Management of Supracondylar Humeral Fracture in Children / Manejo da fratura supracondiliana do úmero na criança

Abstract Supracondylar humeral fracture represents ~ 3 to 15% of all fractures in children. It is the fracture that most requires surgical treatment in the pediatric population. Advances in treatment and care have contributed to a reduction in the most dramatic complication: Volkmann ischemic contracture. Nevertheless, the risks inherent to the fracture remain. Absence of palpable pulse in type-III fractures is reported in up to 20% of the cases. Careful sensory, motor, and vascular evaluation of the affected limb is crucial in determining the urgency of treatment. Older children, male patients, floating elbow, and neurovascular injury are risk factors for compartment syndrome. Medial comminution can lead to varus malunion, even in apparently innocent cases. The recommended treatment of displaced fractures is closed reduction and percutaneous pinning. Technical errors in pin placement are the main cause of loss of reduction. There is enough evidence for the addition of a third lateral or medial Kirschner wire in unstable fractures (types III and IV). Medial comminution may lead to cubitus varus even in mild displaced fractures. Based on current concepts, a flowchart for the treatment of supracondylar humeral fracture in children is suggested by the authors.

Resumo A fratura supracondiliana do úmero representa cerca de 3 a 15% de todas as fraturas na criança, sendo a que mais requer tratamento cirúrgico na população pediátrica. Apesar de os avanços no tratamento e na assistência terem contribuído para uma redução drástica da complicação mais temida, a contratura isquêmica de Volkmann, os riscos inerentes à fratura permanecem. Ausência de pulso palpável em fraturas tipo III é reportada em até 20% dos casos. Uma cuidadosa avaliação sensitiva, motora e vascular do membro acometido é fundamental na determinação da urgência do tratamento. Crianças mais velhas, sexo masculino, cotovelo flutuante, e lesão neurovascular são fatores de risco para a síndrome de compartimento. A cominuição medial pode levar à consolidação em varo, mesmo nos casos aparentemente inocentes. O método de escolha para o tratamento da fratura desviada é a redução fechada e fixação percutânea. Os erros na fixação e posicionamento inadequado dos implantes são as principais causas de perda de redução. Já existem evidências suficientes para a utilização de um terceiro fio de Kirschner, lateral ou medial, nas fraturas instáveis (tipo III e IV). Baseado nos conceitos atuais, um fluxograma para o tratamento da fratura supracondiliana do úmero na criança é sugerido pelos autores.

Locking compression plate combined with medial buttress plate for the treatment of osteoporotic comminuted proximal humerus fractures / 中国骨伤

OBJECTIVE@#To explore clinical effect of lateral locking compression plate combined with medial buttress plate in treating osteoporotic comminuted fractures of proximal humerus.@*METHODS@#From May 2017 to December 2021, 12 patients with osteoporotic comminution of proximal humerus were treated by lateral locking compression plates combined with medial buttress plates, including 5 males and 7 females, aged from 55 to 78 years old, bone mineral density(BMD) less than -2.5 g/cm3, the time from injury to operation was from 2 to 6 days. According to Neer classification, 7 patients were type Ⅲ, 4 patients were type Ⅳ and 1 patient was type Ⅵ. Postoperative complications, fracture healing and internal fixation were observed and Constant-Murley score of shoulder joint was used to evaluate clinical effects at 6 months after operation.@*RESULTS@#Postoperative wound healed well at stage I. All patients were followed up from 6 to 18 months. Humeral head collapse and necrosis occurred in 1 patient and humeral head varus in 1 patient. No impact of shoulder joint, internal fixation loosening occurred. Constant-Murley score at 6 months ranged from 45 to 90 points, and 6 patients got excellent result, 3 good, and 3 poor.@*CONCLUSION@#Locking compression plate combined with medial buttress plate could effectively reconstruct medial humeral column support and enhance fracture stability, and receive satisfactory clinical results. However, no control group was established in this study, and function of shoulder joint has not been evaluated many times after operation, so it cannot dynamically reflect changes of shoulder joint function.

Complicaciones de fracturas supracondíleas humerales en niños / Complications of supracondylar humeral fractures in children

Resumen: Introducción: Las fracturas supracondíleas representan la causa más frecuente de las lesiones del codo pediátrico (64% de la población en niños menores de ocho años). Estas fracturas pueden presentar complicaciones como: A) complicaciones previas al tratamiento: 1) neurológicas, 2) vasculares y 3) síndrome compartimental. B) complicaciones posteriores al tratamiento: 1) precoces en los primeros días tras el tratamiento: pérdida de reducción, complicaciones neurológicas, vasculares, síndrome compartimental, infección de las agujas de Kirschner, 2) complicaciones tardías en el tratamiento: deformidad angular, pérdida de movilidad, miositis osificante, necrosis avascular de la tróclea, entre otros. Objetivo: Determinar la frecuencia de las complicaciones en fracturas supracondíleas humerales en menores de ocho años. Material y métodos: Se realizó un estudio retrospectivo y observacional de cohorte en pacientes menores de ocho años en el período de Marzo de 2014 a Febrero de 2018. Resultados: Se obtuvieron 277 pacientes con los siguientes porcentajes: 3.97% presentó lesiones de cúbito varo; 1.44%, lesiones neurológicas previas al tratamiento quirúrgico; 1.44%, complicaciones neurológicas precoces al tratamiento; 0.72%, infecciones de agujas de Kirschner; 0.72%, cúbito valgo y 0.36% con pérdida de la movilidad. Conclusiones: La complicación más frecuente de las fracturas supracondíleas de húmero en este estudio fue cúbito varo y complicaciones neurológicas previas al tratamiento.

Abstract: Introduction: Supracondylar fractures represent the most frequent cause of pediatric elbow injuries, at 64%, in children under eight years old. These fractures can present complications such as: A) Complications prior to treatment: 1) neurological, 2) vascular and 3) compartment syndrome. B) Complications after treatment: 1) early, in the first days after treatment: loss of reduction, neurological, vascular, compartment syndrome, infection of Kirschner wires. 2) Late complications in treatment: Angular deformity, loss of mobility, ossifying myositis, avascular necrosis of the trochlea, others. Objective: To determine the frequency of complications in humeral supracondylar fractures in less than eight years. Material and methods: A retrospective, observational cohort study was conducted in patients under 8 years of age during the period of March 2014 to February 2018. Results: 277 patients were obtained with the following percentages: cubitus varus 3.97%, neurological lesions prior to surgical treatment 1.44%, early neurological complications to treatment 1.44%, infections of Kirschner needles 0.72%, cubitus valgus 0.72%, loss of mobility 0.36%. Conclusions: The most common complication of humerus supracondylar fractures in this study was cubitus varus and neurological complications prior to treatment.

Continuous pain and swelling after humerus fracture in an 86-years-old woman / Dolor e inflamación continua posterior a fractura de húmero en una mujer de 86 años

Abstract: Metastases to bone are the most frequent cause of destructive lesions to the skeleton in adults. The tumours that are most likely to metastasize to bone are prostate (32%), breast (22%), kidney (16%), lung and thyroid. The typical distribution of metastatic lesions are to the spine, ribs, pelvis, and proximal limb girdles. The humerus is the second most common site for long bone metastases, behind only the femur in its frequency of involvement. It represents the 20% of all bony metastases. We present a clinical case of an 86 yo woman with a previous diagnosis of myofibroblastic sarcoma of the maxillaris who suffers a pathological fracture of the humeral shaft secondary to metastasis and was misdiagnosed and treated for a typical humeral fracture using and intramedullary pinning (Hackethal technique), producing the progression of the disease within the humeral shaft. Due to the end state of the disease (multiple metastases), we decided to perform a palliative treatment with radiotherapy. This particular case report does confirm that is very important to rule out a malignancy in cases of osteolytic or poorly marginated lesions, particularly in patients older than 40 years of age. Therefore, it is imperative that the treating physician has a rational and effective approach to the diagnostic evaluation and treatment of these patients in order to avoid a malpractice.

Resumen: Las metástasis del hueso son la causa más frecuente de lesiones destructivas del esqueleto en adultos. Los tumores que tienen más probabilidades de metastatizar a los huesos son próstata (32%), mama (22%), riñón (16%), pulmón y tiroides. La distribución típica de las lesiones metastásicas es a la columna vertebral, las costillas, la pelvis y las cinturas escapular y pélvica. El húmero es el segundo sitio más común para metástasis en huesos largos, sólo detrás del fémur en su frecuencia, representando el 20% de todas las metástasis óseas. Se presenta un caso clínico de una mujer de 86 años con diagnóstico previo de sarcoma miofibroblástico de mandíbula que sufre una fractura patológica de la diáfisis humeral secundaria a metástasis, se diagnosticó erróneamente y se trató como si fuera una fractura normal utilizando pinning intramedular (técnica de Hackethal), produciendo la progresión de la enfermedad dentro de la diáfisis humeral. Debido al estadio final de la enfermedad (metástasis múltiples), decidimos realizar un tratamiento paliativo con radioterapia. Este caso en particular confirma que es muy importante descartar una neoplasia maligna en casos de lesiones osteolíticas o mal delimitadas, particularmente en pacientes mayores de 40 años de edad. Por lo tanto, es imprescindible que el médico tratante tenga un enfoque racional y efectivo para la evaluación diagnóstica y el tratamiento de estos pacientes con el fin de evitar una mala práctica.

Pulse Oximetry for the Diagnosis and Prediction for Surgical Exploration in the Pulseless Perfused Hand as a Result of Supracondylar Fractures of the Distal Humerus

BACKGROUND: The management of the pulseless perfused hand in association with a supracondylar humerus fracture following operative stabilisation remains controversial. Previous authors have suggested the use of color-flow duplex monitoring, magnetic resonance angiography and segmental pressure monitoring as objective steps to ascertain blood flow following adequate internal fixation. We examine the use of the waveform of the pulse oximeter in objectively determining a perfused limb and in predicting the need for surgical exploration in patients who present with a pulseless perfused hand after operative stabilisation for supracondylar fracture of the humerus. METHODS: A retrospective review of all supracondylar fractures over a 60 month duration (2005-2009) in our instituition was performed. Each electronic record was reviewed and limbs which had absent radial pulse following admission were identified. X-ray films of each of the patients were reviewed. A search using the Pubmed database was performed with the following keywords, supracondylar humerus fracture, pediatric, pulseless, vascular injury, arterial repair. RESULTS: In this series of pulseless perfused hands following operative fixation of supracondylar fracture, a total of 26 patients were reviewed. All were Gartland grade III extension type fractures. Postoperative pulse oximeter waveforms were present in all but 4 patients. These patients subsequently had exploration of the brachial artery with significant findings. In the remaining 22 patients, waveforms were present and the child had return of the radial pulse soon after operative fixation without any further need for surgical exploration. At 24 months follow-up, all children were well with no neurovascular compromise. CONCLUSIONS: The presence of a waveform on a pulse oximeter is a sensitive and easily available modality in determining vascular perfusion as compared to other more complex investigations. The high sensitivity of this test will allow surgeons to objectively determine the requirement for surgical exploration of the brachial artery.

Complicações neonatais do diabetes mellitus gestacional ­ DMG / Neonatal complications of gestacional diabetes mellitus ­ GDM

O diabetes mellitus gestacional (DMG) está associado a um risco aumentado de complicações fetais, neonatais e no desenvolvimento a longo prazo. As taxas de aborto espontâneo, natimorto, mal formações congênitas e morbidade e mortalidade perinatal são maiores em filhos de mães diabéticas. As principais complicações neonatais são: macrossomia, hipoglicemia neonatal, deficiência de ferro, alterações da função cardiorrespiratória, hiperbilirrubinemia, anormalidades neurológicas, hipocalcemia, hipomagnesemia e policitemia. A macrossomia predispõe a lesões do parto, especialmente distócia de ombro, maior risco de lesão do plexo braquial, fraturas de clavícula ou do úmero, asfixia perinatal, e, menos frequentemente, hemorragia subdural e paralisia facial. O controle glicêmico rigoroso pré-concepção e durante a gestação associa-se com menor morbimortalidade perinatal. Assim, o controle do DMG representa tarefa de fundamental importância para impedir sequelas em neonatais. (AU)

The gestational diabetes mellitus (GDM) is associated with an increased risk of fetal, neonatal, and possibly long-term complications. The rates of spontaneous abortion, stillbirth, congenital malformations, and perinatal morbidity and mortality are higher in infants of a diabetic mother than in pregnancies with normal glycemic control. The main neonatal complications are: macrosomia, neonatal hypoglycemia, iron deficiency, changes in cardiac and respiratory function, hyperbilirubinemia, neurological abnormalities, hypocalcemia, hypomagnesemia and polycythemia. Macrosomia predisposes to birth injury, especially shoulder dystocia, increased risk of brachial plexus injury, clavicular or humeral fractures, perinatal asphyxia, and, less often, subdural hemorrhage and facial palsy. Strict glycemic control preconception and during pregnancy is associated with lower perinatal morbidity and mortality. Thus, GDM control is of paramount importance to prevent neonatal harm. (AU)

Anterior shoulder dislocation and ipsilateral humeral shaft fracture

Simultaneous dislocation of shoulder and humeral shaft fracture is a rare injury, and there is no clear protocol for its treatment. Herein we present a case of a 15-year-old boy, who suffered from a job-related accident and sustained fracture of humeral shaft associated with ipsilateral anterior shoulder dislocation and fracture of greater tuberosity 15 years ago. He received closed reduction of both injuries and coaptation plaster splint for four weeks, followed by Sarmiento splint at that time. Fifteen years after the injury, he has no problem related to the previous injury, and does not experience any episode of shoulder instability

Tratamento de fraturas e complicações pós-traumáticas do úmero com fixadores externos osteoline®: uma opção de tratamento / Treatment of post-traumatic humeral fractures and complications using the osteoline® external fixator: a treatment option

OBJETIVO: Avaliar os resultados obtidos no tratamento das fraturas diafisárias do úmero e suas complicações com o uso de fixadores externos uniplanares Osteoline®. MÉTODOS: Foram avaliados, retrospectivamente, os resultados radiográficos e funcionais de 78 pacientes com fraturas diafisárias do úmero tratados com a técnica de fixação externa uniplanar. A idade variou de 23 a 71 anos, com média de 47 anos. O sexo masculino foi predominante em 79 por cento dos casos. Dos 78 pacientes, 45 apresentavam fraturas expostas, 14 pseudartroses e seis falhas de síntese. Não houve nenhuma perda durante o seguimento, sendo que todos os pacientes receberam alta após a consolidação da fratura e recuperação funcional. Os resultados foram avaliados com base nos trabalhos de Catagni em bom, regular e mau. RESULTADOS: Observamos a consolidação da fratura em 98 por cento dos casos tratados com fixação externa uniplanar. Somente um caso de pseudartrose necessitou de conversão para fixação interna rígida e enxerto ósseo autólogo. Ao final do tratamento, todos os pacientes receberam alta com consolidação da fratura, sem dor e com boa função do membro. CONCLUSÃO: A fixação externa descrita no presente trabalho mostrou-se eficiente e segura como método de tratamento das fraturas diafisárias do úmero e suas complicações, preservando o status biológico local e propiciando movimentação passiva e ativa no pós-operatório imediato.

OBJECTIVE: To evaluate the results obtained from treatment of humeral shaft fractures and their complications using the Osteoline® uniplanar external fixator. METHODS: The radiographic and functional results from 78 patients with humeral shaft fractures treated using the uniplanar external fixation technique were retrospectively assessed. The patients' ages ranged from 23 to 71 years, with a mean of 47 years. Male patients predominated (79 percent). Out of the 78 patients, 45 presented open fractures, 14 presented pseudarthrosis and six presented synthesis failure. There were no losses during the follow-up and all the patients were discharged after fracture consolidation and functional recovery. The results were evaluated based on the studies by Catagni, as good, fair or poor. RESULTS: Fracture consolidation was observed in 98 percent of the cases treated with uniplanar external fixation. Only one pseudarthrosis case required conversion to rigid internal fixation and autologous bone grafting. At the end of the treatment, all the patients were discharged with consolidated fractures, without pain, and good limb function. CONCLUSION: The external fixation described in this paper was shown to be an efficient and safe method for treating humeral shaft fractures and their complications. It preserved the local biological status and enabled passive and active movement immediately after surgery.

Mieloma múltiplo com fratura no colo do úmero: relato de caso / Multiple myeloma with fracture in the neck of the humerus: a case report

O Mieloma Múltiplo (MM) é uma proliferação neoplásica dos plasmócitos. A proporção entre homens e mulheres é de 3:2, sendo mais comum em negros do que em brancos. A incidência aumenta com a idade e pouco se sabe sobre os fatores de risco para o aumento da incidência da neoplasia. Foi realizada uma breve revisão sobre MM e os benefícios do suporte nutricional em uma paciente de 49 anos que desenvolveu uma fratura de úmero e necessitou de internação em hospital público para tratamento de complicações relacionadas à doença.

Multiple myeloma (MM) is characterized by the neoplastic proliferation of a single clone of plasma cells in bone marrow. The proportion between men and women is 3:2, is more common in blacks than in whites. The incidence increases with age and little is known about risk factors for the increased incidence of the neoplasia. We performed a brief review of MM and the benefits of nutritional support in a 49 year old patient who developed a fracture of humerus and required hospitalization in public hospital for the treatment of complications related to the disease.

Management of supracondylar fractures in pediatric age group

The pediatric musculoskeletal system differs greatly from that of an adult. Although these differences diminish with age, they present unique injury patterns and challenges in the diagnosis and treatment of pediatric orthopedic problems. Pediatric bone is highly cellular and porous, and it contains a large amount of collagen and cartilage compared with adult bone. The larger amount of collagen leads to a reduction of tensile strength and prevents the propagation of fractures, whereas the abundance of cartilage improves resilience but makes radiologic evaluation difficult. The tensile strength of pediatric bone is less than that of the ligaments, so children are more likely to have bone injuries with mechanisms that would cause only ligarnentous injuries in adults. The periosteum of pediatric hone is comparatively more metabolically active than the adult periosteum, leading to rapid and large callus formation, rapid union of fractures, and a higher potential for remodeling. The periosteum is also thicker and stronger in children. This difference is responsible for some of the unique fracture patterns seen in children [1], [2]

Complicaciones en el tratamiento de las fracturas del húmero proximal / Complications in the treatment of fractures of the proximal humerus

Las complicaciones propias al tratamiento quirúrgico de las fracturas del húmero proximal son la rigidez articular, la necrosis aséptica de la cabaeza humeral, la consolidación de la fractura en posición defectuosa del foco fracturario. Se describe cada una de ellas y la manera más adecuada para prevenirlas.

La fractura suprancondílea del húmero cuando es quirúrgica / Supracondyleal fracture of humerus treated with surgery

Se realizó un estudio retrospectivo lineal por un período de 4 años, en un grupo de pacientes operados de fractura supracondílea del húmero en el Hospital Comunitario de Araguaína, Brasil. Los resultados se compararon con otro grupo de pacientes operados en el Hospital Comandante Pinares de Pinar del Río; en un período de tiempo similar. Ambos estudios se confrontaron con otra serie de pacientes tratados con reducción incruenta y yeso, atendidos en un año. Entre los resultados obtenidos se destacó que la fractura supracondílea del codo en niños, cuando es quirúrgica, no tiene buen efecto, que por lo general se obtienen con el tratamiento conservador. Las complicaciones que conspiraron contra la evolución fueron la rigidez, la limitación de la flexoextensión del codo y las infecciones posquirúrgicas, tanto de las partes blandas como del hueso. La osteosíntesis con alambres de Kirshner cruzados percutáneos fue la técnica de elección en las fracturas cerradas quirúrgicas.

A retrospective linear study was made for 4 years in a group of patients operated on from supracondylar fracture of the humerus in the Community Hospital of Araguaina in Brazil. The results were compared with those of another group of patients operated on at Comandante Pinares General Teaching Hospital in San Cristóbal municipality, Pínar del Río province in a similar period of time. Both studies were compared with another series of patients treated with closed reduction and a cast in a year. Some of the results showed that suprachondyleal fracture of elbow in children when treated with surgery has not as good effect as that of the conservative treatment generally. The complications going against recovery are rigidity or limited flexoextension of the elbow and the postsurgical infections infections both in soft parts and the bone. Osteosynthesis with crossed percutaneous Kishner's wires is the technique of choice in closed fractures needing surgery.

Un étude rétrospective linéale d'un groupe de patients opérés de fracture supracondylienne de l'humérus a été réalisée pendant 4 ans à l'hôpital communautaire à Araguaina, Brésil. Les résultats de cette étude ont été comparés avec ceux d'un groupe de patients opérés à l'hôpital général universitaire ½ Comandante Pinares ¼ à San Cristobal, Pinar del Rio, pendant une période de temps similaire. Ces deux études ont été aussi comparées avec une série de patients traités par réduction non-sanglante et plâtre au cours d'un an. On a remarqué que le traitement chirurgical de la fracture supracondylienne du coude chez les enfants, à l'opposé du traitement conservateur, n'est pas effectif. Les complications empêchant la correction de cette fracture sont la rigidité ou la limitation de la flexion et l'extension du coude et les infections post-opératoires, aussi des parties molles que des parties osseuses. L'ostéosynthèse aux fils de Kirshner croisés percutanés est le traitement de choix dans les fractures fermées ayant besoin de chirurgie.

Predicting cubitus varus in supracondylar fractures of the humerus by Baumann's angles in post reduction X-rays.

OBJECTIVES: The present study presents the technique to predict cubitus varus by post reduction Affected Side and Normal Side Baumann's angle difference (ASBA and NSBA) respectively. It intends to correlate the Baumann's angle to the final carrying angle of the injured elbow and presents the relevant mathematical clinical rule along with its prediction test characteristics. MATERIAL AND METHODS: Total 57 patients of 6.5+/-1.67 yrs, 22 were males and 8 females with 19/30 having left side injury. Isolated closed supracondylar fractures of humerus up to 5 days duration included and previous trauma, pathological fracture, other injury, elbow disease were excluded .30/57 completed >1 year follow-up. RESULTS: The Mean NSBA was 74.4+/-4.14 masculine. The mean normal side carrying angles (NSCA) were 9.56 +/- 2.2 masculine. The NSCA IQR (Inter Quartile Range) was 8.8-10 masculine. The ASBA was 79.9+/-9.1 masculine and affected side carrying angles (ASCA) was 0.20+/-8.7 masculine. The ASCA was best predicted by the difference between ASBA-NSBA (ASCA=3.87-0.65(ASBA- NSBA; F=15.91). At a cut off of 8.8 masculine (the lower limit of IQR for NSCA), a value >0 masculine for ASBA- NSBA was 80% predictive of cubitus varus. With pre test probability of varus at 70%, sensitivity was 0.94 and specificity 0.42. DISCUSSION: A prediction rule to predict the final carrying angle from ASBA NSBA difference is presented with a positive predictive value 0.80, specificity of 0.42, and sensitivity of 0.94 at a pre test probability of 0.70.When the diagnosis of cubitus varus is ASCA<8.8 masculine (Lower limit of the IQR for NSCA). CONCLUSION: If affected side Baumann's Angle - Normal Side Baumann's Angle is equal to or greater than 0 then there was 80% probability of having cubitus varus.

Validity and reliability test of parent's satisfaction in children with closed totally displaced supracondylar humeral fracture.

OBJECTIVE: To construct a questionnaire with validity and reliability test of the parents' satisfaction in children with closed totally displaced supracondylar humeral fractures and to compare the satisfaction score between group A, closed reduction and pinning and group B,open reduction and pinning. MATERIAL AND METHOD: The questionnaire was developed in 19 items 5 dimensions 1. The deformity 2. The doctor and nursing care 3. The cosmetic results 4. The range of motion of the elbow 5. The complications. The content validity was approved by 5 experts. In item score. From 1996 to 2004, the parents of the children with fractures were included.Sixteen parents gave the satisfaction score 2 times by 1 month interval after 6 months from the initial injuries. Nine parents were in group A and 7 parents were in group B. The reliability test by Cronbach's alpha was done. The satisfaction score was compared between group A and group B. RESULTS: The average item score was 0.86 (0.6-1). The Cronbach's alpha was 0.6482 in group A and 0.8037 in group B. The mean parents satisfaction score were 81.4 in group A and 70.0 in group B with statistical significant difference (P = 0.008). CONCLUSION: The questionnaire had good validity and reliability and could be helpful in decision making for the choice of the treatment. The closed reduction should be done first from the parent's point of view.

O emprego de hastes intramedulares bloqueadas no tratamento das fraturas diafisárias do úmero / Use of blocked intramedullary shaft for the treatment of humeral diaphyseal fractures

Estudamos os resultados clínicos e radiográficos de 31 pacientes portadores de fraturas diafisárias do úmero que foram operados com hastes intramedulares. Destes quatro apresentaram fraturas no local da inserção da haste e foram tratados com outro método. Dos 27 pacientes restantes o índice de consolidação foi de 96,1 por cento e que durou em média de 63,4 dias. Cinco queixaram-se de dor no ombro e em apenas um apresentou limitação da abdução. Paralisia temporária do nervo radial foi constatada em dois pacientes e pseudartrose em um que após 5 meses da cirurgia foi submetido a nova intervenção cirúrgica com o emprego de placa e enxerto ósseo autólogo. Concluímos que embora o emprego de hastes intramedulares bloqueadas apresentou alto índice de a via de acesso retrógrada pode levar a fraturas no seu ponto de entrada e via anterógrada com violação do manguito rotador pode gerar dores no ombro.

Surgical management of non-union of humeral diaphyseal fracture

To evaluate results of operative management of established non-union of humeral diaphysis with Dynamic compression plating [DCP] and Rush pinning with cancellous bone graft. Hospital based prospective study. Conducted at Department of Orthopedic Surgery, Jinnah Postgraduate Medical Centre, Karachi. A total of 21 patients of established un-united humeral diaphyseal fracture, between 15 to 65 years were included in this study. Patients underwent DCP and Rush pinning with bone grafting. Union of fractures clinico-radiographically and functional outcomes with Modified Constant and Murley Scale for shoulder and range of motion for elbow were considered. Among 18 available patients, 14/18 nonunion [77.8%] united within 5.1 +/- 1.8 months. For DCP group 11/13 [84.6%] united in 4.45 +/- 0.96 months. For Rush pin group 3/5 [60%] united in 7.7 +/- 2.1 month [P< 0.001]. Modified Constant and Murley Scale for shoulder assessment, for DCP group, excellent 05, good 03, fair for 03, poor 02 and for Rush pin group excellent 00, good 00, fair 02 and poor 03. Average range of motion of elbow joint 71.7 +/- 15.3% to 82.7 +/- 16.0%. Persistent non-union in four, radial nerve palsy in one, implant failure in two and shoulder impingement in one case noticed. No severe deep infection occurred. Dynamic compression platting with bone graft has shown significantly higher union rate for non-union of humeral diaphysis, while the functional outcome regarding shoulder [P<0.03] and elbow movements [P<0.05] are also proved to be significantly better in DPT as compared to Rush pin

Correction of cubitus varus by supracondylar lateral closing wedge osteotomy

The purpose of this study was to report our experience in treating cubitus varus with closing lateral wedge osteotomy. During the period 1996 to 2003, sixteen patients underwent supracondylar osteotomies for the correction of cubitus varus. The results of surgery were assessed in 12 patients. The indication for osteotomy was cubitus varus that was cosmetically unacceptable to either the child or the parents. All patients were treated with excision of an appropriate wedge of bone from the lateral side of the lower humerus and then closing the gap. Physical examinations for the gross carrying angle and the postoperative scar were assessed. Carrying angle and range of movement were used as criteria to categorize the results. Surgery results were excellent in 8, good in 3, and poor in one patient. The most important factor affecting the outcome in our series was the loss of fixation with recurrence of the deformity which occurred in one patient. The follow up ranged from 1 to 5 years, with an average of 2 years [mean 2.3 years]. Lateral closing wedge ostetomy is a safe and effective method of correcting cubitus varus deformity in the majority of patients

Prevençäo de cúbito varo e cúbito valgo na fratura supracondiliana do úmero / Prevention of cubitus varus and cubitus valgus from humerus supracondylar fractures

Num levantamento retrospectivo de 50 casos de fratura supracondiliana do úmero com desvio, em crianças, foi estudada a incidência e causa de cúbito varo e valgo residuais. Foi medido o ângulo de Baumann nas radiografias iniciais e finais. Houve um alto índice de deformidade residual em varo, quando o desvio inicial é para medial e varo e o antebraço é imobilizado em supinaçäo. Por outro lado, os casos com desvio inicial para lateral e valgo, quando mantidos com antebraço em supinaçäo, deram um bom índice de bons resultados; apareceram deformidades residuais em valgo, quando imobilizados em pronaçäo. Estabeleceu-se que, em casos de desvio inicial medial e varo, o antebraço deve ser imobilizado em pronaçäo e nos casos de desvio inicial para lateral e valgo usa-se a posiçäo de supinaçäo. Nos casos de desvios mistos o número de fraturas foi insuficiente para estabelecer regras. Säo analisados ainda o mecanismo de açäo da posiçäo do antebraço e da ædobradiçaÆ periostal.