Application Value of Sevoflurane Combined with Brachial Plexus Block in Children with Humeral Fracture Surgery and its Effect on Hemodynamics: A Clinical and Anatomical Study

SUMMARY: To observe the effect of sevoflurane combined with brachial plexus block (BPB) in children with humeral fracture surgery and its effect on hemodynamics. 84 children who received surgical treatment of humeral fracture in our hospital from September 2019 to September 2022 were selected. According to different anesthesia methods, the children were divided into control group and study group. The control group only received laryngeal mask sevoflurane; the study group received laryngeal mask sevoflurane combined with BPB. The operation situation, hemodynamic indexes, stress level, pain and adverse reactions of children was observed. The postoperative awakening time in the study group was lower than control group, the postoperative pain onset time in the study group was higher than control group (P0.05). Postoperative 2h, the levels of serum cortisol, b-endorpin, norepinephrine and epinephrine in the study group were lower than control group (P0.05). Sevoflurane combined with BPB is helpful to shorten the postoperative awakening time of children with humeral fracture, reduce the degree of postoperative pain, improve hemodynamics, and reduce stress response, and has good safety.

El objetivo fue observar el efecto del sevoflurano combinado con bloqueo del plexo braquial (BPB) en niños con cirugía de fractura de húmero y su efecto sobre la hemodinámica. Se seleccionaron 84 niños que recibieron tratamiento quirúrgico de fractura de húmero en nuestro hospital desde septiembre de 2019 hasta septiembre de 2022. Según diferentes métodos de anestesia, los niños se dividieron en grupo control y grupo de estudio. El grupo control solo recibió sevoflurano en mascarilla laríngea; el grupo de estudio recibió sevoflurano con mascarilla laríngea combinado con BPB. Se observó la situación operatoria, índices hemodinámicos, nivel de estrés, dolor y reacciones adversas de los niños. El tiempo hasta el despertar postoperatorio en el grupo de estudio fue menor que el del grupo control, el tiempo de aparición del dolor postoperatorio en el grupo de estudio fue mayor que el del grupo control (P0,05). A las 2 horas postoperatorias, los niveles séricos de cortisol, β-endorfina, norepinefrina y epinefrina en el grupo de estudio fueron más bajos que los del grupo control (P 0,05). El sevoflurano combinado con BPB es útil para acortar el tiempo de despertar del posoperatorio de los niños con fractura de húmero, reduce el grado de dolor postoperatorio, mejora la hemodinámica y reduce la respuesta al estrés, además de tener buena seguridad.

Finite element analysis of PMMA bone cement reinforced screw plate fixation for osteoporotic proximal humeral fracture / 中国骨伤

OBJECTIVE@#With the help of finite element analysis, to explore the effect of proximal humeral bone cement enhanced screw plate fixation on the stability of internal fixation of osteoporotic proximal humeral fracture.@*METHODS@#The digital model of unstable proximal humeral fracture with metaphyseal bone defect was made, and the finite element models of proximal humeral fracture bone cement enhanced screw plate fixation and common screw plate fixation were established respectively. The stress of cancellous bone around the screw, the overall stiffness, the maximum stress of the plate and the maximum stress of the screw were analyzed.@*RESULTS@#The maximum stresses of cancellous bone around 6 screws at the head of proximal humeral with bone cement enhanced screw plate fixation were 1.07 MPa for No.1 nail, 0.43 MPa for No.2 nail, 1.16 MPa for No.3 nail, 0.34 MPa for No.4 nail, 1.99 MPa for No.5 nail and 1.57 MPa for No.6 nail. These with common screw plate fixation were:2.68 MPa for No.1 nail, 0.67 MPa for No.2 nail, 4.37 MPa for No.3 nail, 0.75 MPa for No.4 nail, 3.30 MPa for No.5 nail and 2.47 MPa for No.6 nail. Overall stiffness of the two models is 448 N/mm for bone cement structure and 434 N/mm for common structure. The maximum stress of plate appears in the joint hole:701MPa for bone cement structure and 42 0MPa for common structure. The maximum stress of screws appeared at the tail end of No.4 nail:284 MPa for bone cement structure and 240.8 MPa for common structure.@*CONCLUSION@#Through finite element analysis, it is proved that the proximal humerus bone cement enhanced screw plate fixation of osteoporotic proximal humeral fracture can effectively reduce the stress of cancellous bone around the screw and enhance the initial stability after fracture operation, thus preventing from penetrating out and humeral head collapsing.

Clinical study of double plate system in the treatment of complex proximal humeral fractures in the elderly / 中国骨伤

OBJECTIVE@#To explore the clinical outcomes of anteromedial combined with lateral locking plate for complex proximal humeral fractures in the eldery.@*METHODS@#From June 2018 to October 2020, 30 patients who underwent surgical treatment for Neer grade 3 to 4 proximal humeral fractures, including 8 males and 22 females, aged from 51 to 78 years old with an average of (61.5±7.5) years old. Of them, 15 patients had fractures fixed with anteromedial combined with lateral locking plate(ALLP group), whereas 15 received internal fixation with proximal humerus locking plate only(PHLP group). The clinical data, simple shoulder test (SST), humeral head height loss, varus angle and shoulder range of motion were compared between the two groups.@*RESULTS@#All fractures were healed. The follow-up time ranged from 12 to 24 months, with an average of(14.3±2.9) months. The operation time of ALLP group was longer than that of PHLP group (P<0.05). There was no significant difference in intraoperative blood loss between the two groups (P>0.05). There was no significant difference in SST score between the two groups at 1, 3 and 12 months after operation (P>0.05). In terms of radiographic measurement, there was no significant difference in humeral head height loss and varus angle between the two groups at 1 and 3 months after operation (P>0.05). At 12 months after operation, the height loss and varus angle of humeral head in ALLP group were lower than those in PHLP group (P<0.05). In shoulder range of motion, the range of forward elevation in ALLP group was larger than that in PHLP group 1 year after operation(P<0.05). There was no significant difference in external rotation between the two groups.@*CONCLUSION@#Anteromedial combined with lateral locking plate in the treatment of complex proximal humeral fractures in the elderly can increase the stability of the medial column and obtain a good fracture prognosis. But there are also disadvantages such as longer operation time, so it should be individualized according to the fracture type of the patient.

A new fluoroscopy technique for supracondylar humerus fractures / Uma nova técnica de fluoroscopia para fratura supracondilar do úmero

ABSTRACT Introduction To compare two different intraoperative fluoroscopy techniques used for closed reduction and percutaneous pinning (CRPP) in pediatric patients with supracondylar humerus fractures (SHF). Materials and Methods Thirty-six patients who underwent SHF surgery from May 2011 to June 2019 were included in the study. During surgery, the classical fluoroscopy method (CFM) was used in 21 patients and the new fluoroscopy method (NFM) was used in the remaining 15 patients. Results The mean age was 5.14±1.13 years in the NFM group and 5.38±1.36 years in the CFM group. Mean operative time was 38.14±5.92 minutes in the CFM group and 21.54±3.48 minutes in the NFM group (p=0.001), while mean fluoroscopy times were 25.65±3.91 seconds and 39.84±7.50 seconds in the NFM and CFM groups, respectively (p=0.001). The NFM and CFM groups demonstrated similar functional capacity as measured by the Mayo Elbow Score (p=0.168). Direct radiographs obtained to measure Baumann's angle also showed that the two groups had similar results (p=0.848). Conclusions The NFM is a reliable and successful technique as it leads to shorter operative and fluoroscopy times, as well as providing improvement in functional scores and radiological outcomes in short-term follow-up. Level of Evidence III, Therapeutic Studies-Investigating the Results Level of Treatment.

RESUMO Introdução Visamos comparar duas técnicas de fluoroscopia intraoperatória usadas para redução fechada e fixação percutânea com pino (CRPP) em pacientes pediátricos com fratura supracondilar do úmero (SHF). Materiais e Métodos Trinta e seis pacientes submetidos à cirurgia de SHF de maio de 2011 a junho de 2019 foram incluídos no estudo. Durante a cirurgia, o método clássico de fluoroscopia (CFM) foi usado em 21 pacientes e o novo método de fluoroscopia (NFM) foi usado nos 15 pacientes restantes. Resultados A média de idade foi de 5,14 ± 1,13 anos no grupo NFM e 5,38 ± 1,36 anos no grupo CFM. O tempo operatório médio foi de 38,14 ± 5,92 minutos no grupo CFM e 21,54 ± 3,48 minutos no grupo NFM (p = 0,001), enquanto os tempos médios de fluoroscopia foram 25,65 ± 3,91 segundos e 39,84 ± 7,50 segundos nos grupos NFM e CFM, respectivamente (p = 0,001). Os grupos NFM e CFM demonstraram capacidade funcional semelhante medida pelo Mayo Elbow Score (p = 0,168). As radiografias diretas obtidas para medir o ângulo de Baumann também mostraram que os dois grupos tiveram resultados semelhantes (p = 0,848). Conclusões O NFM é uma técnica confiável e bem-sucedida, pois reduz o tempo operatório e de fluoroscopia, além de proporcionar melhora nos escores funcionais e resultados radiológicos no acompanhamento de curto prazo. Nível de Evidência III, Estudos terapêuticos - Investigação dos resultados do tratamento.

Humeral Shaft Fracture Sustained During Arm Wrestling with Review of Factors Contributing to its Causation

@#Introduction: Humeral shaft fractures are the most common injury sustained in arm wrestling, and its various biomechanical, anatomical, kinematic and electromyographic aspects have been studied and reported. We present a series of six cases of humeral shaft fractures in the arm wrestlers and a review of basic science studies to determine the factors contributing to their causation. Materials and methods: Six humeral shaft fractures associated with arm wrestling were treated between December 2018 and January 2020. The medical records and radiographs were retrospectively reviewed. In addition, the characteristics of the patients, their opponents, and the fractures were noted in a pre-designed data sheet. Results: There were six men with an average age of 27.5 years (SD ± 8.9). All were amateurs who were occasional arm wrestlers. Three fractures each were sustained in the sitting and standing position, four in the losing phase, one in the winning phase, and one in the stalling phase. The dominant side humerus was involved in all but one case. The fracture types were 12-A1 (n=4); 12-B1 (n=1); 12-A2 (n=1). Three fractures were treated by open reduction and internal fixation, while three were treated conservatively with satisfactory healing. Conclusion: Humeral shaft fractures in arm wrestling are common in amateurs. There is no association of the fracture with the position of the players or the phase of the match. However, arm wrestlers should be aware of this complication and should receive proper guidance to reduce the risk of humeral shaft fractures.

Distal Humeral Shaft Fracture with Simultaneous Ipsilateral Supracondylar Humeral Fracture in a Child: A Case Report

@#In children, simultaneous ipsilateral fracture of the distal shaft humerus and supracondylar humerus is rare. To the best of our knowledge, there are no available data on supracondylar humeral fracture (SCHF) combined with ipsilateral distal humeral shaft fracture. This report aimed to discuss a novel case with an appropriate management scheme. We present a case of a 5-year-old boy with ipsilateral distal shaft humerus fracture and SCHF. He underwent closed reduction and antegrade elastic stable intramedullary nail (ESIN) fixation with good clinical outcome. These injuries affect a child’s bony growth, and careful treatment is warranted. Upper extremity fractures could present in different combinations. The ESIN procedure with antegrade technique facilitated reduction and fixation of the fracture by prevention of iatrogenic ulnar nerve injury or pin-tract infection. Moreover, it allowed performance of early range of motion exercises.

Tuberosity Healing after Reverse Shoulder Arthroplasty for Proximal Humerus Fractures: Is there Clinical Improvement? / Consolidação dos tubérculos na artroplastia reversa do ombro após fratura proximal do úmero: Existe melhoria nos resultados funcionais?

Abstract Objective To compare the functional results of patients with complex proximal humerus fracture submitted to total shoulder reverse arthroplasty with and without tuberosity healing. The secondary goal was to know the tuberosity healing rate after reverse shoulder arthroplasty with our surgical technique. Methods A retrospective, cohort type study, with a prospective database collection. In total, 28 patients fulfilled the inclusion criteria: age ≥ 65 years, reverse shoulder arthroplasty for complex proximal humerus fracture (type-3 or -4, according to Neer), and a minimum of 24 months of follow-up. At six months of follow-up, all of the patients were evaluated radiographically for tuberosity, and then they were divided into 2 groups: those with healed tuberosities and those with non-healed tuberosities. A clinical evaluation using the Constant score, active range of motion and the Visual Analog Scale (VAS) at the last follow-up was also performed. Results Tuberosity healing occurred in 21 patients (76.3%). There were statistically significant differences in the Constant scoring system (p < 0.001), forward elevation (p = 0.020), internal rotation (p = 0.001) and external rotation (p = 0.003) when comparing the group of healed tuberosities with the group of non-healed tuberosities. No differences were found regarding the VAS score. Conclusion Tuberosity healing results in an improvement of the functional outcomes of patients submitted to reverse shoulder arthroplasty as a treatment for complex proximal humeral fractures in the elderly.

Resumo Objetivo Comparar os resultados funcionais entre pacientes com fratura complexa do úmero proximal submetidos a artroplastia reversa com tubérculos consolidados e tubérculos não consolidados. O objetivo secundário foi determinar a taxa de consolidação dos tubérculos com este tipo de prótese. Métodos Estudo de tipo coorte, retrospectivo, com coleta prospectiva de dados. No total, 28 pacientes cumpriram os critérios de inclusão: idade superior a 65 anos, prótese reversa do ombro por fratura complexa do úmero proximal (3 ou 4 partes, segundo Neer), e tempo de seguimento mínimo de 24 meses. Aos seis meses, todos os pacientes foram avaliados radiograficamente quanto à consolidação dos tubérculos e divididos em dois grupos: grupo com tubérculos consolidados e grupo com tubérculos não consolidados. A avaliação funcional realizou-se segundo o sistema de pontuação de Constant, da amplitude de movimento ativo, e da Escala Visual Analógica (EVA) à data da última consulta. Registaram-se todas as complicações. Resultados A consolidação dos tubérculos ocorreu em 21 pacientes (76,3%). Verificou-se diferenças estatisticamente significativas no sistema de pontuação de Constant (p < 0.001), elevação anterior (p = 0.020), rotação interna (p = 0.001) e externa (p = 0.003), quando se comparou o grupo dos tubérculos consolidados com o grupo dos tubérculos não consolidados. Não houve diferenças significativas na EVA entre os 2 grupos. Conclusão A consolidação dos tubérculos traduz uma melhoria dos resultados funcionais em pacientes submetidos a artroplastia reversa do ombro como tratamento de fraturas complexas do úmero proximal em idosos.

Alteración de mediciones radiográficas en osteosíntesis de húmero proximal con clavo centromedular / Alteration of X-ray measurements in proximal humerus osteosynthesis with intramedullary nail

Resumen: Introducción: La calidad de reducción en las fracturas de húmero proximal es posible valorarla a través de criterios radiográficos (ACD = ángulo cervicodiafisario; OM = offset medial; DTC = distancia tuberosidad-cabeza y ES = espacio subacromial), los cuales predicen la funcionalidad. Sin embargo, estos criterios establecidos para otros implantes no están descritos para el clavo centromedular. Material y métodos: Estudio de cohorte observacional y retrospectivo en pacientes > 18 años con osteosíntesis con clavo centromedular (durante el período de 2014 a 2017), en donde se evaluaron las características demográficas, severidad de lesión (clasificación de Neer) y las mediciones radiográficas progresivas y complicaciones. Resultados: Se analizaron 84 casos, cuya edad en promedio fue de 65 ± 2 años y la media de seguimiento de 13.9 meses. Por clasificación de Neer: 40.4% fueron grado II; 29.7%, grado III y 29.7%, grado IV. La consolidación en varo aumenta 10.7% al final del seguimiento, siendo aquellos pacientes Neer grado III y IV los más frecuentes. La deformidad > 140o predomina para Neer grado II (n = 15/34). En 30.9%, se presenta un cambio de ACD (ΔACD) ≥ 10o. En general, 86.9% tiene cambios de DTC < 5 mm. En los casos Neer grado III/IV, 32% tiene una alteración de ES > 5 mm. La complicación más frecuentemente es la necrosis avascular (NAV) con 44% de los casos. Conclusiones: Las mediciones radiográficas presentan cambios en valoraciones a largo plazo. Las alteraciones en ACD (> 10o) y ES (> 5 mm) se dan en mayor proporción en aquellos pacientes Neer grado III/IV (acorde con la severidad de la fractura), lo que favorece consolidaciones viciosas en varo o valgo y una mayor presencia de NAV.

Abstract: Introduction: The quality of reduction in proximal humerus fractures is valuable with radiographic criteria (Neck-shaft angle [NSA]; medial offset [MO]; distance head tuberosity [DHT] and subacromial space [SS]) that predict functionality. These criteria set for other implants are not described for the intramedullary nail. Material and methods: Observational cohort study, retrospective, with patients > 18 years, with osteosynthesis with intramedullary nail (2014 to 2017), evaluating demographic characteristics, severity of injury (Neer classification), progressive radiographic measurements and complications. Results: 84 cases with an average age of 65 ± 2 years and an average follow-up of 13.9 months were analyzed. By Neer rating 40.4% were grade II, 29.7% grade III and 29.7% grade IV. Consolidation in varus increases to 10.7% at the end of follow-up, with Neer III and IV patients. The >140o deformity is prevalent for Neer II (n = 15/34). 30.9% have a change of neck-shaft angle of ≥ 10o. Overall 86.9% has HTD changes < 5 mm. Cases Neer III/IV 32% has alteration of SS > 5 mm. The most common complication is avascular necrosis (AVN) with 44% of cases. Conclusions: Radiographic measurements have changes in long-term follow-up. Alterations in NSA (> 10o) and SS (> 5 mm) occur in higher proportion of Neer III/IV patients, according to the severity of the fracture, favoring vicious consolidations in varus or valgus and increased presence of AVN.

Inter/intra-observer evaluation between radiographs and tomographies for proximal humerus fracture / Avaliação inter e intra-observador entre radiografias e tomografias para fratura de úmero proximal

ABSTRACT Objective: The use of images in 3D reconstruction is an instrument that facilitates the interpretation of the fracture, observations of deviations, rotations and articular surface. Objective: To evaluate the inter-observer and intra-observer reliability of the Neer x AO proximal humerus fracture classification on radiographs versus computed tomography with three-dimensional reconstruction (3D). Methods: We evaluated the digital radiographs (anteroposterior and profile) and computerized tomography with 3D reconstruction of patients presenting with a proximal humerus fracture, surgically treated at an Orthopedics and Traumatology Service. All radiographs and computed tomography were classified (Neer and AO) by eight (8) orthopedic surgeons, specialists in the upper limb and sent, following the pre-established numeration by the author, in a spreadsheet to the author of the study. Results: The Neer and AO scores were more reproducible when determined by computed tomography with 3D reconstruction, mainly in fractures of greater complexity (Neer 4 parts and AO group C). However, in absolute values, inter and intra-observer reproducibility and concordance still remain low. Conclusion: Computed tomography with 3D reconstruction allows a better analysis of fractures of group C and Neer 4 parts. However, the inter and intra-observer agreement does not increase significantly in comparison to the radiographs. Level of evidence III, Study of non-consecutive patients, without gold standard, applied uniformly.

RESUMO Objetivo: O uso de imagens em reconstrução 3D são um instrumento facilitador na interpretação da fratura, observações dos desvios, rotações e superfície articular. Objetivo: Avaliar a confiabilidade inter-observador e intra-observador da classificação da fratura de úmero proximal, descrita por Neer x AO, em radiografias versus tomografias computadorizadas com reconstrução tridimensional (3D). Métodos: Avaliamos as radiografias digitais (anteroposterior e perfil) e tomografias computadorizadas com reconstrução 3D de pacientes que apresentavam fratura de úmero proximal, tratados cirurgicamente em um Serviço de Ortopedia e Traumatologia. Todas as radiografias e tomografias computadorizadas foram classificadas (Neer e AO) por oito (8) cirurgiões ortopédicos especialistas em membro superior e enviadas, seguindo a numeração pré-estabelecida pelo autor, em uma planilha para o autor do trabalho. Resultados: A classificação de Neer e AO foram mais reprodutíveis quando determinadas pela tomografia computadorizada com reconstrução 3D, principalmente em fraturas de maior complexidade (Neer 4 partes e AO grupo C). Porém, em valores absolutos, a reprodutibilidade e concordância inter e intraobservador ainda permanecem baixas. Conclusão: A tomografia com reconstrução 3D, permite uma melhor análise das fraturas do grupo C e Neer 4 partes. Entretanto, não aumenta significativamente a concordância global inter e intraobservador em comparação as radiografias. Nível de Evidência III, Estudo de pacientes não consecutivos, sem padrão ouro, aplicados uniformemente.

Fractura supracondílea de húmero y extremidad sin pulso. Uso de oximetría de pulso como predictor de lesión vascular en un caso pediátrico / Pulseless limb and supracondylar humeral fracture; use of pulse oximetry as a predictor of vascular injury in a pediatric case

Las fracturas supracondíleas del húmero (FSCH) representan la segunda lesión más frecuente en la infancia. La clasificación de Gartland, de acuerdo con la dirección y magnitud del desplazamiento orienta hacia su tratamiento. Las fracturas grado I solo requieren inmovilización y los grados del II al IV necesitan reducción generalmente cerrada, y fijación con agujas de Kirschner percutáneas. En los grados III y IV las lesiones neuro-vasculares se pueden presentar debido a las relaciones anatómicas de la fractura. La lesión vascular se debe sospechar y tener siempre en cuenta, debido a las secuelas que se pueden presentar de no tomar una conducta adecuada a tiempo. Actualmente existe controversia acerca de cuándo realizar la exploración quirúrgica ante una extremidad bien perfundida, sin pulso radial como resultado de una FSCH. Varios autores han reportado la utilidad de la onda de pulso en la oximetría como predictor de lesión vascular. En este artículo se presenta un caso clínico de FSCH con extremidad sin pulso y lesión de la arteria braquial, su manejo y evolución final.

Supracondylar fractures of the humerus are the second most frequent lesion of infancy. Gartland's classification uses the direction and magnitude of the displacement to determine its treatment. Grade I fractures need only immobilization and grades II to IV need reduction, generally closed, and percutaneous fixation with Kirschner needles. Neurovascular lesions may be present in grades III and IV because of the anatomic relations to the fracture. Vascular injury must always be suspected and taken into consideration because of the sequelae that may occur if not given adequate treatment promptly.There is currently controversy over when to do a surgical exploration in a well-perfused limb with absent radial pulse resulting from a supracondylar humeral fracture. Several authors have reported the usefulness of the waveformof the pulse oximeter in predicting vascular injury. In this article we present a clinical case of supracondylar humeral fracturewithpulseless limb and brachial artery injury, its management, and the outcome.

Metástasis bilateral de húmero, en paciente con cáncer renal, tratado con inmunoterapia y cirugía: reporte de un caso / Bilateral Humeral metastases, in a patient with renal cancer, treated with immunotherapy and surgery: case report

El carcinoma de células renales es el 7mo cáncer en frecuencia a nivel mundial con más de 300.000 casos nuevos al año y es la 3era malignidad genitourinaria más frecuente. El sitio más común de metástasis es el pulmón mientras que el esqueleto ocupa el segundo lugar con una frecuencia que varía entre un 20% a un 35%. Se ha reportado una sobrevida de 12 meses en promedio luego de la aparición de metástasis óseas. Reporte del caso de un paciente con diagnóstico de cáncer renal de células claras y metástasis óseas (en columna, pelvis y ambos húmeros), que evoluciona con fractura de ambos brazos. El paciente es aceptado en un ensayo clínico de tratamiento con inmunoterapia y además se somete a una reducción y osteosíntesis bilateral de húmero con clavo endomedular, logrando la consolidación de ambas fracturas y, por ende, la regresión de la enfermedad.

Renal cell carcinoma is ranked 7th in frequent cancer worldwide with more than 3000.000 new cases per year, as well as it's ranked 3rd in frequent genitourinary malignancy. The most common area of metastases is lung followed by skeleton in second place. The frequency of skeleton metastases varies from 20% to 35%. A survival average time of 12 months is generally observed after the appearance of bone metastases. This case report is about a patient diagnosed with clear cell renal cancer and bone metastases (in the spine, pelvis and both humerus) that evolves with fracture of both arms. The patient undergoes a clinical trial with immunotherapy and also a reduction and osteosynthesis of both arms with intramedullary nail, achieving consolidation of both fractures and regression of the disease.

Meta-analysis of open reduction and internal fixation versus total elbow arthroplasty for distal humeral fracture in the elderly / 中国组织工程研究

BACKGROUND: The most common surgical procedure for the treatment of distal humeral fracture in the elderly is open reduction and internal fixation and total elbow arthroplasty. There is still a lack of systematic evaluation of the efficacy between the two methods, and further research is needed to better guide clinical work. OBJECTIVE: To compare the clinical efficacy of open reduction and internal fixation combined with total elbow arthroplasty in the treatment of elderly patients with distal humeral fractures. METHODS: The computer was used to retrieve information in databases such as PubMed, The Cochrane Library, EMBASE, Science Direct, CNKI, Wanfang, and VIP. An observational cohort study or randomized controlled trial was performed in the study of open reduction and internal fixation/total elbow arthroplasty for the treatment of elderly patients with distal humeral fractures. The search period was 1998-2018. Studies were read and screened; data were extracted and the quality of the study was assessed by two persons independently. Data analysis was performed using RevMan 5.3. RESULTS AND CONCLUSION: (1) A total of 10 studies were included in 1 069 patients. (2) Meta-analysis results showed that total elbow arthroplasty group was superior to the open reduction and internal fixation group in the incidence of total complications (OR=1.67, 95%C/: 1.19-2.35, P=0.003), Mayo elbow performance score at the last follow-up (MD=-12.68, 95%C/: -16.60 to -8.77, P 0.05). (4) These results confirmed that the total complication rate of the total elbow arthroplasty group was lower than that of the open reduction and internal fixation group, and the elbow joint function was better than that of the open reduction and internal fixation group. For elderly patients with distal humeral fracture, the degree of osteoporosis is different, and the articular surface is difficult to be effectively reset. The treatment of total elbow arthroplasty should be considered.

Meta-analysis of intramedullary nail and locking plate in the treatment of proximal humeral fractures / 中国组织工程研究

BACKGROUND: Proximal humeral fractures are one of the most common types of upper limb fractures In adults. With the aging of the population, the Incidence of proximal humeral fractures has been increasing in recent years, and its treatment is still controversial. OBJECTIVE: To compare the clinical efficacy of locking plate and intramedullary nail in the treatment of proximal humeral fractures using meta-analysis. METHODS: We retrieved PubMed, the Cochrane Library, Embase, CNKI, Wanfang, and VIP database to collect studies on intramedullary nail and locking plate in the treatment of proximal humeral fractures. In accordance with the inclusion and exclusion criteria, studies were included. Data were extracted from the included studies. Continuous variables (Constant score, operation time, blood loss) and binary classification variables (total complications, postoperative infection, screw cutout and internal fixation failure, humerus head necrosis, secondary surgery, and acromial impact) were analyzed, and considered as evaluation indexes for the meta-analysis. Statistical software Stata12.0 was used to analyze the data. RESULTS AND CONCLUSION: (1) A total of 8 articles and 891 patients were included, and 9 data were analyzed. (2) The amount of blood loss (SMD=-1.82, 95%C/: -2.77—0.87, P 0.05). (3) These results confirmed that intramedullary nailing is superior to locking plate in operation time and intraoperative blood loss in the treatment of proximal humeral fractures. The results were similar in total complication rate, common complication rate and postoperative recovery of shoulder joint function between the two groups.

Two-stage reverse total shoulder arthroplasty for treating postoperative deep infection after internal fixation of proximal humeral fracture / 中国修复重建外科杂志

Objective: To summarize the effectiveness of two-stage reverse total shoulder arthroplasty for treating postoperative deep infection after internal fixation of the proximal humeral fracture. Methods: Between June 2014 and January 2018, 17 patients with deep infection and humeral head necrosis or bone nonunion after internal fixation of proximal humeral fractures were treated. There were 8 males and 9 females, aged from 52 to 78 years (mean, 63.8 years). The infection occurred at 19-66 months after the initial internal fixation (mean, 34.8 months). Microbial culture of joint fluid was positive in 14 cases and negative in 3 cases. The preoperative Constant score, American shoulder and elbow surgeons (ASES) score, and visual analogue scale (VAS) score were 36.41±8.65, 31.06±7.43, and 7.29±0.99, respectively. The preoperative ranges of forward flexion, abduction, external rotation were (45.88±12.46), (42.18±12.31), and (16.76±4.92)°, respectively. The preoperative range of internal rotation was buttock in 9 cases, lumbosacral joint in 3 cases, L 3 in 5 cases. At the first-stage surgery, the thorough debridement was done and the antibiotic-impregnated bone cement spacer was placed after the removal of internal fixation. After the infections disappeared, the two-stage reverse total shoulder arthroplasty was performed. The mean interval between the two procedures was 4.2 months (range, 3.0-6.5 months). Results: All the incisions healed primarily and no complications such as recurrent infection or vascular nerve injury occurred. All patients were followed up 15-32 months (mean, 22.0 months). At last follow-up, the ranges of forward flexion, abduction, and external rotation were (109.00±23.66), (98.53±16.92), (41.41±6.82)°, respectively; and the range of internal rotation was lumbosacral joint in 5 cases, L 3 in 8 cases, T 12 in 4 cases. The range of motion of shoulder joints at last follow-up was significant improved when compared with the preoperative range of motion ( P<0.05). The Constant score (64.88±8.70), ASES score (65.18±8.10), and VAS score (2.94±1.25) were significantly superior to the preoperative scores ( P<0.05). X-ray films showed that no prosthesis loosening occurred. Conclusion: Two-stage reverse total shoulder arthroplasty is an effective treatment for the postoperative deep infection after internal fixation of the proximal humeral fracture, which has advantages of low risk of infection recurrence, good shoulder function, and satisfactory short-term effectiveness.

Research progress in treatment of proximal humeral fracture with fibular allograft and locking plate / 中国修复重建外科杂志

Objective: To review the research progress in the treatment of proximal humeral fractures with fibular allograft and locking plate. Methods: The literature about the treatment of proximal humeral fractures with fibular allograft and locking plate was reviewed and analyzed from the aspects such as the biomechanics, imaging prognosis, and clinical prognosis. Results: Fibular allograft and locking plate can provide effective medial support for proximal humeral fracture and increase the strength of internal fixation system. Compared with locking plate, fibular allograft combined with locking plate can maintain better humeral neck-shaft angle and the humeral head height after operation in the treatment of proximal humeral fractures, and has better shoulder mobility and shoulder joint function, and does not increase the risk of complications. Conclusion: Fibular allograft combined with locking plate may be a new and effective treatment for proximal humeral fractures. However, the long-term follow-up results are insufficient, the final outcome of fibula is uncertain, and the long-term potential adverse reactions caused by this treatment are still indefinite.

Progress on diagnosis and treatment of low transcondylar fractures of distal humerus / 中国骨伤

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.

Comparison of emergency versus selective surgical operations for extra-articular fractures of distal radius complicated with dorsal displacement and comminuted metaphysis in elderly females / 中华创伤骨科杂志

Objective To compare the functional outcomes between emergency operation and delayed selective operation for extra-articular fractures of distal radius complicated with dorsal displacement and comminuted metaphysis in elderly females.Methods Included for this study were 60 elderly female patients who had been treated at Department of Orthopedic Trauma,The Second People's Hospital of Shenzhen from March 2016 to March 2017 for extra-articular fractures of the dorsally displaced distal radius with a volar locking plate.They were all female,aged from 65 to 80 years (average,73.8 years).Of them,30 received surgical operation on the day or the next day after injury (emergency group) and the other 30 did 5 to 15 days after surgery (mean,8 days) (selective group).Follow-ups were conducted at 4,12 and 48 weeks after surgery to assess the ranges of motion (ROMs) of the wrist and forearm,grip strength (GS),the Disability of Arm,Shoulder and Hand (DASH) scores and complications.Results The 2 groups were comparable because there were no significant differences between them in their preoperative general data (P ＞ 0.05).A 4 weeks after operation,the ROMs,GS and DASH scores were all significantly improved in both groups,but the ROM of dorsal extension (49.6° ± 4.1°),ROM of volar flexion (58.6°± 3.5°),ROM of supination (78.1° ± 7.5°),ROM of pronation (81.4°± 7.0°),GS (58.5％ ± 11.2％) and DASH scores (17.3 ± 7.9) in the emergency group were all significantly better than those in the selective group (37.0° ± 6.3°,45.1 ° ± 3.6°,70.7 ° ± 9.6°,67.1 ° ± 10.3°,37.3％ ±9.1％ and 32.5 ± 9.6,respectively) (all P ＜ 0.05).At 12 weeks after operation,the ROM of dorsal extension (64.8° ± 7.9°),ROM of volar flexion (70.5°± 9.7°),GS (80.4％ ± 9.9％) and DASH scores (7.7 ± 4.9) in the emergency group were significantly better than those in the selective group (41.2°± 7.0°,61.6°±10.9°,66.9％ ±18.2％ and 14.2±7.3,respectively) (P ＜0.05),but there were no significant differences between the 2 groups in ROM of supnition or pronation (P ＞ 0.05).At 48 weeks after operation,there were no significant differences between the 2 groups in ROMs,GS or DASH scores (P ＞ 0.05).Postoperatively,superficial infection happened in one case and the extensor pollicis longus muscle tendon was ruptured in another in the emergency group.Conclusion In the elderly women with dorsally displaced extra-articular fracture of the distal radius,emergency surgery with a volar locking plate may lead to better functional recovery within 12 weeks post-surgery than the elective or delayed surgery.

Biomechnical stability of proximal humeral fracture fixated by a locking plate plus different fibular allografts / 中华创伤骨科杂志

Objective To investigate the ability of locking plate construct plus fibular autograft that varies in way of augmentation to withstand varus stresses in a model of proximal humeral fracture.Methods Wedge osteotomy was conducted in the humeral surgical necks of 12 shoulders from 6 cadaveric specimens to create models of proximal humeral fracture.There were 3 males and 3 females;their average age at death was 83 years (from 75 to 87 years).The 12 left and right cadaveric humeri were randomly divided into equal groups A and B (n =6) for autogenous iliac bone graft.All the fibular autografts were harvested without distinction from the thinnest and even part of the fibular shaft.A fibular autograft of 8 cm was placed vertically in group A while a fibular autograft of 6 cm was placed slantly in group B.After the fractures were fixated with the proximal humerus internal fixation locking system (PHILOS),varus stress was repeatedly applied to the proximal humerus until the internal fixation failed in the fracture model.The 2 groups were compared in terms of number of compression,number of compression leading to 1 mm deformation,and average shape variable after each press.Results Cut-out of the lateral cortex of the humeral head by the humeral screw and plate loosening to different extents were observed in both groups.The number of compression leading to internal fixation failure was 31,338 ± 5,994 for group A and 30,608 ± 8,015 for group B;the number of compression leading to 1 mm deformation was 2,808 ± 1,501 for group A and 3,153 ±2,024 for group B;the average shape variable after each press was 0.52 ±0.39 μm/time for group A and 0.53 ±0.47 μm/time for group B.All the above comparisons between the 2 groups showed no significant differences (P ＞ 0.05).Conclusion As locking plate construct plus slant fibular autograft augmentation provides no more strength to withstand repetitive varus stresses than locking plate construct plus vertical fibular autograft augmentation,it is not necessary to adopt the former way of augmentation in clinic practice for proximal humeral fracture.

Modified Mclaughlin procedure combined with locking plate for posterior shoulder dislocation with fracture / 中国骨伤

OBJECTIVE@#To study clinical effects of modified Mclaughlin procedure combined with locking plate for posterior shoulder dislocation with proximal humeral fracture which area of femoral head injury less than 40%.@*METHODS@#From July 2012 to June 2017, 7 patients with posterior shoulder dislocation were treated, including 5 males and 2 females; aged from 37 to 53 years old. Three patients combined with split of humerus head and 4 patients combined with humerus surgical neck fracture. All patients treated with modified Mclaughlin procedure combined with locking plate. Motion of shoulder joint after operation was observed, postoperative UCLA score was used to evaluate clinical effects.@*RESULTS@#Seven patients were followed up from 10 to 33 months. The motion of anteflexion and up-lift ranged from 130° to 170°, the motion of extorsion ranged from 45° to 75°, the motion of abduction ranged fron 105° to 150°, and the internal rotation was between L₃ to buttock. UCLA score ranged from 29 to 34; and 1 patient reached excellent, and 6 patients good.@*CONCLUSIONS@#The modified Mclaughlin procedure combined with locking plate showed satisfying result for posterior shoulder dislocation combined with fractures. However, the internal rotation of shoulder could be compromised.

Humerus Shaft Fractures Occurring in Fly Fishing Boat Riding: Injury Scene Analysis / 대한스포츠의학회지

PURPOSE: The aim of this study was to analyze an injury scene during fly fish boat riding (FBR).METHODS: We conducted survey on 12 patients who had humerus shaft fractures during FBR between 2011 and 2016 at three university-based emergency rooms. Individual information, injury mechanism, classification of humerus shaft fracture, and combined injury were recorded from medical document and telephone interview.RESULTS: The injury happened when the kite was turned over and fall into the water in 10 patients (82%); the kite was turned over in the air in one patient (9%), and a leash between kite and boat was broken in one patient (9%). All patients showed 12-B1 or 12-B3 type distal humerus shaft fracture. And there were combined contralateral distal humeral shaft fractures in two patients, vertebral compression fracture in one patient, and radial nerve injury in four patients.CONCLUSION: Riding position and injury mechanism such as turning over may affect distal humerus shaft fractures with butterfly fragment during FBR.