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Background: Supracondylar humerus (SCH) fractures are the most common type of pediatric elbow fractures that require surgical intervention. Studies suggest limiting the first postoperative visit to the time of pin removal or limiting radiographs at first postoperative follow-up may not increase complication rates, but few comparative studies exist. This study aims to determine if routinely examining surgical pins sites at the first postoperative visits affects the complication rates or outcomes compared to only evaluating pin sites if a clinical indication exists., Methods: This cohort study retrospectively reviewed patients who were surgically treated for a supracondylar humerus fracture at a Pediatric Level 1 Trauma Hospital from 2011-2017. Clinical records and surgical reports were reviewed, and data was extracted to determine fracture type, surgical treatment, and postoperative course. Complications were recorded., Results: Three hundred and fifty-five patients were included; 138 patients had a routine pin evaluation at first postoperative visit, 183 had no pin evaluation until time of pin removal, and 34 had a clinical indication for pin site evaluation at the initial postoperative visit. No patients in the routine pin evaluation or the no early pin evaluation group had a loss of reduction. In the clinical indication group, three patients returned to the operating room (8.82%) due to a loss of reduction, as determined by radiographs. No significant differences were found in healing outcomes or complications between the group that had a routine evaluation versus the group that did not., Conclusion: Routine pin site evaluation in the initial postoperative setting after closed or open reduction and pinning of supracondylar humerus fractures without clinical indication does not lead to fewer complication, return to operating room, or improved outcomes. The initial dressing and immobilization can be continued until pin removal unless clinical/radiographic indication to evaluate pin sites exists., Level of Evidence: Level III., Competing Interests: Declarations. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Background: The unique anatomy and biomechanics of the distal humerus make distal humeral shaft fractures a significant challenge in orthopedic surgery. Conventional posterior surgical approaches are associated with risks such as iatrogenic radial nerve injury and increased soft tissue trauma., Objective: This study aimed to assess the clinical efficacy of an inverted PHILOS plate using an anterior minimally invasive percutaneous approach for treating distal humeral shaft fractures., Methods: We enrolled 32 patients with distal humeral shaft fractures. The surgical technique involved an anterior minimally invasive percutaneous application of an inverted PHILOS plate. Outcome measures included operative time, intraoperative blood loss, incision length, fracture healing time, and functional scores (Constant-Murley and Mayo Elbow Performance Scores). Postoperative complications, including nerve injury and nonunion, were documented., Results: The mean operative time was 1.69 ± 0.66 h, with a median blood loss of 50 ml (IQR: 50-100 ml). The mean incision length was 10.9 ± 1.78 cm, and the mean time to fracture healing was 11.2 ± 3.68 weeks. Functional outcomes were satisfactory, with a mean Constant shoulder score of 92.69 ± 6.6 and a mean Mayo Elbow Performance Score of 91.4 ± 8.04. No instances of iatrogenic nerve injury or nonunion were observed., Conclusion: The anterior minimally invasive percutaneous approach using an inverted PHILOS plate is an effective method for treating distal humeral shaft fractures. This technique minimizes soft tissue damage, reduces the risk of iatrogenic radial nerve injury, and ensures reliable fracture stabilization, thus offering a promising alternative to conventional posterior approaches., Competing Interests: Declarations. Ethics approval and consent to participate: Institutional Review Board approval was received from the ethics committee of Fuzhou second hospital (2024308) and all consents were signed to participate and publish. Consent for publication: All presentations of case reports have consent for publication. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Background: Cubitus varus, a common complication of pediatric supracondylar humerus fractures, presents with internal rotation, extension, and varus angulation. While primarily considered a cosmetic concern, it can lead to significant complications, including chronic pain, ulnar nerve palsy, and posterolateral elbow instability. This study evaluates the effectiveness of supracondylar dome osteotomy in decreasing lateral condylar prominence and improving functional outcomes in patients with cubitus varus., Methods: This retrospective cohort study analyzed 65 patients under 18 who underwent dome-shaped corrective osteotomy between 2017 and 2022 at the Hospital and Rehabilitation Center for Disabled Children, Nepal. Inclusion criteria comprised patients with cubitus varus deformity greater than 10 degrees and at least six months post-trauma. Outcomes were assessed using the Mayo Elbow Performance Score (MEPS), Lateral Condylar Prominence Index (LPI), and radiological measurements of carrying angle (CA)., Results: The mean age at surgery was 11.77 years (± 3.76), with an average time since injury of 54.15 months (± 31.76). Post-operatively, the radiological carrying angle improved from 23.90° (± 8.84) varus to 5.14° (± 7.64) valgus. The LPI changed from 0.58 (± 16.68) preoperatively to -3.18 (± 16.39) post-operatively. MEPS improved from 89.54 (± 6.66) to 95.23 (± 5.26). Significant improvements in LPI were observed in patients older than 12 years (p = 0.00) and patients with radiological CA less than 20° (p = 0.02) and with a clinical CA less than 20°(p = 0.04)., Conclusions: Supracondylar dome osteotomy effectively reduces lateral condylar prominence in cubitus varus, particularly in post-pubertal patients and cases with radiological carrying angles less than 20 degrees. The procedure demonstrates good functional outcomes with acceptable complication rates, making it a viable surgical option for treating cubitus varus deformity., Competing Interests: Declarations. Ethics approval and consent to participate: Ethical clearance for this study was granted by the Institutional Review Committee (IRC) of B&B Hospital, under approval number B&BIRC-22-47, dated April 23, 2023. This approval confirms adherence to ethical standards, protecting participants’ rights and welfare. This study was carried out in adherence to Declaration of Helsinki. The patient’s privacy and confidentiality of personal information was maintained. Informed consent was obtained from all patient’s parents and assent from the patient as applicable at the time of admission, allowing for the use of their data in future studies. The participants were free to opt out and this would not compromise the treatment process. This process ensured that participants were fully aware of the study’s purpose and procedures, thereby upholding ethical principles of voluntary participation and autonomy. Consent for publication: Not applicable. This manuscript does not contain any individual person’s data in any form (including individual details, images, or videos) that requires explicit consent for publication. However, all participants provided written informed consent, ensuring they understood the study’s purpose and the potential use of anonymized data for publication. Anonymity was maintained throughout, and no identifiable information is included in this manuscript. Conflict of interest: The authors declare no conflicts of interest. Clinical trial number: Not applicable., (© 2025. The Author(s).)

Objective: To evaluate the impact of postoperative radiographs on treatment decisions for skeletally immature dogs undergoing repair of a fractured humeral condyle., Study Design: Retrospective observational multicenter study., Sample Population: A total of 139 dogs (<12 months of age)., Methods: Medical records of dogs who underwent humeral condylar fracture repair were retrieved and analyzed. Data collected included dog's signalment, fixation method, reported client's concerns, follow-up clinical examination findings, radiographic assessment, and any documented changes to the postoperative plan., Results: Out of the 139 cases, 23 dogs (17%) required a change in their postoperative plan. Owner concerns (OR: 7.6), prolonged use of analgesic drugs (OR: 7.9), presence of lameness (OR: 5.9), abnormal clinical findings at the time of follow-up examination (OR: 44.8) and radiographic abnormalities (OR: 51.9) significantly increased the likelihood of a change in the postoperative plan. Most importantly, none of these postoperative plan changes were solely attributed to radiographic abnormalities at the time of the follow-up examination., Conclusion: Follow-up radiographs did not influence the postoperative management plan in cases where clients reported no concerns, the dogs did not require prolonged analgesic treatment, showed no lameness on examination, and had unremarkable clinical findings CLINICAL SIGNIFICANCE: In the absence of client concerns, prolonged use of analgesic drugs, lameness on examination, and clinical abnormalities, the necessity of follow-up radiographs in immature dogs that underwent humeral condylar fracture repair is debatable., (© 2024 American College of Veterinary Surgeons.)

Introduction: Intramedullary nailing is one of the surgical treatments for humeral shaft fracture. Non-union is a common complication, with rates of 10-20%. The objective of this study was to compare non-union in humeral shaft fractures treated by intramedullary nailing with double distal locking, single distal locking or no locking., Hypothesis: Nailing with double distal locking decreases non-union rates compared to single or no locking., Material and Methods: This single-center retrospective comparative study included 87 patients with closed humeral shaft fracture without neurologic deficit treated by anterograde intramedullary nailing: group 1 (double locking): 15 fractures; group 2 (single locking): 63 fractures; group 3 (no locking): 9 fractures. Non-union was defined as absence of radiographic callus at 6 months without clinical pain. The primary endpoint was non-union rate per group. The secondary endpoints were Constant score at 6 months, and postoperative use of non-steroidal anti-inflammatory drugs (NSAIDs)., Results: There were no significant differences in non-union rate: 20.0% in group 1, 20.3% in group 2, and 0% in group 3 (p=0.32). Constant score at 6 months was significantly different between the 3 groups (p=0.01). Group 2 used more NSAIDs than the other groups (39.1% vs. 20.0% in group 1 and 33.3% in group 3; p=0.37)., Discussion: Non-union rates were similar regardless of distal locking for closed humeral shaft fractures without neurologic deficit treated by intramedullary nailing. Nevertheless, patients in the double locking group had higher Constant scores at 6 months, probably related to greater stability of fixation, allowing more efficient rehabilitation., Level of Evidence: III; retrospective comparative study., (Copyright © 2024 The Author(s). Published by Elsevier Masson SAS.. All rights reserved.)

Case: A 48-year-old man with multiple injuries sustained a Gustilo type 3A right open distal humerus fracture with a 4-cm wound, contralateral radius shaft, and ilium fractures. Following wound irrigation on the day of injury, second look debridement showed crushed triceps and severe contamination extending into the distal humerus medullary canal. After 6 days of initial plate fixation, he developed signs of deep infection. Radical debridement twice resulted in a 10-cm bone defect, necessitating reconstruction with a Lambda-shaped free vascularized fibula for both columns., Conclusion: Lambda-shaped column reconstruction using free vascularized fibula flap yields satisfactory clinical and radiographic outcomes in metaphyseal distal humerus bone defects., Level of Evidence: V., Level of Clinical Care: Level I Tertiary trauma center., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C536)., (Copyright © 2025 by The Journal of Bone and Joint Surgery, Incorporated.)

Case: We describe a 13-year-old adolescent girl experiencing persistent pain and reduced grip strength following nonoperative treatment of a medial epicondyle fracture-dislocation with closed reduction over 5 years before her referral to our clinic. Neurological examination and magnetic resonance imaging of the elbow revealed damage to the median nerve due to an entrapment within the elbow. Surgical release of the nerve resulted in complete pain relief and improved neurological function with normalized nerve conduction., Conclusion: Persistent neurologic deficits should be investigated following pediatric elbow trauma. Promising results can be achieved with surgical treatment even after long-term entrapment of the median nerve., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C533)., (Copyright © 2025 by The Journal of Bone and Joint Surgery, Incorporated.)

Case: A 34-year-old man, amateur weight lifter presented with acute worsening of right shoulder pain after 5 months of prodromal, progressive, atraumatic pain. Imaging showed a short oblique proximal third humeral shaft fracture without evidence of other osseous abnormalities. He was treated operatively with open reduction and internal fixation, healed uneventfully, and returned to weight lifting within 3 months., Conclusion: Humeral shaft stress fractures most commonly occur in athletes or military personnel who engage in repetitive overhead activity. It is important to include stress fracture on the differential diagnosis for chronic pain in the upper extremity, especially in a physically active patient., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C519)., (Copyright © 2025 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Supracondylar humerus fractures (SCHFs) are the most common elbow fractures in children and are typically treated with closed reduction and Kirschner pin fixation. However, varying degrees of residual rotational displacement may remain after closed reduction. Several methods exist to assess rotational displacement, but none account for the effect of elbow rotation on the results. We hypothesize that the accuracy of the primitive rotational calculation formula (PRCF) decreases as elbow rotation increases and propose a modified rotational calculation formula (MRCF). This study aims to investigate the impact of elbow rotation on PRCF and validate the reliability of MRCF., Methods: Mimics software was used to reconstruct the distal humerus in a child and create a transverse SCHF, which was then subjected to X-ray fluoroscopy simulation. Axial rotational displacement was simulated in 5° increments, from 0° to 45°. Internal and external elbow rotations were simulated by adjusting the "LAO" and "RAO" angles. Five physicians measured and calculated displacement using both the primitive and modified rotational calculation formulas., Results: The PRCF method showed an average error of 17.98° ± 12.31° with a maximum error of 46.46%. Additionally, 13% of measurements had an error under 3°, and 29% had an error under 10°. With MRCF, the mean error for internal rotation was 2.04° ± 1.67°, with a maximum of 6.09%; 68% of cases had an error under 3° and 94% under 5%. For external rotation, the mean error was 2.74° ± 2.66°, with a maximum of 8.29%; 57% of cases had an error under 3° and 98% under 8°. Intraclass correlation coefficients for the five physicians were 0.966 for internal rotation and 0.989 for external rotation., Conclusions: This study demonstrates that the accuracy of PRCF decreases as elbow rotation increases, supporting our hypothesis. MRCF effectively addresses the limitations of PRCF and provides stable, accurate measurements of rotational displacement even with varying elbow rotations. Accurate assessment of rotational displacement in the horizontal plane is essential to understanding the relationship between residual rotational displacement and SCHF prognosis. MRCF will play a critical role in this process., Competing Interests: Declarations. Ethics approval and consent to participate: The study was approved by the Clinical Research Ethics Committee of the Xi’an Jiaotong University Affiliated Honghui Hospital (style no.202407001). Written informed consent was obtained from all parents or legal guardians of participants under the age of 16 prior to their participation in the study. All procedures were conducted in accordance with relevant guidelines and regulations, following the Declaration of Helsinki. Consent for publication: All parents or legal guardians of participants under the age of 16 provided written informed consent for the publication of identifying images and clinical data. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Background: Supracondylar humerus fractures are the most common type of elbow fractures in children. Nerve injuries, primarily neuropraxia, are frequent complications and are often managed with a "wait-and-see" approach. Electroneuromyography (ENMG) is the standard method for evaluating peripheral nerve injuries, while ultrasound (US) is valuable for localizing lesions., Objective: This case report aims to highlight the beneficial role of US in the follow-up and rehabilitation of nerve injuries following pediatric supracondylar humerus fractures., Case Presentation: A 4-year-old boy presented with a supracondylar humerus fracture that was treated with closed reduction and K-wire fixation. He exhibited weakness in the first two fingers of his left hand, difficulty grasping, and nail changes. Ultrasound revealed a median nerve lesion adjacent to the fracture site. ENMG indicated an acute severe axonal injury involving the branch innervating the flexor carpi radialis muscle. Following rehabilitation, there was improvement in hand grip strength, measured using a JAMAR hand dynamometer, and in health-related quality of life (QoL), assessed by the Pediatric Outcomes Data Collection Instrument (PODCI) score. Follow-up ENMG showed signs of mild reinnervation., Conclusion: Pre-ENMG ultrasound provides crucial information regarding which nerve should be examined with a nerve conduction study and identifies the initial muscle to be evaluated during needle EMG. This aids in accurately localizing nerve damage and guiding effective treatment., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Two skeletally immature female dogs were each investigated for chronic weight-bearing thoracic limb lameness. The first patient was lame for 2 months following a tumble whilst playing, and the second patient had been intermittently lame since 3 weeks of age. In both cases, radiographic examination of the shoulder revealed fissuring of the caudal humeral head consistent with an incomplete proximal humeral Salter-Harris type IV fracture with an Enoki-mushroom-like appearance of the caudal fragment, where two heads rise from a common stem. There was secondary neoarthrosis of the caudal humeral head fragment with the glenoid rim of the scapula. Humeral head-split fracture is an unusual fracture pattern that rarely occurs in skeletally immature patients, and conservative management appears to result in reasonable short-term outcomes. The role of early detection and surgical intervention remains unknown., (© 2025 The Author(s). Veterinary Radiology & Ultrasound published by Wiley Periodicals LLC on behalf of American College of Veterinary Radiology.)

Background: The most frequent sequelae of pediatric lateral condyle fractures is lateral condyle overgrowth (LCO). The purpose of our study was to investigate LCO in relation to age, quality of reduction, type of fixation, and fracture displacement., Methods: We retrospectively analyzed operatively treated lateral condyle fractures in children. The percent change in interepicondylar width (IEW) ((final - initial)/ initial x 100) was used to quantify LCO. IEW was measured from the medial and lateral epicondyles of the distal humerus, using the AP radiographs taken at admission (initial) and follow-up visits (final). The Song classification was used to classify fractures. Fixation was classified as pins, screws or both. The quality of reduction was defined as anatomic or nonanatomic (>2 mm of displacement). Patients were stratified into mild (0% to 10% overgrowth), moderate (10% to 20% overgrowth), and severe (>20% overgrowth) subgroups for further analysis., Results: Two hundred one patients were included in the study with an average time between initial and final radiograph measurements of 11.32 weeks. There was an average 11.84 %LCO. Using multivariable analysis, three variables demonstrated significant, independent associations with %LCO: age, race, and quality of reduction. Increasing age remained inversely associated with %LCO. Compared with White patients, Black and Asian patients had significantly greater %LCO. Patients with nonanatomic reductions had a significantly greater %LCO compared with anatomic reductions. When patients were stratified into mild, moderate, and severe groups, age in the mild group, nonanatomic reduction in the moderate group, and race in the severe group were found to be independently associated with increased %LCO using multivariable analysis., Conclusions: The amount of LCO was found to be related to nonanatomic reduction, younger age, and Black and Asian race. Interestingly, it was not related to the amount of initial displacement or type of hardware used. To date, this is the largest study investigating LCO in surgically treated lateral condyle fractures., Level of Evidence: Level III-retrospective cohort study., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Supracondylar humerus fractures (SHFs) are common pediatric injuries, with type II fractures being a topic of debate regarding optimal treatment. Our goals are to compare the functional and radiographic outcomes of conservative and surgical treatment of type II SHFs and their subgroups and to identify parameters for determining the optimal treatment option., Methods: We retrospectively reviewed a total of 55 patients (23 conservative, 32 surgical) between 2010 and 2020. The mean follow-up was 66 months. Neurovascular status, range of motion, complications, and functional scores (Mayo elbow, Quick DASH) were evaluated. We performed radiographic assessment on initial, postreduction, and final follow-up radiographs using the humerocondylar angle (HCA), Baumann angle, and anterior humeral line (AHL)., Results: Neither groups nor subgroups showed significant differences in clinical and functional outcomes. HCA was significantly higher in the operative group than in the conservative group. The subgroup analysis revealed that the HCA difference resulted from the difference between the conservative IIb and operative IIb subgroups. None of the patients required a corrective osteotomy, but 1 patient initially treated conservatively underwent operative treatment due to loss of reduction., Conclusions: Reconstructing the sagittal, coronal, and rotational alignment in type II SHFs led to good mid-term results in the range of motion and functional scores for the elbow joint, whether conservative or surgical treatment was used. A limited range of remodeling might be expected in the long term., Level of Evidence: Level III-retrospective comparative study., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Olecranon osteotomy has been associated with loss of reduction, nonunion, implant failure, and migration of wires. We aim to evaluate quality of reduction of the osteotomy site as a predictor of olecranon osteotomy nonunion., Methods: One hundred and twenty-five distal humerus fractures that underwent open reduction internal fixation (ORIF) were reviewed. Amount of dorsal step-off was measured from the lateral radiograph from the second postoperative visit. A receiver operating curve (ROC) analysis was used to assess the predictability of nonunion based on dorsal displacement of the olecranon osteotomy., Results: Between 2014 and 2022, 36 patients underwent a chevron olecranon osteotomy (29%). Of the 36 patients, 7 (19%) failed to successfully unite at the osteotomy site. Two experienced aseptic nonunion, 2 were malreduced leading to nonunion, 2 malunited, and 1 had persistent fracture lines following poor osteotomy cut. Patients that developed nonunion had a mean dorsal displacement of 3.87 mm versus 1.15 mm (p < 0.001). The ROC demonstrated excellent prediction for nonunion based on displacement (AUC = 0.896, p = 0.002). Youden's index was determined at a sensitivity of 86% and a specificity of 73% corresponding to a dorsal step-off of 2.07 mm. This finding was confirmed on multivariate logistic regression showing a step-off over 2.07 mm is an independent predictor of olecranon osteotomy nonunion (p = 0.021)., Conclusion: A malreduction resulting in a dorsal step-off larger than 2.07 mm is predictive of olecranon osteotomy nonunion or malreduction. Therefore, the success of the olecranon osteotomy approach is directly dependent on quality of anatomic reduction., Level of Evidence: III; Retrospective Cohort Study., Competing Interests: Declarations. Conflict of interest: The authors declare no competing interests., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Epiphyseal displacement of the distal humerus is rare and difficult to diagnose. In addition, the literature on the prognosis and treatment is limited. Here, we present a case of distal humeral physeal separation with significant displacement in a neonate. A favorable outcome was obtained following closed reduction and percutaneous fixation with Kirschner wires assisted by arthrography. This report adds valuable information on this subject to the existing literature.

Cubitus varus deformity is a common complication of supracondylar fractures in children. Anatomic correction is the key to obtaining good functional results and avoiding later symptomatic degradation. Different techniques have been described, mainly lateral closing wedge osteotomy. A medial opening wedge osteotomy seems more intuitive, allowing an anatomic reduction, but it is technically challenging. Two-plane radiographs are too simplistic to appreciate the 3D deformity. With medical imaging and image processing advances, three-dimensional (3D) virtual models of a patient's anatomy can be generated. Rapid 3D printing has allowed virtual simulations of surgical corrections to be transferred to real-world applications in the operating room, allowing more precise and accurate surgery with better 3D corrections. 3D computer modeling with the development of customized drilling and cutting guides allows complex medial opening wedge osteotomy for correction of cubitus varus deformity in immature children with best-fit plate synthesis. LEVEL OF EVIDENCE: IV., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

Purpose: Distal humeral coronal shear fractures (CSF) are uncommon and may be challenging to treat due to their size, location, and intraarticular nature. The purpose of this study was to analyze treatment concepts of this rare entity in the growing age., Methods: Based on a multi-center data analysis we retrospectively reviewed patients below 16 years of age with CSF treated at 13 high-volume pediatric trauma centers., Results: Data from 51 patients with a CSF treated between 01/2012 and 12/2021 were analyzed. The mean age was 12.9 years (10-15), and there was a trend towards male patients (30: 21). The initial diagnostic approach was conventional X-ray in all cases. In addition, a CT scan (n = 33), MRI scan (n = 9), or both (n = 3) were performed. All fractures except two showed relevant displacement. Consequently, only two cases received conservative treatment consisting of plaster immobilization. Surgical treatment was performed in 49 cases consisting of open or mini-open reduction and metal/resorbable screw osteosynthesis (n = 39), plates (n = 4), K-wire pinning (n = 6), and others (n = 6), as well as combinations. In 1 case open reduction without osteosynthesis was performed. Postoperative additional plaster immobilization was performed in 40 cases (for a mean of 19 days (2-42)), physiotherapy was initiated in 29 cases, and metal removal was performed in 28 cases (after a mean of 18.1 weeks (4-44)). After a mean follow-up of 9.9 months (2-25), elbow axial deviation (5° valgus) was observed in one case and mild loss of elbow ROM in six cases (11.7%). Complications included revision of the osteosynthesis because of insufficient articular reconstruction (n = 4), removal of a free joint body (n = 1), an osteonecrosis (n = 1), and a cartilage defect (n = 1)., Conclusion: In pediatric patients CSFs start to occur at the age of 10, but are typically observed at the age of 13 and older. Because of their intraarticular nature and predilection toward displacement, these fractures are frequently treated operatively. The surgical strategy requires open reduction and anatomic reconstruction of the articular surface. Stable internal fixation, most often achieved by screws, permits early mobilization and leads to good outcomes in most cases. This is presumably due to the fact that mostly simple fractures occur in children and mostly complex injuries in older adults., Level of Evidence: III, retrospective analysis., Competing Interests: Declarations. Conflict of interest: The authors have no conflicts of interest or financial ties to disclose. Ethics approval: This study was approved by the ethical committee of the University of Halle (Saale) (project no. 2022-103). Consent to participate: Not applicable. Consent for publication: Not applicable., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Background and Purpose: Supracondylar humerus fractures (SCHFs) are the most common elbow fractures in children. Traumatic median nerve injury and isolated lesions of its pure forearm motor branch, anterior interosseus nerve (AIN), have both been independently reported as complications of displaced SCHFs. Our main objectives were to characterize the neurological syndrome to distinguish median nerve from AIN lesions and to determine the prognosis of median nerve lesions after displaced SCHFs., Methods: Ten children were prospectively followed for an average of 11.6 months. Patients received a standardized clinical examination and high-resolution ultrasound of the median nerve every 1-3 months starting 1-2 months after trauma. Electrodiagnostic studies were performed within the first 4 months and after complete clinical recovery., Results: All children shared a clinical syndrome with predominant but not exclusive affection of AIN innervated muscles. High-resolution ultrasound uniformly excluded persistent nerve entrapment and neurotmesis requiring revision surgery but visualized post-traumatic median nerve neuroma at the fracture site in all patients. Electrodiagnostic studies showed axonal motor and sensory median nerve neuropathy. All children achieved complete functional recovery under conservative management. Motor recovery required up to 11 months and differed between involved muscles., Conclusions: It was shown that neurological deficits of the median nerve in displaced SCHFs exceeded an isolated AIN lesion. Notably, detailed neurological follow-up examinations and sonographic exclusion of persistent nerve compression were able to guide conservative therapy in affected children. Under these conditions the prognosis of median nerve lesions was excellent despite severe initial deficits, development of neuroma and axonal injury., (© 2024 The Author(s). European Journal of Neurology published by John Wiley & Sons Ltd on behalf of European Academy of Neurology.)

Background: Supracondylar humerus fractures (SCHF) in children are common and can lead to serious complications, including neurovascular injury. The optimal management of children with a 'pink pulseless' hand following such a fracture is unclear. This study aimed to ascertain an appropriate therapeutic approach for children with SCHF and a pink pulseless hand. Methods: A retrospective analysis of medical records from paediatric patients under 16 years old with SCHF and clinically perfused but pulseless hands between 1 January 2016 and 30 June 2021 was conducted. Clinical characteristics, imaging, treatment processes and follow-up results were analysed to predict arterial injuries requiring vascular repair and determine the optimal timing for exploratory surgery. Results: The study included 88 patients, predominantly male (58%) with an average age of 6 years. Most fractures resulted from falls onto outstretched arms. Satisfactory outcomes, indicated by the return of the pulse following closed reduction and percutaneous pinning (CRPP) alone, were seen in 66% of patients, negating the necessity for vascular exploration. Amongst patients with a persistently absent radial pulse 72 hours after CRPP, 83% were diagnosed with brachial artery injuries, with all such patients experiencing recurrent pulse loss after surgery. Conclusions: Urgent reduction and CRPP are effective initial treatments for children with SCHF and a pink pulseless hand. Immediate vascular exploration is generally not necessary in these patients. Further research is needed to determine the optimal management for persistent pulselessness and recurrent pulse loss. Level of Evidence: Level IV (Therapeutic).

Purpose: The management of infected humeral shaft nonunion (HSN) remains challenging due to the lack of consensus and the potential for occult infection. The aim of this study was to evaluate a surgical strategy based on a two-stage treatment for suspected infection or a one-stage treatment for infection diagnosed retrospectively based on systematic bacteriological sampling., Methods: We retrospectively reviewed 16 patients with a median age of 36 years who were treated for septic HSN: 9 patients underwent a two-stage procedure using the induced membrane technique, and 7 patients were treated in a single stage. Revision parameters included achieving bone union, its time frame, and a functional assessment based on joint motion and the Quick-DASH score., Results: At a median follow-up of 47.5 months, 12 out of 16 patients were cured with acquired bone union and no septic recurrence. The median time to bone union was 5.5 months. Smoking and previous surgeries were adverse factors for bone healing. Radiological and functional outcomes were comparable between patients treated in a single stage and those treated in two stages., Conclusions: This study confirms the relevance of one-stage surgery for HSN with occult infection and the value of systematic bacteriological sampling during the revision of humeral diaphyseal osteosynthesis., Competing Interests: Declarations. Human ethics: Ethical approval was waived by the local Ethics Committee of Edouard Herriot Hospital in view of the retrospective nature of the study and all the procedures being performed were part of the routine care. Consent for publication: Informed consent was obtained from all individual participants included in the study. Competing interests: The authors declare no competing interests., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Intra-articular fractures of the distal humerus are complex injuries that often require surgery with the goal of restoring elbow range-of-motion and function. Open reduction and internal fixation has been the preferred surgical modality; however, restoration of the medial and/or lateral columns can be complicated in fractures involving a major loss of the articular surface and bony structure. Over the past decade, 3-dimensional (3D) printing has made significant advances in the field of orthopedic surgery, specifically in guiding surgeon preoperative planning. Recently, the incorporation of 3D-printing has proven to provide a safe and reliable construct for the restoration of anatomy in complex trauma cases. We present a 47-year-old woman who sustained a complex, intra-articular distal humerus fracture with associated shearing of the capitellum that went onto malunion. Patient was treated with a patient-specific 3D-printed custom elbow prosthesis with excellent outcomes. Our goal was to shed light on the use of 3D-printing technology as a viable salvage option in treating complex, intra-articular distal humeral fractures associated with lateral condylar damage that subsequently went onto malunion., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: E.R.W. reports a relationship with Restor3d Inc that includes consulting or advisory. The remaining authors have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this article.

Background: The use of in situ screw fixation for the treatment of pediatric lateral humeral condyle (LCH) delayed unions has recently been reported. While attractive, the currently available literature consists of small retrospective studies with mixed results. As such, the present study aims to describe the outcome of a group of children with delayed unions of LCH fractures treated with in situ fixation using a single, percutaneously placed cannulated screw in compression., Methods: A retrospective review of all pediatric patients (below 18 y) with lateral condyle fractures of the humerus treated surgically for delayed union between 2013 and 2023 at a single, tertiary referral center was completed. Clinical and radiologic variables related to the initial injury and delayed union were abstracted from the medical record, as were surgical variables. Radiographs were evaluated for union postoperatively; time to union was determined by the senior authors. Descriptive statistics were used to summarize demographic and outcome variables., Results: A total of 12 consecutive patients met the inclusion criteria. The mean age at the time of initial injury was 5.6 years; subjects were followed for a mean of 3.0 years following initial presentation. All were treated with a single, percutaneously placed screw in compression at a mean of 10.5 months after the original injury. Radiographic union was achieved in 11 (91.7%) patients. At the latest follow-up, all patients were pain free and demonstrated a functional arc of motion without evidence of avascular necrosis. A total of 2 patients required revision for loss of fixation. In one patient, a persistent lucent line was observed, and 1 patient was found to have a cubitus valgus deformity, both of which were not clinically relevant., Conclusions: Our results suggest that with the use of proper technique (a 4.5 cannulated screw inserted through the metaphyseal portion of the lateral condyle fragment, engaging the most medial/distal aspect of the humeral shaft), radiographic union and clinical healing can be achieved in the majority of patients. Percutaneous screw fixation should be considered as an option for cases of noninfected pediatric lateral condyle delayed unions., Level of Evidence: Level IV-evidence therapeutic studies., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The purpose of this study was to develop and validate a classification system that describes the injury pattern of pediatric medial humeral condyle fractures and provide treatment guidelines., Methods: Patients less than 18 years old with medial humeral condyle fractures from 2012 to 2022 were identified. A classification system was developed based on fracture pattern and putative mechanism of injury. Type 1 fractures were characterized by a valgus/avulsion type injury while type 2 fractures were characterized by a vertical shear pattern. Each type was subdivided by amount of fragment displacement: (A) nondisplaced or minimally displaced (<2 mm) versus (B) displaced (>2 mm). Three attending orthopaedic surgeons evaluated and classified each patient's fracture. Intrarater and inter-rater reliability was calculated with Kappa statistics., Results: Twenty-seven patients (16 males) with an mean age of 10.5 years were included. There were 4 type 1A, 17 type 1B, and 6 type 2B fractures with substantial agreement in inter-rater (ĸ=0.62, CI=0.45-0.78), and intrarater (mean ĸ=0.79, range=0.70-0.93) reliability analysis. Surgical treatment was performed in 25/27 patients; 4 patients underwent closed reduction percutaneous pinning (CRPP) and 21 underwent open reduction and internal fixation (ORIF). Ten patients required advanced imaging to assist in surgical decision making. Both nonoperative patients had type 1A fractures. Nearly one-fourth of patients (6/27, 22%) had some functional loss of motion and poor outcomes based on Flynn's criteria, with a Fisher exact test revealing an increased risk of functional loss of motion in skeletally mature children ( P =0.02). Two patients had complications including 1 nonunion after initial nonoperative management (type 1B) and 1 patient (type 2B) required manipulation under anesthesia for postoperative stiffness., Conclusion: Moderate to strong inter-rater and intrarater reliability was demonstrated with the proposed classification system. Type 1A fractures are amenable to nonoperative treatment while types 1B and 2B require surgical management. Skeletally mature patients may be at greater risk of motion loss following injury., Level of Evidence: Level IV-case series., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Pediatric humerus lateral condyle fractures (PHLCF) are one of the most common fractures among children. PHLCF is approximately 20% of all pediatric elbow fractures. Among the treatment modalities are: nonoperative treatment with splinting, closed reduction with percutaneous K-wire fixation (CRPP), and open reduction with K-wire fixation (ORIF). We aimed to evaluate radiological, functional, and clinical outcomes of Jakob type 2 PHLCF treated either with CRPP or ORIF. We hypothesized that CRPP may be as safe and effective as ORIF for Jakob type 2 PHLCF. In this retrospective study, we included patients with Jakob type 2 PHLCF operatively treated in a single center. Patients with multiple fractures or open fractures were excluded from the study. 69 patients between ages 2 and 12 were included and they were divided into two groups. Group 1 included the patients treated with CRPP, whereas Group 2 included the patients treated with ORIF. Demographical, radiological, clinical, and functional parameters were evaluated. Average duration of surgery ( P  < 0.001), initial displacement ( P  = 0.014), and duration of admission ( P  < 0.001) were significantly less in group 1. Group 2 had significantly higher percentage of left-sided injury than group 1 ( P  = 0.038). Average varus deformity score was significantly higher in group 1 ( P  = 0.014). CRPP was associated with shorter duration of surgery and hospital stay. Functional, clinical, and radiological outcomes were identified similar between CRPP and ORIF for Jakob type 2 PHLCF. CRPP may be as safe and effective as ORIF for Jakob type 2 PHLCF., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Extra-articular distal humerus locking plates (EADHPs) have been widely employed for the treatment of extra-articular fractures of the distal humerus, but interference with the radial nerve and poor fastening of distal fracture fragments by screws remain. The aim of this study is to evaluate the clinical and imaging effects of the anterolateral approach in the treatment of extra-articular fractures of the distal humerus with the upside-down use of proximal humerus internal locking system (PHILOS) plates in front of the humerus., Method: A retrospective analysis (10/2018-10/2022) was conducted on the clinical data of patients with extra-articular fractures of the distal humerus treated with the upside-down use of the PHILOS via the anterolateral approach. The fracture union time, range of motion of the elbow joint, Mayo elbow performance score (MEPS), Disabilities of the Arm, Shoulder and Hand (DASH) score, Visual Analogue Scale (VAS) score for pain and incidence of complications were analysed at the final follow-up., Results: A total of 20 patients (11 males, 9 females) with a mean age of 40.3 ± 17.0 years (16-87 years) and a follow-up of 28.3 ± 10.8 months (15-53 months) were evaluated. The average number of screws in the distal humeral fragment was 5.7 ± 0.6. The average fracture union time was 23.3 ± 3.3 weeks. The mean longest and shortest cortical lengths from the coronoid fossa were 87.3 ± 13.4 mm and 47.9 ± 9.4 mm, respectively. At the final follow-up, the average range of elbow motion was - 3.3 ± 2.6° of extension and 135.1 ± 3.1° of flexion. The mean MEPS score was 97.8 ± 6.0. The mean DASH score was 1.25 ± 3.6 (range, 0-15.9), and the mean VAS score was 0.1 ± 0.4 (range, 0-2). None of the patients developed serious complications that required reoperation., Conclusions: The upside-down use of PHILOS plates in front of the humerus has good results in the treatment of extra-articular fractures of the distal humerus, so it is an alternative for fixing distal humerus extra-articular diaphyseal fractures when EADHPs are not suitable or preferred, especially for smaller distal fracture fragments, and reducing interference with the radial nerve., Competing Interests: Declarations. Consent for publication: Patients signed informed consent regarding the publication of their data. Competing interests: The authors declare no competing interests. Conflict of interest: The authors declare that they have no conflicts of interest. Ethical approval and consent to participate: This retrospective study was approved by the Ethics Committee of the First Affiliated Hospital of Anhui Medical University and was performed in accordance with the Declaration of Helsinki. Written informed consent was obtained from all participants. Clinical trial number: Not applicable., (© 2024. The Author(s).)

Objectives: The objective of this study was to present the follow-up findings obtained through computed tomography in skeletally immature French bulldogs previously diagnosed with humeral intracondylar fissures., Materials and Methods: Medical records from a surgical referral centre between January 2018 and September 2022 were evaluated for all dogs with a humeral condylar fracture where preoperative CT of both humeri was performed. French bulldogs between the age of 12 weeks and 12 months were identified and evaluated for the presence of contralateral humeral intracondylar fissure. The dogs with follow-up CT were evaluated for humeral intracondylar fissure resolution., Results: A total of 137 humeral condylar fractures were operated on within the study period, 58 of which were in French bulldogs. Twenty-seven French bulldogs had a contralateral humeral intracondylar fissure with 12 dogs matching the inclusion criteria. Follow-up CT demonstrated resolution of the humeral intracondylar fissure in 11 (91.7%) of 12 cases., Clinical Significance: Contralateral humeral intracondylar fissures are common in skeletally immature French bulldogs sustaining humeral condylar fractures and the majority of these fissures tend to fuse within the follow-up period. Due to the potential for breed variation in ossification of the humeral condyle, follow-up CT may be warranted in skeletally immature French bulldogs before considering prophylactic transcondylar screw placement., (© 2024 British Small Animal Veterinary Association.)

There are several methods for the assessment and follow-up of reduction of supracondylar humerus fractures, which offer the possibility of evaluation in different planes. The Gordon lateral rotation index (GLRI) is one of the methods used to assess the axial plane. This study aims to evaluate the validity, reliability, and applicability of the GLRI to assess rotational alignment. The study included 50 patients with Gartland type 3 supracondylar humerus fracture. After closed reduction, fixation with 2 lateral pins and 1 medial pin was applied to all patients. Eight observers made measurements using follow-up radiographs in the early postoperative period and at the 3 rd week. Gordon lateral rotation percentage (GLRP) significantly decreased from baseline to week 3 in all participants ( P  < 0.01). When the intraclass correlation coefficient (ICC) between the GLRP measurements of the observers in the early postoperative period was examined, a moderate agreement of 0.453 was seen between measurements of the observers (ICC = 0.453; P  = 0.001; P  < 0.01). When the ICC between the 3 rd week GLRP measurements of the observers was analyzed, poor agreement of 0.294 was seen (ICC = 0.294; P  = 0.001; P  < 0.01). The GLRI has moderate validity, applicability, and reliability in the early postoperative period, and low validity, applicability, and reliability in the follow-up period. Consequently, GLRI is an objective method that can be used to assess rotational alignment in the early postoperative period of supracondylar humerus fractures. It is, however, not recommended for follow-up periods., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Supracondylar humerus fractures (SCHFs) are the most common injuires of the elbow in children, often categorized by the Gartland classification. While type 1 and 2 fractures commonly managed conservatively, type 3 and 4 fractures typically require surgical treatment. Although closed reduction and percutaneous pinning have shown success, open reduction may be required in cases where adequate reduction cannot be achieved. This study aims to identify radiological and clinical risk factors associated with transitioning from closed reduction to open reduction in Gartland type 3 and 4 SCHF in children., Study Design and Methods: We retrospectively analysed 159 patients operated on between 2014 and 2022 for Gartland type 3 and 4 SCHF. Parameters including age, gender, injury severity, time to surgery, neurovascular damage, medial spike angle, fracture-skin distance, medial-lateral deviation, rotation, fracture level, and Baumann angle were evaluated., Results: A total of 159 SCHF in children aged 3 to 12 years, classified as Gartland type 3 (106 patients, 66.6%) and type 4 (53 patients 33.4%), underwent surgical intervention. Notably, 46 patients (28.9%) initially managed with closed reduction exhibited failure, prompting the necessity for conversion to open reduction. Injury severity, lateral deviation, advanced age, low medial spike angle, and low fracture tip-to-skin distance were found to be factors that could potentially increase the need for open reduction ( P <0.05). Logistic regression analysis showed that the low medial spike angle, flexion type injury, and low fracture type increased the likelihood of open surgery ( P <0.05). Sex, side, duration to surgery, and Baumann angle showed no significant associations., Conclusions: SCHF commonly necessitate surgical intervention in children. Although the risk factors for failed closed reduction and the need for open surgery have been discussed in the literature, there is no consensus. Preoperative planning, particularly for patients with specific factors like lateral deviation, advanced age, low medial spike angle, low fracture-to-skin distance and high injury severity, should consider potential open surgery requirements., Level of Evidence: Level III., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Aim: Orthopedic trauma results in the injury of bone joints and tendons of the body. A radiologist reviews and monitors large numbers of radiographs daily, which can lead to the diagnostic error. Therefore, there is a need to automate the detection of bone fractures in X-ray images, particularly humerus bone fractures. In this paper, we have proposed an ensemble model that can detect the fracture in an x-ray image., Materials and Methods: In this paper, we proposed an ensemble model designed for fracture detection in X-ray images. An ensemble model combines multiple diverse models to improve predictive accuracy and robustness by aggregating their individual predictions. The model leverages MobileNetV2, Vgg16, InceptionV3, and ResNet50, using histogram equalization for preprocessing and a Global Average Pooling layer for feature extraction. The entire humerus from the public Mura-v1.1 dataset is utilized for analysis, utilizing a single training-validation split. The dataset is divided into a ratio of 80:20 for experiments for the training and validation datasets., Results: The proposed model outperformed the modified deep-learning models and achieved 92.96%, 91.62%, and 92.14% accuracy, recall, and F1 scores, respectively., Conclusion: The ensemble model presented effectively automates bone fracture detection in X-ray images of the humerus, demonstrating superior performance compared to modified deep-learning models. A comparison has been made between a novel ensemble model and state-of-the-art models, bench-marking their performance. These findings underscore its potential for enhancing diagnostic accuracy and efficiency in orthopedic radiology., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

This study was aimed to compare the clinical and radiographic outcomes of patients with intercondylar fractures of the humerus treated with orthogonal and parallel plating methods via precontoured plates. This was a retrospective comparative study conducted on 50 adult patients with intercondylar humerus fractures that were surgically treated over an eleven-year period. The patients were divided into two groups: Group A underwent internal fixation via parallel plating, whereas Group B received orthogonal plating. Clinical outcomes were evaluated via the Mayo Elbow Performance Score (MEPS), and the radiographic assessments included time to consolidation, pseudoarthrosis, malunion and hardware removal. Both groups presented similar demographic and preoperative characteristics. The functional outcomes assessed by the MEPS were not significantly different between the groups. Radiographically, comparable healing times and rates of complications, including pseudoarthrosis, malunion and hardware removal, were observed. The study findings suggest that both orthogonal and parallel plating methods yield comparable clinical and radiographic outcomes in the treatment of intercondylar humerus fractures. These results underscore the effectiveness of both techniques and emphasize the importance of further research to elucidate the optimal plating method for specific fracture patterns., (© 2024. The Author(s).)

Background: Humeral shaft fractures account for up to 3% of all fractures, but complex forms of those fractures (type AO/OTA B or higher) are rare. Plate and screw fixation of the fracture are rated as consolidated from 80 to 97%. Reported complications include non-union, secondary radial nerve palsy and infection. Minimally invasive plate osteosynthesis (MIPO) should provide the same union rate as open reduction and internal fixation (ORIF) but potentially with fewer complications. The aim of our study was to review patients treated for complex humeral fractures with ORIF through an extended delto-pectoral approach using a long pre-contoured locking plate. The morbidity of the open approach, complication rates, union rate and clinical outcomes were assessed., Methods: We performed a retrospective analysis of 26 consecutive complex humeral shaft fractures (7 males, mean age 59 years; 19 females, mean age 67 years) treated in our institution with a long pre-contoured locking plate between June/2011 and December/2017. Fracture healing was evaluated with standard radiographs. Eventual complications and the morbidity of the approach were assessed through chart review. The final clinical outcome and quality of life were assessed via telephone interview with DASH score and EQ-5D-3 L in 25 of the 26 patients included., Results: There were no complications related to the open approach with uneventful wound healing in all cases without any infections. Mechanical complications occurred in 3 cases (11%): one tuberosity dislocation (revised) and two plate failures (one revised). Postoperative radial nerve palsy was observed in two patients (7%), of which one was transient, the other was persistent. The plate was removed in 4 cases (15%). The average radiological and clinical follow-up was 21 months (range: 12-56). At 12 months follow-up complete fracture healing was confirmed in 22 out of 26 cases and in three more patients after 18 months. After an average of 44 months, the mean DASH score was 35 (SD ± 15.83) points; the EQ-5D-3 L score 0.7 (SD ± 0.31)., Conclusion: ORIF with a long locking plate though an extended delto-pectoral approach is certainly still a viable option to treat complex humeral shaft fractures with good soft tissue and bone healing as well as good functional recovery. No increased morbidity was attributed to the open surgical approach. In our series, radial nerve palsy could not be completely avoided, accentuating the potential risk of this specific fracture in close proximity to the radial nerve., Trial Registration: Ethics Committee: Ethikkommission Ostschweiz (EKOS), Project ID: 2019-00323., (© 2024. The Author(s).)

Background: High-resolution nerve ultrasonography (HRUS) could have an emerging importance in diagnosis and follow-up of axonopathic radial palsy associated with humeral shaft fractures due to closed trauma. The aim of our study was to establish the role of HURS in this context through a longitudinal multimodal analysis., Methods: Clinical, electrodiagnostic (EDX) and HRUS evaluations were prospectively performed at month 1, 3, 6, 12 and 24 from injury, in a continuous series of 19 patients collected in a 5-year study. Clinical severity was scored on MRC of involved muscles, EDX on presence/absence of functional continuity; anatomical continuity and nerve cross sectional area (NCSA) of radial (RN) and posterior interosseus (PIN) nerves were evaluated through HRUS., Results: All patients showed clinical improvement during follow-up; EDX functional continuity was reached by all patients within 12 months; HRUS revealed RN anatomical continuity in all patients and PIN involvement in 74%. RN NCSA progressively reduced during FU, but it was still significantly higher than contralateral at month 24; PIN NCSA became normal within 24 months., Conclusions: When anatomical RN continuity is confirmed by HRUS, good functional outcome is reached even in patients with EDX loss of functional continuity. Together with clinical and EDX evaluations, HRUS may provide useful data in the follow-up of radial palsy due to humeral shaft fractures.

Background: The purpose of this study was to evaluate the advantages of robot navigation system-assisted intramedullary nail treatment for humeral shaft fractures and compare it's efficacy with that of traditional surgical intramedullary nail treatment., Materials and Methods: This was a retrospective analysis of patients with humeral shaft fractures who received intramedullary nail treatment at our centre from March 2020 to September 2022. The analysis was divided into a robot group and a traditional surgical group on the basis of whether the surgery involved a robot navigation system. We compared the baseline data (age, sex, cause of injury, fracture AO classification, and time of injury-induced surgery), intraoperative conditions (surgery time, length of main nail insertion incision, postoperative fluoroscopy frequency, intraoperative bleeding), fracture healing time, and shoulder joint function at 1 year postsurgery (ASES score and Constant-Murley score) between the two groups of patients., Results: There was no statistically significant difference in the baseline data or average fracture healing time between the two groups of patients. However, the robotic group had significantly shorter surgical times, longer main nail incisions, fewer intraoperative fluoroscopies, and less intraoperative blood loss than did the traditional surgery group (P < 0.001)., Conclusion: Robot navigation system-assisted intramedullary nail fixation for humeral shaft fractures is a reasonable and effective surgical plan. It can help surgeons determine the insertion point and proximal opening direction faster and more easily, shorten the surgical time, reduce bleeding, avoid more intraoperative fluoroscopy, and enable patients to achieve better shoulder functional outcomes., (© 2024. The Author(s).)

Background: Gartland Type III supracondylar humerus fractures (SCHFs) are commonly treated using closed reduction followed by percutaneous pin fixation. However, conversion to open reduction may be necessary if closed reduction fails. This study aimed to identify risk factors associated with failed closed reduction and provide a theoretical basis for clinical decision-making in the treatment of Gartland Type III fractures., Methods: A retrospective analysis was conducted on children with Gartland Type III SCHF who underwent surgical treatment between April 2017 and June 2018. Based on whether or not the closed reduction was successful, patients were split into the open reduction group and the closed reduction group. Within the closed reduction group, subgroup analysis based on surgery duration was carried out. Data were collected from medical records and X-ray images. Univariate and multivariate regression analyses were utilized to evaluate the relationship between variables and failed closed reduction., Results: The study included 36 patients in the open reduction group and 135 patients in the closed reduction group. Multivariate analysis revealed that the presence of angle (P = .024, OR = 3.199), rotation (P = .000, OR = 6.359), skin creases (P = .013, OR = 4.077), anterior-posterior displacement ratio (P = .011, OR = 4.337), fracture angle in the anteroposterior view (P = .014, OR = 0.939), and fracture distal displacement direction (P = .002, OR = 5.384) were independent risk factors for failed closed reduction. Subgroup analysis showed that fracture distal displacement direction (P = .013), skin folds (P = .013), lateral displacement ratio (P = .016), and anterior-posterior displacement value (P = .005) significantly influenced the duration of closed reduction surgery., Conclusion: The presence of sharp angle or rotation at the fracture ends, skin folds on the anterior elbow, minor anterior-posterior displacement of the fracture, higher medial inclination of the fracture plane, and distal fracture displacement toward the radial side are independent risk factors for failed closed reduction in pediatric Gartland Type III SCHF., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

The supracondylar humerus fracture is the most frequent fracture of the elbow region during the growth period. The peak age is around 5 years. Extension fractures predominate. The clinical diagnostics are supplemented by X‑ray images in two projections. Growth-associated spontaneous corrections of posttraumatic deformities rarely occur. The goal of treatment is therefore the active transformation of every displaced fracture into a nondisplaced stably fixed fracture.If this is not successful, the consequences of healing in a malalignment can be, e.g., restriction of elbow flexion due to remaining antecurvation or cubitus varus. Combinations are often present. The causes include technical problems with reduction and retention but also misjudgement of the X‑ray findings, ignorance of the growth prognosis or inadequate verification of whether the treatment goal has been achieved.Unsatisfactory treatment results should be corrected as early as possible. This can be done primarily before bony healing is completed or secondarily as a corrective osteotomy at any later point in time. The earlier the correction of the malalignment is performed, the greater the chances of a complete restoration to the original condition. Depending on the type and extent of the deformity various techniques for corrective osteotomy are suggested in the literature., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: Control of humeral torsion can present a challenge, especially intraoperatively during closed reduction and fixation of humeral shaft fractures or 2-part surgical neck fractures of the proximal humerus. The objective of this study is to develop and validate an indirect method for the assessment of humeral torsion using an index that is linearly correlated with rotational arm position and can be derived from only a single plain radiographic image of the proximal humerus., Methods: The Humeral Head Offset Index (HHOI) is calculated as the ratio of the medial and lateral offset of the humeral head measured from the outer cortices of the shaft on a plain radiographic or fluoroscopic image. The relationship of HHOI with humeral torsion was first verified on a sawbone model with radiopaque characteristics under fluoroscopic control. Different degrees of retroversion were simulated through manual rotation of the humerus with a digital protractor in 5° increments until 40° internally rotated and then in 5° increments until 40° externally rotated from the neutral position. The same procedure was subsequently performed digitally on Digitally Reconstructed Radiographs (DRRs) from computed tomography (CT) dataset of the sawbone. Next, the HHOI index was applied to eight randomly selected patients with total humerus CT using the same method. Spearman's rho was calculated for the bivariate analysis of correlation between the simulated degree of retroversion and the HHOI. Strength of correlation was classified according to Koo and Li. Interrater and intrarater reliability of three blinded observers with repetition of measurement after three months were analyzed by assessing the intraclass correlation coefficient (ICC)., Results: Both in the sawbone model and in DRRs, we demonstrated a high to very high significant linear correlation between simulated retroversion and the HHOI. ICC values demonstrated excellent interrater reliability and excellent intrarater reliability for measurement of the HHOI., Conclusions: The HHOI is a new, simple, reliable index that has a linear relationship to the rotation of the humerus and can therefore allow an indirect control of humeral torsion in comparison to the contralateral side., (© 2024. The Author(s).)

Introduction: In our retrospective study we compared the outcomes of paediatric lateral condyle fractures of the elbow fixed by bioabsorbable pins and tension-band sutures or by metallic tension-band with K-wires., Materials and Methods: We reviewed the data of children operated on for lateral condyle fractures between 2010 and 2020. Patients were classified as follows: 1. fractures treated with metallic (KW group), 2. fractures treated with resorbable implants (BR group). We compared the distribution of age, sex and fracture type in each group. Operative times of the two techniques were also recorded and compared. We analysed the X-rays taken one year after the injury and measured the following parameters: presence of possible non-union, varus or valgus deviation, lateral spur formation. Patients whose follow-up period was less than one year were excluded. For categorical data, group comparisons were performed with Chi-square test or Fisher's exact test, depending on the sample size. The evaluation of discrete variables was performed with Mann-Whitney U test., Results: 42 patients met the above criteria. We found 19 children in the Kirschner -wire + tansion band wire (KW) group and 23 in the Bioresorbable pin + tension band suture (BR) group. There were no significant differences between the study groups in terms of age, sex, left-right ratio, number of complications, operation time, number of Jacobs II and III cases or follow-up time. The operation time was on average 5 min longer in the bioresorbable group (K-wire mean = 62.1 min, Bioresorbable mean = 67 min), this difference, however, is not statistically significant (P = 0.177). In terms of minor and major complications, there was no statistically significant difference between the two groups. (P = 0.729)., Conclusions: We did not notice any difference between the complication rates of the two methods, so the real advantage of the absorbable implant technique is that no second intervention is necessary. The benefits of using biodegradable implants in various osteosynthesis techniques need further confirmation by randomised trials., Competing Interests: Declaration of competing interest The authors declare there is no conflict of interests., (Copyright © 2024. Published by Elsevier Ltd.)

Fat emboli may occur in patients after traumatic fractures or orthopedic procedures; however, their clinical detection is a very rare finding. Here, we describe a 77-year-old female who was admitted to the emergency department with a fracture of the right humerus. We diagnosed fat embolism after an ultrasound of the right subclavian vein. The embolism was detected by high-intensity transient signals present on the spectral Doppler. While these signals are well known for microembolization in transcranial Doppler, to our knowledge this is the first case report in the medical literature to observe and describe high-intensity transient signals seen in the upper extremities by spectral Doppler. Although it is unusual to detect a fat embolism in transit, we believe clinicians should be aware of this finding, particularly when evaluating high-risk patients., Competing Interests: The authors have no competing interests to declare., (Copyright: © 2024 The Author(s).)

Objectives: To assess the treatment and outcomes of supracondylar humeral fractures (SHFs) in children older than 10 years of age at the time of injury., Methods: The study analyzed clinical data from 60 patients who sustained SHF, all over the age of 10 years, were analyzed. The patients included 49 males and 11 females with a mean age of 10.9 ± 0.9 years (range, 10 to 14.5). All patients underwent surgical treatment under general anesthesia. Closed reduction (CR) and percutaneous fixation were the primary treatment, with open reduction and internal fixation being employed only in cases CR was unsuccessful. The study assessed the healing of fractures by measuring the radiographic angles, including the carrying angle (RCA), Baumann's angle (BA), and metaphyseal-diaphyseal angle (MDA) on anteroposterior radiographs of the elbow joint. In addition, the study evaluated whether the anterior humeral line (AHL) appropriately passed through the middle third of the capitellum. The final follow-up visit used the Mayo Elbow Performance Index score (MEPI) and Flynn's criteria to analyze the recovery of elbow function., Results: There were 15 (25%) SHF type II, 17 (28.3%) type III and 28 (46.7%) type IV. Of the 60 patients, 56 (93.3%) underwent successful CR, whereas 4 (6.7%) required open reduction and internal fixation because of an unsuccessful CR. The final follow-up showed the average BA as 72° ± 5.3°, the average MDA as 88.3° ± 2.8°, and the average RCA as 9.6° ± 3.9°. The AHL bisected accurately the capitellum in 59 cases (98.3%). The average range of elbow flexion-extension was 146.6° ± 8.6°, whereas the average MEPI score was 99.9 ± 0.6; 98.3% (n=59) were rated as excellent and 1.7% (n=1) were rated as good. According to Flynn's criteria, 86.7% had an excellent outcome (n=52), 10% had a good outcome (n=6), and 3.3% had a poor outcome (n=2). Only 1 patient (1.7%) experienced redisplacement. Eight cases of nerve injury were reported, with 7 involving the radial nerve and 1 involving the ulnar nerve; all resolved spontaneously., Conclusions: CR and percutaneous fixation have been shown to be effective in treating SHF in 93.3% of children aged 10 years old and older at the time of injury, with favorable radiographic and functional outcomes and a low risk of secondary displacement. Open reduction should only be considered when CR is ineffective., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The aim of the operation is to replace the articular surface of the distal humerus in cases of nonreconstructible fractures of the distal humerus., Indications: Active patients with high functional requirements, in whom weight limitation of total elbow arthroplasty should be avoided., Contraindications: Contraindications include fractures with irreconstructible epicondyles and/or irreconstructible collateral ligaments, as well as ulnohumeral, or radiohumeral osteoarthritis., Surgical Technique: Following subcutaneous anterior transposition of the ulnar nerve, surgical dislocation of the elbow joint is achieved through a paratricipital approach with release of the soft tissue structures from the humerus. After resection of the trochlea, the intramedullary canal of the humerus is prepared using rasps in order to implant the hemiprosthesis with retrograde cementing. Finally, the medial and lateral collateral ligaments as well as the flexors and extensors are repaired., Postoperative Management: Early functional rehabilitation in a hinged elbow orthosis while avoiding varus/valgus stress after wound healing is completed., Results: Between 2018 and 2022, 18 patients with coronal shear fractures were treated with elbow hemiarthroplasty. The mean Mayo Elbow Performance Score (MEPS) was 79 (70-95) after a mean follow-up of 12 months. The mean range of motion was 99° (70-130°) in extension-flexion and 162° (90-180°) in pronation-supination., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Purpose: The radial nerve may be painfully irritated or damaged by open reduction and internal fixation (ORIF) of humeral fractures. Secondary radial nerve lesions after ORIF of humeral shaft fractures are described in up to 16%. Not only peripheral nerves but also orthopaedic instruments and osteosynthesis material are well visible by ultrasound. The aim of this study was to evaluate the accuracy of ultrasound in assessing the relation between the bone overlapping screw tips and the radial nerve close to the humeral bone., Methods: Ultrasound-guided drilling was used to place screws as close as possible to the radial nerve in 8 humeral bones of four cadavers. The relation between the radial nerve and the screw tips was assessed by high-resolution ultrasound, and the overlap of all screw tips over the bone was measured by ultrasound and fluoroscopy. Thereafter, the findings were validated by anatomical dissection., Results: We could correctly identify all screw tips and their relation to the radial nerve by ultrasound. In 7 of 8 cases, the screw tip had direct contact with the radial nerve. The overlaying length of the screw tip was accurately measured by using ultrasound in all cases. In contrast fluoroscopy underestimated this length in 50% of cases., Conclusion: With this study, we show that ultrasound can reliable visualize the screw tips and its relation to the radial nerve. Ultrasound is a promising diagnostic tool to evaluate patients with radial nerve irritations or lesions after ORIF of humeral fractures. Furthermore, ultrasound could be an adequate tool to guide drilling., (© 2024. The Author(s).)

Distal humerus intra-articular comminuted open fracture is a challenging injury, with nonunion, infection and stiffness considered as major concerns. We report a 58-year-old woman who was admitted to the emergency department from a car accident, sustaining an open wound with severe comminution of distal humerus and complete articular fracture, classified as AO/OTA 13C2 and Gustillo Anderson type IIIA. Debridement and external fixation was done first, followed by open reduction and internal fixation with fibular strut allograft. The patient showed excellent results in radiological and functional outcomes. Level of Evidence: Level V (Therapeutic).

Objective: In this study, we investigated the efficacy of percutaneous poking reduction and Kirschner wire fixation in older children with irreducible supracondylar flexion-type fractures of the humerus., Methods: This retrospective investigation included 27 children, comprising 15 males and 12 females, aged between 10 years and 3 months to 14 years and 11 months, all diagnosed with a flexion-type supracondylar fracture of the humerus within one week of trauma. All patients underwent surgery under general anesthesia. Following unsuccessful manual reduction, percutaneous poking reduction with Kirschner wires was performed under C-arm fluoroscopy to achieve fracture reduction. Following successful reduction, three 2.0 mm Kirschner wires were inserted in a cross pattern to secure the fracture ends. Postoperatively, the elbow joint was immobilized in a functional position with a plaster cast for four weeks., Results: Follow-up in the outpatient department ranged from 9 to 36 months. Clinical functional assessment using Flynn's criteria rated 24 cases as excellent, 2 as good, and 1 as fair, yielding an overall efficacy of 96.3%. No cases of fracture re-displacement, fracture fragment necrosis, or other complications such as nonunion, iatrogenic nerve injury, myositis ossificans, or long-term elbow joint dysfunction were observed during the postoperative follow-up., Conclusion: The percutaneous poking reduction and Kirschner wire fixation technique is a simple and reliable procedure for treating irreducible flexion-type supracondylar fractures of the humerus in older children, with minimal trauma. This technique offers substantial stability for the fracture and results in excellent long-term recovery of joint function., (© 2024. The Author(s).)

Greater tuberosity fractures of the humerus can be challenging to manage due to their complex anatomy and the potential for compromised shoulder function. We present a novel technique for treating greater tuberosity fractures utilizing specialized anatomical plates and rotator cuff reinforcement. The technique involves the use of an anatomically T-shaped plate designed specifically for the greater tuberosity region of the humerus, allowing for precise fixation and stability. Additionally, rotator cuff reinforcement is performed using sutures to enhance structural integrity and promote early mobilization. The simplified process is as follows: After administering anesthesia, a 3 cm incision is made along the lateral aspect of the shoulder to precisely expose the fracture site of the greater tuberosity. A suture of size 5 is skillfully threaded through the tough rotator cuff tendon to securely attach the proximal humerus to the anatomical plate after the greater tuberosity has been reduced. Intraoperative fluoroscopy is utilized to verify the accurate positioning of plates and screws. After ensuring everything is correct, the surgery concludes.

Case: A 10-year-old, postmenarchal girl presented to the emergency department with a closed, displaced, intercondylar T-type distal humerus fracture. Open reduction and internal fixation was performed 3 days following initial presentation. The patient healed but experienced elbow stiffness in the 7 months following the procedure. Implant removal and capsular release were performed at that time. At the 31-month follow-up, the patient reported satisfactory elbow functionality., Conclusion: There is limited literature available discussing optimal management and associated outcomes of intercondylar T-type distal humerus fractures in the young-adolescent population. This report presents a possible method for management of the initial injury and the most common associated complication., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C378)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Purpose: Comminuted coronal shear fractures of the distal humerus represent rare injuries and are difficult to treat, especially comminuted capitellum and trochlear fractures (Dubberley Type III). The on-table reconstruction technique of comminuted articular fractures may be an option, although it has not been reported in the coronal shear fracture of the distal humerus. The aim of the present case series is to determine the functional and radiological outcomes of on-table reconstructed Dubberley III fractures., Methods: A retrospective review was conducted of 10 patients with Dubberley type III fractures in coronal shear fractures of the capitellum and trochlea who underwent an 'on-table' reconstruction technique between January 2009 and October 2019. All patients were evaluated using the disabilities of the arm, shoulder, and hand (DASH) score, American Shoulder and Elbow Surgeons(ASES) score, Mayo Elbow Score Performance Index (MEPI) score and at least 4 years later., Results: All cases achieved union. At the final follow-up, the mean range of elbow motion was 11.5°of flexion contracture and 131.9° of further flexion. The mean DASH score was 21.2 (5.7) points (range 13.3-32.5). The mean ASES score was 88.6 ± 7.4 (range, 77 to 100). The mean MEPI score was 87 (10) points (range 70-100). In complication, partial osteonecrosis of capitellum is developed in one patient. One patient had heterotopic ossification without functional impairment., Conclusion: The on-table reconstruction technique can be a reliable option in the surgical treatment of complex distal humerus fractures. This technique allows anatomical reduction of comminuted capitellum and trochlea, with a low risk of avascular necrosis over 4 years of follow-up., Level of Evidence: Level IV, retrospective case series., (© 2024. The Author(s).)

Objective: Supracondylar humerus (SCH) fractures are common among pediatric patients, with the severity categorized using the Gartland classification system. Type 1 SCH fractures are nondisplaced and treated with immobilization, while more displaced fractures require surgery. The need for follow-up radiographs, particularly for type 1 fractures, is an area where evidence is lacking. This study investigates the clinical value and financial implications of follow-up radiographs for type 1 SCH fractures, hypothesizing that they do not alter clinical management and, therefore, represent an unnecessary expense., Methods: This retrospective cohort study, approved by the Institutional Review Board, focused on patients under 18 with nondisplaced SCH fractures treated nonoperatively. One hundred one type 1 SCH fractures, in which the fracture was visible on presenting radiographs, were chosen from patients presenting between January 2021 and December 2022. Charts were reviewed for demographic information, time of cast removal, and complications. A pediatric orthopaedic surgeon and orthopaedic resident reviewed the radiographs to confirm the injury to be a type 1 SCH fracture., Results: Among the 101 patients, after the initial presentation, 79 attended an interim visit and 101 attended a "3-week follow-up" at an average of 23 days postinjury. All patients underwent radiographs during these visits for a total of 180 radiographs after confirmation of type 1 SCH fracture. No changes in management resulted from follow-up radiographs. One instance of refracture was noted ~3 months after cast removal. There were 180 superfluous follow-up radiographs taken at subsequent clinic visits. The total charge for these radiographs was $76,001.40, averaging $752.49 per patient., Conclusion: Follow-up radiographs for type 1 SCH fractures did not lead to changes in clinical management, aligning with previous findings in more severe SCH fractures. This approach can reduce costs, radiation exposure, and clinic time without compromising patient care. The study can reassure providers and parents about the lack of necessity for follow-up radiographs to document healing., Level of Evidence: Level-IV., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Fractures of the lateral condyle of the humerus in children are articular fractures with difficult diagnostics due to the incompletely ossified elbow joint. The aim of this study was to evaluate the method of treatment at initial presentation and to analyze the frequency of subsequent displacement during follow-up., Material and Method: Retrospective analysis of the frequency of primary fracture dislocation and subsequent displacement of fractures of the lateral condyle of the humerus in children under 16 years of age between 2004 and 2021. Conventional radiographs in two planes at the time of the accident and in the follow-up after 5-7 days were evaluated., Results: A total of 285 fractures of the lateral condyle of the humerus were evaluated. The average age was 5.3 years. Of the fractures 109 (38.3%) were directly surgically treated in cases of primary displacement and 176 fractures (61.7%) were not primarily displaced and were initially treated conservatively. During follow-up, subsequent displacement was evident in 46 fractures (26.1%). A total of 130 fractures (45.6%) were treated conservatively and 155 fractures (54.4%) were treated surgically using open joint visualization and screw osteosynthesis or K‑wire osteosynthesis., Conclusion: Fractures of the lateral condyle of the humerus occur more frequently in a certain age group and require targeted radiological diagnostics. Nondisplaced fractures can be treated conservatively but essential radiological follow-up shows a high number of subsequent displacements, so that open surgical stabilization is often necessary., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: Fractures of the capitellum are rare in children. The purpose of this study was to report fracture characteristics, treatment, and outcomes of pediatric capitellar fractures at a single children's hospital. We also aimed to update the classification of these fractures based on a large sample size by revising the Murthy (Boston) classification., Methods: In a retrospective study at a single tertiary care children's hospital, fractures of the capitellum in patients below 18 years of age were queried and reviewed for demographics, injury characteristics, imaging, treatment, outcomes, and complications. Three surgeons reviewed all imaging to classify the fractures and assess interobserver and intraobserver reliability., Results: Forty-four patients (25 male) with capitellar fractures with a mean age of 11.7±3.7 years were identified. Seven fractures did not belong to an existing type and were grouped into a new type IV capitellar fracture, defined as LCL avulsions with extension to the articular surface of the capitellum. We found good to excellent inter-rater and intrarater reliability for the new classification system. Our raters believed that cross-sectional imaging was essential to classifying fractures in 84% of the cases. Thirty-three of 44 patients underwent early surgical intervention, with favorable outcomes. Five patients presented late with substantial elbow contracture and malunion and were treated surgically with the excision of the fragment., Conclusions: The new classification of pediatric capitellar fractures is more comprehensive and offers good to excellent reliability. We found excellent outcomes in the majority of cases with early diagnosis and management, but substantial risk for complications with missed and delayed diagnosis. Malunion and subsequent loss of ROM were the most common presentations of a missed diagnosis, which can be surgically treated with favorable outcomes., Level of Evidence: Level III-retrospective cohort study., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Competing Interests: Competing interests: None declared.