p  < 0.001), whereas type I fractures decreased from 22.4 to 20.9 per 100,000 (β = -0.3, p  = 0.026).Surgical treatment increased during the 10 years study period from 32.6 to 51.8% ( p  = 0.022); it was in particular due to increase of operative care of type II fractures (from 5.9% in 2000-2001 to 37.1% in 2008-2009; p  = 0.011). Lateral pin fixation increased from nil to six (10.7%) ( p  < 0.001). Conclusion  The incidence and surgical stabilization of type II fractures in particular are increasing. There is a trend toward lateral pin fixation., Competing Interests: Conflict of Interest: None., (Georg Thieme Verlag KG Stuttgart · New York.)

The aim of this study was to evaluate our treatment modalities in pediatric supracondylar humerus fractures according to the recently published Appropriate Use Criteria (AUC) by the American Academy of Orthopaedic Surgeons. A total of 991 patients with supracondylar humerus fractures were included. After reviewing medical records, 38 different clinical scenarios described in the AUC were observed. Of the 991 patients, 127 were type I, 423 were type II, and 405 were type III fractures according to the Gartland classification. The AUC was appropriate for 100% of type I, only 25 (5.9%) of type II, and 389 (96.0%) of type III fractures. Overall, the total appropriateness rate was 54.5%. We concluded that application of the AUC is useful but burdensome and that AUC provides important guidance especially for rarely encountered urgent clinical scenarios.

Many long bone fractures that are not considered repairable in the adult horse are repairable in the foal. This is largely because of reduced patient size and more rapid healing in the foal. When there is no articular communication, the long-term prognosis for athletic function can be very good. Emergency care and transport of the foal with a long bone fracture is different than the adult., (Copyright © 2017 Elsevier Inc. All rights reserved.)