The Baumann Angle: An Analysis from Theory to Practice / O ângulo de Baumann: Uma análise da teoria à prática

Abstract Objective To analyze how the Baumann angle (BA) is affected by inadequate radiographic inclinations. Methods The study was performed from radiographs of the distal humerus of children aged 3 to 10 years. The BA measurements performed by five observers were compared, and each radiograph was evaluated for its quality as "adequate" or "inadequate." The correlation between radiographic quality and the normality of the angles was evaluated. Results Sample was composed of 141 patients, 44% between 3 and 6 years of age and 56% between 7 and 10. We observed the BA between 52.01 and 89.82 degrees, with about 16% of the measurements outside the normal limits of the literature. A total of 33.3% of the evaluated radiographs were classified as "inadequate". On the BA measurements outside the normality parameter, we observed that its proportion was higher among images with inadequate radiographic quality (31.1 vs. 6.2%), and this difference was significant (p< 0.001). Conclusions The BA is a very variable measurement and, alone, it is unreliable for the evaluation of angular deformities of the pediatric elbow, with radiographic quality proven to be an important causal factor of this variability.

Resumo Objetivo Analisar como o ângulo de Baumann (AB) é afetado por inclinações radiográficas inadequadas. Métodos Estudo realizado a partir de radiografias do úmero distal de crianças de 3 a 10 anos. Foram comparadas as aferições do AB realizadas por cinco observadores, e cada radiografia foi avaliada quanto à sua qualidade em "adequada" ou "inadequada". A correlação entre a qualidade radiográfica e a normalidade dos ângulos foi avaliada. Resultados Amostra composta por 141 pacientes, 44% entre 3 e 6 anos e 56% entre 7 e 10. Observamos AB entre 52,01 e 89,82 graus, tendo cerca de 16% das medidas fora dos limites de normalidade da literatura. Um total de 33,3% das radiografias avaliadas foram classificadas como "inadequadas". Sobre as medidas do AB fora do parâmetro da normalidade, observamos que sua proporção foi maior entre as imagens com qualidade radiográfica inadequada (31,1% vs. 6,2%), tendo essa diferença se mostrado significativa (p< 0,001). Conclusões O AB é uma medida muito variável e, isoladamente, pouco confiável para a avaliação de deformidades angulares do cotovelo pediátrico, tendo a qualidade radiográfica se mostrado um fator causal importante dessa variabilidade.

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.

Análisis comparativo de la técnica de enclavado percutáneo transfocal, endomedular y fijación cruzada de las fracturas supracondíleas de húmero en niños del Hospital Baca Ortiz, Quito, Ecuador / Comparative analysis of the percutaneous transfocal, endomedular nailing technique and cross fixation of supracondíleas fractures of humer in children in the Baca Ortiz Hospital, Quito, Ecuador

La reducción cerrada y la fijación percutánea ha sido el gold standard para las fracturas supracondíleas de Gartland tipo II y III. La técnica de enclavado percutáneo transfocal endomedular (TEPTE) ha surgido como alternativa quirúrgica con los beneficios de no lesionar nervios importantes en la región del codo. El objetivo del presente estudio fue comparar los resultados funcionales y estéticos de niños con diagnóstico de fracturas supracondíleas de húmero Gartland tipo II y III, tratados con la TEPTE y la técnica de fijación cruzada (TFC). Se realizó un estudio retrospectivo, observacional, transversal, durante los meses de enero de 2017 a mayo de 2018 de niños con fracturas supracondíleas, tratados con el TEPTE (grupo uno) y TFC (grupo dos). Evaluamos la funcionalidad y la deformación mediante la escala de Flynn. Para el análisis estadístico, se utilizó el test Mann-Whitney para muestras independientes en el programa SPSS. Fue considerado como significativo valores de como p ≤ 0,05. Los resultados demostraron un valor de 4,500 con un p = 0,000, evidenciando diferencias significativas entre los resultados de ambas técnicas respecto a la perdida de movilidad y el ángulo de transporte, a favor de la TFC.

Closed reduction and percutaneous fixation has been the gold standard for Gartland supracondylar fractures type II and III. Percutaneous transfocal intramedullary nailing (TEPTE) has emerged as a surgical alternative with the benefits of not damaging important nerves. The aim of the present study is to compare the functional and aesthetic results of children diagnosed with Gartland humerus supracondylar fractures type II and III, treated with TEPTE and crossed fixation. A retrospective, observational, transverse cohort study was conducted during the months of January 2017 to May 2018 of children with supracondylar fractures, treated with TEPTE (group 1) and cross-fixation (group 2). We evaluate functionality and deformation using the Flynn Scale. For statistical analysis, the Mann-Whitney test was used for independent samples in the SPSS program. Values of p ≤ 0.05 were considered significant. The results showed a value of 4,500 with a p = 0.000, as p≤0.05, it indicates that there are significant differences between the results of both techniques, for the loss of mobility and the transport angle, in favor of the crossed technique, so that we conclude not TEPTE about crosslinking.

Periprosthetic humeral fractures after reverse shoulder arthroplasty. Case report / Fratura periprotética após artroplastia reversa do ombro. Relato de caso

ABSTRACT Periprosthetic fractures is a severe complication after joint replacement. The rapidly increase of reverse shoulder arthroplasty surgeries, periprosthetic humeral fractures, which are described as rare, may increase in the near future. We report the case of displaced humeral fracture bellow the stem of reverse shoulder prosthesis. The patient was an 85-year-old woman who had a total shoulder replacement 6 years previously. The surgical solution consisted of plate osteossynthesis and cerclage. This report describes an unprecedented case in Brazilian literature; and gives an overview of the existing literature including this injury classification.

RESUMO As fraturas periprotéticas do ombro representam uma grave complicação após a substituição da articulação. Devido ao rápido aumento do número de cirurgias de artroplastia reversa no ombro, as fraturas periprótese do úmero, descritas como raras, podem aumentar no futuro próximo. Descrevemos um caso de fratura desviada do úmero abaixo do componente umeral de uma artroplastia reversa. A paciente era uma mulher de 85 anos de idade, que tinha uma artroplastia reversa do ombro há 6 anos. O tratamento cirúrgico consistiu em osteossíntese com placa, parafusos e cerclagem. Os objetivos do presente trabalho foram reportar um caso inédito na literatura brasileira, e revisar a literatura existente e as classificações da lesão.

Risk Factors Associated with Distal Humeral Fractures: A Radiological Study of Nigerians Admitted at National Orthopedic Hospital; Igbobi; Lagos State; Nigeria

Aim: This study is aimed at investigating the possible risk factors associated with distal humeral fractures among Nigerians. Materials and Methods: The study was carried out retrospectively at the Department of Medical Records; National Orthopedic Hospital; Igbobi; Lagos State; Nigeria using Plain films of X-ray from a total number of 144 patients of ages from birth to 100 years (0-100 years); comprising of 88 males and 56 females. Results: It reveals that the age group 1-10 years were affected more than other age groups. This study also shows that fall is the main cause of distal humeral fractures (68.7) followed by road traffic accidents (27.8). The predominance of fracture of the left humerus in this study was statistically significant. Conclusion: Since distal humeral fracture is an issue of harsh economic consequences; various measures should be taken by all the parties involved so as to address the menace

Modified Combined Approach for Distal Humerus Shaft Fracture: Anterolateral and Lateral Bimodal Approach

BACKGROUND: Due to the anatomical nature of the radial nerve, dissection and attainment of an adequate operative field in mid to distal humerus fracture is dangerous and limited. We devised a combined anterolateral and lateral approach that ensures protection of the radial nerve. This is achieved by performing bimodal dissection of the proximal humerus anteriorly and the distal humerus laterally. METHODS: Thirty-five consecutive patients were treated using a combined anterolateral and lateral approach for a minimum follow-up period of 24 months. We analyzed time to bony union, time to return to daily work, range of motion, elbow joint function as assessed by the Mayo elbow performance index and complications. RESULTS: Radiologic bony union was observed at 11.2 weeks (range, 8 to 20 weeks) on average. Four cases of incomplete radial nerve palsy before surgery all recovered. Time to return to work was 10.2 weeks (range, 2 to 32 weeks) on average. The average range of motion of the elbow was 3.3degrees (range, 0degrees to 10degrees) of extension and 135.9degrees (range, 125degrees to 145degrees) of flexion. There were 21 cases of excellent and 13 cases of good or better recovery, comprising over 97.1% on the Mayo elbow performance index. There were no complications of radial nerve palsy, non-union, mal-union, or infection. CONCLUSIONS: Our a modified combined anterolateral and lateral approach is a clinically effective surgical method of achieving protection of the radial nerve and securing easy and firm internal fixation.

Outcome of supracondylar fractures of the humerus in children treated by closed reduction and percutaneous pinning.

Supracondylar fractures of humerus in children are common injuries. Displaced fractures are inherently unstable. Conservative treatment results in malunion. Open reduction and internal fixation (ORIF) is more invasive and recovery is prolonged. From September 2004 to September 2005, 102 displaced supracondylar fractures of humerus, aged between one and half year to 13 years, were treated using close reduction and percutaneous Kirschner (K) wire fixation under c-arm fluoroscopy. Seventy nine patients were treated by cross K-wires and in twenty three cases lateral two K-wires were put. Above elbow plaster of paris back slab was applied in all cases for at least four weeks. Back slab, K-wires were removed after four weeks and elbow range of motion exercise was started. Results were analyzed using Flynn's criteria. All patients were followed up to 14th week postoperatively. In cross K-wire group(N=79) 70.8% had excellent, 22.7% good, 3.8% fair and 2.5% had poor results at eight weeks follow up which was improved to 91.1% excellent, 6.3 good, 1.2% fair and 1.26% poor results at 14 weeks follow up. In lateral K-wire group (N=23) 70% had excellent, 21.7% good, 4.3% fair and 4.3% had poor result at eighth week which was improved to 91.3% excellent, 4.3% good, 4.3% fair and no poor result at 14th week follow up. Eight patients got superficial pin tract infection and seven patients sustained ulnar nerve injury post operatively. We recommend this procedure for displaced supracondylar fractures in children as it is safe and cost effective procedure with acceptable complication rates.

Fracture of supracondylar process of the humerus

The supracondylar process of the humerus is a rare skeletal anomaly, which is usually an incidental finding while an X-ray is done for some other purpose. The process can fracture resulting in pain and tender mobile swelling over the medial aspect of the arm, and consequent neurovascular symptoms, or entrapment neuropathies. The anomaly, which fractured in a clinical situation, is described, followed by a review of the literature

Closed reduction and percutaneous pinning of displaced supracondylar humeral fractures in children

Supracondylar fracture of the distal humerus is the most common elbow fracture in children [60% of elbow fractures]. The peak age for Supracondylar fractures is between 6 and 7 years. This fracture is classified into extension or flexion injuries based on radiologic appearance. Between November 2002 and August 2005 120 child in the age group between 4 years and 13 [with mean age 7.1 years] including 80 boys [67.7%] and 40 girls [33.3%] with left elbow involvement in 71 patients and right elbow in 49 patients with displaced Supracondylar humeral fracture were treated by closed reduction and percutaneous pinning under image intensifler control using crossed pins for fixation [1.6 or 1.8 K-wires].The follow up ranged between 9 and 12 months. The patients are assessed according to both functional [Range of Motion] and Cosmetic factors [Carrying angle] and the overall results were excellent in 89 cases [74.1%], good in 21 cases [17.5%],fair in 2 cases [1.7%] and poor in 8 cases [6.7%] losed Reduction and percutaneous pinning is safe, cost effective and allows direct assessment of the carrying angle of the extended elbow after fracture stabilization

Interlocking nailing of humeral shaft fractures. A retrospective study of 114 patients.

BACKGROUND: Fractures of the humeral shaft are relatively common injuries. Literature suggests that humeral shaft fractures represent approximately 3 % of all fractures. There are several modalities for the management of diaphyseal humeral fractures. The latest investigations emphasize the concept of minimal exposure and rigid fixation. AIM: The aim of the study is to evaluate the results of antegrade intramedullary nailing in humeral shaft fractures. DESIGN: A retrospective review. SETTINGS: Patients were treated in private hospital settings by 3 orthopaedics surgeon. MATERIAL AND METHODS: Between 1995 and 2003, the technique of antegrade locked intramedullary nailing with UHN in humeral shaft fractures was performed on 114 patients. Forty-two (36%) patients sustained multiple traumas, and 22 (19%) fractures were open. The outcomes were evaluated with a mean follow-up of 41 months. STATISTICAL ANALYSIS USED: Ranges of results given. RESULTS: In 109 fractures primary union observed. In the other five patients union achieved after removal of the nail and fixation with DCP and bone grafting. The average time for union was 13 weeks (range, 10-36 weeks). One hundred-five patients had excellent or satisfactory recovery of shoulder and elbow function. Complications included impingement due to proximal locking screws in two patients and prominent nail in three patients, transient postoperative radial nerve palsy in four patients. CONCLUSIONS: This study shows that antegrade locked nailing in humeral shaft fractures are reliable and also effective in multiply injured patients.

Treatment of non union of humerus using G. A. Ilizarov technique.

The management of the non union of humerus is one of the most challenging problems that the surgeon confronts in his practice. The procedures traditionally used are: I.M. Nailing, interlocking, plating, transplantation of allograft. In our series, 36 cases with non union has been treated by G.A. Ilizarov technique. The age range were: 21-62 years with an average of 32 years. The initial treatment were done by DCP, rush nails & plates with screw fixation. The duration of treatment ranged from 5-11 months (average 8 months). With the application of Ilizarov fixator a good range of elbow & shoulder motion were achieved. The average follow up period was 5 years with a range of 1-8 years. Union was achieved in all the 36 cases.

The open reduction and internal fixation of humeral diaphysis fracture treatment with a medial approach.

From 1995 to 2000, twenty-three patients with fracture of the humeral shaft were treated by medial approach and internal fixation using AO/ASIF plate and screws. Follow-up was possible for 21 fractures. There were 16 male and 5 females. The ages ranged from 16 to 55 years (mean, 29 years). The average period of follow-up was 4.5 months (range, 3-12 months). There was no evidence of implant failure and nonunion during follow-up. The average lack of complete extension of the elbow was five degrees. There was one case of transient radial nerve palsy. As such, the medial approach to humeral shaft and internal fixation with plate and screws for humeral diaphysis fracture was determined to be a viable technique.

Endoscopic bone graft for delayed union and nonunion

We performed endoscopic bone grafting for eight patients of delayed union and nonunion which developed after femoral and humeral shaft fractures. The mean interval from initial intervention to endoscopic bone grafting was 7.3 months. Six patients of delayed union and nonunion healed at 4.1 months on average. Two patients had unsatisfactory healing and eventually underwent non-endoscopic revisional surgery. There was no intraoperative on postoperative complication. Endoscopic bone grafting can be a less invasive alternative, obtaining rapid bone union in cases of compromised healing of the diaphyseal fracture.

The reconstruction twisted wire-screws for internal fixation of two- and three-part fractures of the proximal humerus.

Using the implants for internal fixation of the proximal humeral fractures has several problems which lead to complications and poor results of the fracture treatment. Because there is no suitable implant for internal fixation of the fracture. Therefore, the reconstruction twisted wire was developed in 1990 to improve the results of the fracture treatment. Between 1990 and 1994, the reconstruction twisted wire was used in 31 patients whose ages ranged from 18 to 90 years. Sixteen patients had displaced two-part surgical neck fractures. Fifteen patients had displaced three-part fractures. Postoperative follow-up ranged from two and a half years to five years and one month. All fractures healed. No avascular necrosis of the humeral head was observed at the follow-up. There was temporary subluxation of the shoulder joint in three patients and loosening of the screws in two patients with marked osteoporosis. One had a rupture of wire between the greater tuberosity and the shaft and loosening of the screw at the greater tuberosity and united with 10 degrees varus deformity. According to the functional scale proposed by Hawkins, 28 of the 31 patients achieved a "good" result and 3 patients had a "fair" result.

Repair of nonunion lateral humeral condyle: a case report.

Epiphyseal injury of the lateral condyle of distal humerus is found commonly in children. Complications following such an injury can result in nonunion with late development of angular deformity and ulnar nerve neuritis. Nonunion at this area is extremely troublesome and difficult to treat. Controversy exists as whether late open reduction and fixation can restore the anatomy of the elbow joint and improve the function. We describe a technique of corrective osteotomy to correct the cubitus valgus deformity and repair the nonunion. The patient was treated successfully with 4 years follow-up.

Plastic deformation of forearm.

The unusual occurrence of plastic deformation in an adult is described.

Fracture du 1/3 moyen de l'humerus : attitude chirurgicale; a propos d'un cas

Un jeune garcon a ete hospitalise a l'Hopital de Kintambo pour une fracture de l'humerus gauche deplace. Le traitement a consiste a une immobilisation platree. La radiographie de controle faite visualise une fracture de l'humerus gauche mal reduite et le patient a ete transfere dans le service d'orthopedie et de traumatologie de la Clinique kinoise. Apres examens cliniques et radiographiques; un traitement chirugical a ete decide