Resultados funcionales y radiográficos de la prótesis reversa y la reinserción del troquíter en pacientes con fracturas de húmero proximal / Functional and radiologic outcomes of reverse shoulder arthroplasty and greater tuberosity reattachment in proximal humerus fractures

Objetivo: Comunicar los resultados funcionales y radiográficos de pacientes tratados con prótesis reversa por fracturas complejas. El objetivo secundario fue determinar la relación entre rangos de movilidad y puntaje ASES con la evolución radiográfica del troquíter. Materiales y Métodos: Se incluyeron 16 pacientes >65 años, tratados con prótesis reversa y reinserción del troquíter, entre 2013 y 2017, operados antes de las 4 semanas del trauma y con un seguimiento mínimo de 2 años. Se consignaron el puntaje ASES y el rango de movilidad activa. En las radiografías, se evaluaron la posición y la consolidación del troquíter, y se registraron las complicaciones y su tratamiento. Resultados: La media de la edad fue 74.5 años (RIC 66-78.5), 11 (69%) eran mujeres. Once fracturas (69%) eran a 4 fragmentos y 5, luxofracturas a 4 fragmentos. La media entre el trauma y la cirugía fue 9.4 días y el seguimiento, 29.5 meses. En 9 casos (56%), el troquíter presentó consolidación. Rotación interna: 5 pacientes alcanzaron la región glútea con el pulgar; 4, la vértebra T12; 4, la vértebra L3; 3, la T7. Las medianas de rotación externa y flexión anterior fueron 30° (RIC 17,5-40) y 100° (RIC 87,5-160). El puntaje ASES promedio fue 78,3 (RIC 63,3-87,4). No hubo una asociación estadísticamente significativa entre la evolución del troquíter y la flexión anterior y el puntaje (p = 0,24 y 0,52, respectivamente). Conclusión: La prótesis reversa en fracturas agudas con reinserción de las tuberosidades puede llevar a buenos resultados funcionales. No se encontró relación entre la consolidación del troquíter y el puntaje ASES. Nivel de Evidencia: IV

Objective: To report functional and radiologic outcomes of reverse shoulder arthroplasty (RSA) in patients with complex proximal humeral fractures. A second objective was to assess the relation between the greater tuberosity healing and the range of motion (ROM) and the American Shoulder and Elbow Surgeons (ASES) score. Materials and Methods: Sixteen patients treated between 2013 and 2017, older than 65 years old, operated before 4 weeks after the trauma, and with a minimum of 2-year follow-up were included. ASES scores and active ROMs were recorded. Greater tuberosity and the prosthesis position and healing were radiologically evaluated, and the complications and treatment were recorded. Results: The median age was of 74.5 years (IQR 66-78.5), 11 patients were females (69%). According to Neer classification, 11 cases were four-part fractures and 5 were four-part fracture-dislocations. The average time between trauma and surgery was 9.4 days, and the average follow-up was of 29.5 months. The greater tuberosity was healed in 9 cases (56%). Internal rotation: 5 patients (31.25%) were able to reach up with their thumbs to gluteal level, 4 (25%) to T12, 3 (18.75%) to T7, and 4 (25%) to L3. The medians for external rotation and forward flexion were 30° (IQR 17.5°-40°) and 100° (IQR 87.5°-160°). The average ASES score was of 78.3 (IQR 63.3-87.4). There was no significant statistical relation between greater tuberosity healing and forward flexion or ASES score (P=0.24 and P=0.52, respectively). Conclusion: The use of reverse prostheses for complex fractures with greater tuberosity reattachment could lead to good functional outcomes, low complication rates and reoperations. There was no significant statistical relation between ASES score and greater tuberosity healing or failure to heal. Level of Evidence: IV

An anterior neurovascular interval approach to coronal shear fractures of the distal humerus: a prospective clinical study with short- to mid-term follow-up

SUMMARY OBJECT: To explore the treatment effect of the anterior medial neurovascular interval approach to coronal shear fractures of the distal humerus. METHODS: This prospective study included two female patients who were 30-64 years old, with a mean age of 47 years. Fractures were caused by falling from a bicycle. The time between the injury and operation was 1-2 days, with a mean time interval of 1.5 days. Two patients with coronal shear fracture of the distal humerus were treated with open reduction and internal fixation using anterior neurovascular interval approach. RESULTS: There were no intraoperative and postoperative neurological and vascular complications or infections, and the fracture was united. At 12 months after the surgery, the patient returned to work without pain, and with a normal range of motion for elbow and forearm rotation. The X-rays revealed excellent fracture union, no signs of heterotopic ossification, and no traumatic arthritis. According to Mayo's evaluation standards for elbow function, a score of 100 is excellent. CONCLUSIONS: The application of the anterior neurovascular interval approach of the elbow in the treatment of shear fracture of the articular surface of the distal humerus, particularly the trochlea of the humerus, can reduce the stripping of the soft tissue.

RESUMO OBJETIVO: Explorar o efeito do tratamento com uma abordagem anterior do intervalo neurovascular médio para fraturas de cisalhamento coronal da porção distal do úmero. METODOLOGIA: Este estudo prospectivo incluiu duas pacientes do sexo feminino de 30-64 anos de idade, com idade média de 47 anos. As fraturas foram causadas por quedas de bicicleta. O tempo entre a lesão e a operação foi de 1-2 dias, com um intervalo de tempo médio de 1,5 dias. Duas pacientes com cisalhamento coronal da porção distal do úmero foram tratadas com redução aberta e fixação interna utilizando a abordagem anterior do intervalo neurovascular. RESULTADOS: Não houve complicações neurológicas e vasculares intra e pós-operatórias, nem complicações ou infecções, e a fratura foi unida. Após 12 meses da cirurgia, as pacientes retornaram ao trabalho sem dor e com uma amplitude normal de movimento de rotação do antebraço e cotovelo. Os raios-X revelaram excelente união das fraturas, sem sinais de ossificação heterotópica e sem artrite traumática. De acordo com as diretrizes da clínica Mayo para avaliação da função do cotovelo, uma pontuação de 100 é considerada excelente. CONCLUSÃO: A aplicação da abordagem anterior do intervalo neurovascular do cotovelo no tratamento de uma fratura de cisalhamento da superfície articular da porção distal do úmero, especificamente da tróclea do úmero, pode reduzir o desgaste do tecido mole.

Applicability of polyamide 12 intramedullary locked rods in the stabilization of induced humeral fracture in cockerels (white plymouth rock) - in vivo study / Aplicabilidade da haste intramedular bloqueada de poliamida 12 na estabilização de fratura umeral induzida em galos (Plymouth Rock Branca) - estudo in vivo

The aim of this study was to evaluate the use of polyamide 12 intramedullary rods in osteotomized humerus in cockerels (White Plymouth Rock) and analyze, by radiography and histopathology, bone consolidation and the formation of bone callus. Ten cockerels were subjected to transverse osteotomy of the right humeral diaphysis followed by the insertion of polyamide 12 locked rods, with two nails in each bone fragment. Radiographies obtained at the immediate pre and post-operative period, and every 7 days for 3 months revealed no perioperatory complications. Radiography revealed a radiopaque bone callus between the 4th and 5th week post-surgery. Histopathology detected an amphophylic material (polyamide 12 rod) in the intramedullary region and the proliferation of highly vascularized connective tissue between the rod and the cortical bone. This connective tissue was highly cellular with differentiation into osteoblasts. The collagen fibers varied from loose to dense and a differentiated bone matrix, containing osteocytes in gaps and the development of bone marrow, was also observed; indicating the formation of a bone callus without signs of implant rejection. The polyamide 12 intramedullary rod was effective in the stabilization of the fractures used in this experimental model, with no rejection reaction for at least 90 days.(AU)

O presente estudo teve como objetivo avaliar a implantação de hastes intramedulares de poliamida 12, em úmeros osteotomizados de galos (Plymouth Rock Branca), bem como avaliar a consolidação óssea, por meio da verificação da formação de calo ósseo, analisando exames radiográficos e histopatológicos. Os galos foram submetidos à osteotomia transversa da diáfise do úmero direito, sendo implantadas posteriormente as hastes de poliamida 12 bloqueada com dois parafusos em cada fragmento ósseo. Após o procedimento cirúrgico, foram realizadas radiografias nos momentos pré e pós-operatório imediato e, posteriormente, a cada sete dias, durante três meses, até a realização da eutanásia. Não houve complicações perioperatórias. Ao exame radiográfico, os animais apresentaram formação de calo ósseo radiopaco entre a quarta e quinta semanas de pós-operatório. Ao exame histopatológico, foi possível notar, em todos os animais, presença de material anfofílico (haste de poliamida 12) ocupando a região intramedular óssea, e entre a haste e as corticais ósseas, proliferação de tecido conjuntivo altamente vascularizado. Tal tecido apresentou-se altamente celular com diferenciação em osteoblastos. Notaram-se também fibras colágenas, variando de aspecto frouxo a denso, e observou-se formação de matriz óssea diferenciada com osteócitos em lacunas e formações de medula óssea, denotando formação de calo ósseo sem sinais de rejeição do implante. A haste intramedular de poliamida 12 foi eficaz para estabilização das fraturas utilizando-se esse modelo experimental, sem reação de rejeição pelo período de 90 dias.(AU)

Transposition of latissimus dorsi to the elbow inorder to elbow make extention and homeros coverage

Because of some reasons local flaps are not suitable in the cases with upper extremity injuries, lattismus dorsi flaps are recommended in these cases. We present a twenty eight years old male with upper extremity trauma with type 3C left homerus fracture and destruction of triceps. Reconstruction made using lattismus dorsi flap and in a two month follow up we find a 30° Extention lag comparing to the right elbow while the patient had cosmetically satisfaction

Resultados clínicos y radiológicos de las fracturas de húmero proximal tratadas mediante enclavado intramedular, así como posibles factores de riesgo de un mal resultado / Clinical and radiological results of fractures of the proximal humerus treated with intramedullary nailing and possible risk factors of a poor outcome

Antecedentes: Evaluar los resultados clínicos y radiográficos de las fracturas de húmero proximal tratadas mediante fijación con clavo intramedular, así como los factores de riesgo asociados a un mal resultado. Métodos: Se han revisado retrospectivamente a pacientes con un seguimiento mínimo de un año. Se realizó una revisión clínica objetiva mediante la escala de Constant y subjetiva del grado de satisfacción, EVA y valoración de discapacidad mediante la escala de DASH. Radiológicamente, los enfermos fueron revisados mediante radiografías AP y axial en el plano escapular. Resultados: Se incluyeron 46 pacientes, 91.3% se presentó clínicamente satisfechos con el tratamiento. La movilidad media fue de 155º de flexión, 60º de rotación lateral y rotación medial. La puntuación media del Constant fue de 70 y del DASH de 15 puntos. Se encontraron diferencias significativas en cuanto al Constant en menores de 60 años, no siendo éstas significativas con el tipo de fractura o teniendo en cuenta el DASH. Radiográficamente, la tasa de consolidación fue de 95.7%, apreciándose dos casos de seudoartrosis. En 17 pacientes se observó una consolidación en varo (38.6%). Se encontraron diferencias funcionales comparando los pacientes con consolidación en varo y consolidación anatómica. Discusión: La fijación mediante clavo intramedular es un tratamiento efectivo para las fracturas de húmero proximal, sobre todo para fracturas en dos partes del cuello quirúrgico. La alta tasa de colapso en varo, sobre todo en fracturas con gran conminución, puede acarrear una disminución en la movilidad.

Background: To assess the clinical and radiological results of fractures of the proximal humerus treated with intramedullary nail fixation as well as the risk factors associated with a poor outcome. Methods: Patients were analyzed retrospectively with a minimum follow-up of one year. An objective clinical assessment was made using the Constant scale, the subjective satisfaction scale, VAS, and the DASH scale to measure disability. The radiological assessment included AP and axial X-rays in the scapular plane. Results: Forty-six patients were enrolled. The clinical assessment showed that 91.3% of them were satisfied with treatment. Mean mobility was 155º of flexion, 60º of lateral and medial rotation. The mean Constant score was 70 and the DASH score was 15. Significant differences were found in the Constant score in individuals under 60 years of age, but they were not significant considering the type of fracture or the DASH score. X-rays showed a healing rate of 95.7%, with two cases of pseudarthrosis. Varus healing was observed in 17 patients (38.6%). Functional differences were found when patients with varus healing were compared with those who had anatomical healing. Discussion: Fixation with intramedullary nailing is an effective treatment for fractures of the proximal humerus, particularly for two-segment fractures of the surgical neck. The high rate of varus collapse, particularly in very comminuted fractures, may lead to decreased mobility.

Luxación posterior de hombro: inusual presentación de Bankart reverso asociada a fractura osteocondral anterior de la cabeza humeral / Posterior shoulder dislocation-: unusual presentation associated reverse Bankart previous osteochondral fracture of the humeral head

La luxación traumática posterior del hombro representa un grupo pequeño dentro de las luxaciones de la articulación gleno-humeral, la cual se puede asociar a distintos tipos de fracturas. La fractura por impactación de la superficie anterior de la superficie articular (lesión de Hill-Sachs reversa) es la típica resultante de la luxación posterior. En el siguiente trabajo se describe un caso infrecuente y poco descripto en la literatura, de Bankart Reversa asociada a una fractura osteocondral de la cabeza humeral, y su resolución por medio de una técnica combinada artroscópica y mini invasiva, que utiliza el concepto de viabilidad del fragmento osteocondral libre en la cavidad articular, y un inusual sistema de fijación con el empleo de suturas en puente mediante la utilización de arpones.

HAGL: avulsión humeral de los ligamentos glenohumerales: diagnóstico y reparación artroscópica / Humeral avulsion of the glenohumeral ligament (HAGL): diagnosis and arthroscopic repair

La patología relacionada con la inestabilidad anterior traumática del hombro corresponde a un espectro tanto de lesiones óseas, como de lesiones de partes blandas. La avulsión humeral de los ligamentos glenohumeral (por sus singlas en ingles: HAGL) es una causa poco frecuente de inestabilidad anterior de hombro. Se debe sospechar esta lesión en pacientes con recidivas luego de una reparación o en pacientes con inestabilidad anterior en ausencia de lesión de Bankart. La evaluación artroscópica de la articulación glenohumeral puede identificar la mayoría de las lesiones de HAGL. La reparación artroscópica sigue siendo un procedimiento complejo debido a la difícil angulación para abordar la parte inferior del cuello humeral. A pesar de ello, los resultados iniciales son alentadores.

Displaced supracondylar fractures of humerus in children treated with open reduction and cross k-wire fixation

To describe the outcome of open reduction and cross K-wire fixation through a triceps non disturbing posterior approach used in the treatment of type III supracondylar fractures of humerus in children. This descriptive study was conducted at Orthopaedics Unit District Headquarter Hospital Timergara Dir Lower from December 2005 to September 2008. Fifty children with type III supracondylar fractures, who presented within one week of injury, and in whom satisfactory reduction was not possible by closed means, were evaluated clinically and with radiographs before surgery and at follow up. All these patients underwent open reduction and crossed K-wire fixation through a triceps non disturbing posterior approach. Anatomical reduction of the fracture was achieved and fixation was carried out by two cross K-wires. The patients were regularly followed up and at one the results were measured according to the criteria of Flynn. The mean age was 10+6 years. In 3[6%] patients the fracture was flexion and in 47[94%] the fracture was of extension variety. Traditional bone setters were the initial treatment provider for 54% of the patients. The average delay in presentation was 31 hours. Four patients have ipsilateral fractures of the distal radial epiphysis. Postoperatively 9[18%] patients developed pin track infection, and only 2[4%] had transient neuroprexia of the ulnar nerve. Open reduction and cross K-wire fixation through a posterior triceps non disturbing approach can be satisfactorily used in the treatment of type III supracondylar fractures that could not be reduced satisfactorily by closed methods

Auditing the use of percutaneous pinning as a technique of fixation of unstable humeral supracondylar fractures in Sudanese children

Supracondylar fractures of the humerus in children are commonly treated with closed reduction and percutaneous pin fixation. There has been controversy regarding the optimal pin configuration in the management of supracondylar humeral fractures in children. To evaluate the effectiveness of closed percutaneous pinning [P.C.P.] as a treatment modality of supracondylar fractures of humerus in Sudanese children. Hospital based prospective study conducted in Khartoum teaching hospital during the period from July 2006 to March 2007. It included all children less than 14 years of age, with closed type III supracondylar humeral fracture, extension variant, who treated by closed reduction and percutaneous cross pinning. 34 patients were included in the study. Their age ranged between 4 -12 years, with mean +/- SD of 7.68 +/- 2.34 years. Twenty-four [70.6%] fractures were fixed with crossed pins whereas ten [29.4%] fractures with two lateral pins. The two lateral pins fixation was found to be significantly associated with loss of reduction [p=0.004]. PCP is safe and effective with good functional outcome in treatment of unstable supracondylar fractures. The best wires configuration is that which gives ability to extend elbow with much stability

No consolidaciones del humero proximal. Estabilizacion con clavo-placa bloqueado de 90º / Nonunion of the proximal humerus. Stabilization with 90º locked blade plates

Introducción: La obtención de una fijación estable y duradera en las no consolidaciones del húmero proximal es demandante. Materiales y métodos: Entre 2004 y 2007 evaluamos prospectivamente a 12 pacientes tratados con clavo-placa bloqueados por presentar no consolidaciones del tercio proximal del húmero. La edad de los pacientes promedió 59 años. Nueve fueron atróficas, dos oligotróficas y una hipertrófica. El tiempo entre el traumatismo inicial y la cirugía definitiva promedió 21 meses. Ocho pacientes habían tenido cirugías previas. Resultados: El seguimiento promedió 19 meses. En todos los casos se obtuvo la consolidación sin pérdida de la reducción, luego de un promedio de 5,5 meses. El DASH promedió 17 puntos (rango 8 a 34) y el puntaje de Constant, 72 (rango 62 a 82). La escala analógica del dolor promedio 1 punto (rango 0 a 3). Discusión: El tratamiento quirúrgico en las no consolidaciones del húmero proximal sigue siendo un desafío, aunpara el cirujano más avezado, debido a su frecuente asociación con un fragmento proximal pequeño, mala calidad ósea, infección, pérdida ósea, rigidez articular y múltiples intervenciones quirúrgicas previas. Conclusiones: Los clavos-placa bloqueados de 90° tienen la ventaja de combinar dos diferentes pero bien conocidos métodos de fijación de fracturas en el mismo implante, aumentando las propiedades mecánicas de ambas técnicas de fijacion.

Comparison of posterior and lateral surgical approach in management of type III supracondylar fractures of the humerus among the children.

OBJECTIVE: To compare the results between posterior and lateral approaches in surgical treatment of the type III supracondylar humeral fractures in children. STUDY DESIGN: Retrospective analytical study. MATERIAL AND METHOD: Two groups of patients who needed surgical treatment of type III supracondylar humeral fractures, 52 in posterior approaches and 30 in lateral approaches were followed up for 6 months, in Chaiyaphum Hospital between 2004 and 2007. RESULTS: The posterior approach had a shorter operative time than the lateral approach (p < 0.001). The overall scores by Flynn's criteria showed that good and excellent outcomes were 80.7% in the posterior approach group and 80% in the lateral approach group and there was no significant difference of complications. CONCLUSION: The posterior approach had a shorter operative time than the lateral approach but no significant differences were found in terms of results and complications.

Epifisiólise proximal do úmero em atleta de ginástica olímpica / Proximal humeral epiphysiolysis in a gymnast

CONTEXTO: Existem diversas causas de dor no ombro do atleta. Estruturas como tendões e ligamentos são freqüentemente acometidas por lesões. No atleta jovem com esqueleto imaturo, as afecções ósseas devem ser lembradas como possíveis causas de dor. RELATO DE CASO: Os autores relatam a ocorrência da epifisiólise proximal do úmero em um atleta de ginástica olímpica e discutem a literatura a respeito do assunto. CONCLUSÃO: A lesão da placa fisária proximal do úmero em atletas é pouco freqüente. O diagnóstico precoce e correto tratamento evitam que ocorra deformidades severas e déficits funcionais.

CONTEXT: There are different causes for shoulder pain in athletes. Structures such as tendons and ligaments are frequently affected by injuries. In young athletes with immature skull, bone injuries must be ruled as a cause of pain. CASE REPORT: The authors present a case of proximal humeral epiphysiolysis in a gymnast and review literature addressing this topic. CONCLUSION: Injuries on proximal humeral physeal plates of athletes are uncommon. The early diagnosis and correct treatment can avoid deformity and functional deficits.

Closed reduction and percutaneous pinning of fracture surgical neck of the humerus

In dealing with displaced proximal humeres fractures, there is still much controversy in treatment modalities. The aim of this work was to evaluate the out come of closed reduction and percutaneous pinning as a line of treatment. The technique of closed reduction and percutaneous fixation was carried out for 20 cases with displaced two part fracture of the surgical neck of the humerus. The study included 15 males and 5 females. The average age was 43.7 years with an average follow up period of 10.65 months and the average healing time was 9.2 weeks. All patients were available for follow up and all fractures achieved union. The functional outcome was evaluated using the University of California at Los Angeles Shoulder Scale [UCLA] scoring system. According to this scoring system, the results were: 9 excellent cases [45%], 8 good cases [40%] and 3 fair cases [15%]. With proper patient reelection, closed reduction and percutanoues pinning is a good modalities for treatment of displaced two part fracture of the surgical neck of humerus

Early results of treatment of proximal humeral fractures in the elderly by modified hackethal technique

Proximal humerus fractures resulting from low energy trauma are common among elderly osteoporotic population and remain a challenging therapeutic problem because of the poor bone quality in addition to the comminution which is usually present in these patients. The purpose of this study is to evaluate the clinical and radiological results of treatment of displaced two and three part proximal humeral fractures in the elderly by closed reduction and retrograde intramedullary K-wires fixation. Sixteen patients [10 females and 6 males, average age 61 years] with displaced two and three parts proximal humeral fractures according to Neer's classification were evaluated and treated with closed reduction and retrograde intramedullary K-wires fixation. All patients were followed up clinically and radi-ologically according to the score of Constant for the average period of 17 months. All the fractures united within 6-9 weeks, with an average of 7 weeks. Out of 100 points according to the Constant's functional outcome scoring, 4 cases [25%] with two part fractures had an average 75 points and 12 cases [75%] with three part fractures 68 points. The method of closed reduction and retrograde intramedullary K-wires fixation yields satisfactory results in two part and three part proximal humerus fractures and can be a treatment of choice especially in elderly osteoporotic patients

Biomechanical properties of the biceps-labral complex submitted to mechanical stress

OBJETIVO: Determinar as propriedades biomecânicas do complexo labrum-glenóide bicipital superior submetido ao estresse mecânico contínuo ou repetitivo (repentino).

Management of type C intercondylar fractures of lower end humerus in adults: A clinical study.

Thirty-six patients of type C intercondylar fractures of lower end of humerus who visited JN Medical College, Aligarh between January, 2001 and January, 2003 were included in the study. All patients were treated surgically by open reduction and internal fixation with 4mm cancellous screws, reconstruction plates, one-third tubular plates. Early physiotherapy was started and the results graded using Krishnamoorthy criteria.

A retroversão da cabeça do úmero: revisão da literatura e mensuração em 113 úmeros de cadáveres / Humerus head retroversion: literature review and measurement of 113 cadaveric humeri

Objetivo: Realizar avaliação osteométrica (anatômica) dos ângulos de retroversão da cabeça de 113 úmeros de adultos. Método: Determinou-se como parâmetro proximal o eixo longo da superfície articular da cabeça do úmero e, como parâmetros distais, uma linha passando pelos epicôndilos do úmero e outra linha tangente à superfície articular anterior do cotovelo, formando respectivamente os ângulos a e beta. Projetando-se no plano axial essas linhas, mediante um goniômetro foi possível mensurar o ângulo de retroversão da cabeça desses úmeros. Resultado: A média do ângulo a dos 113 úmeros foi de 22,26 graus (variando de 2 graus a 76 graus), enquanto que a média do ângulo beta foi de 27,76 graus (variando de 8 graus a 82 graus). Não há evidências de diferenças estatísticas em relação aos lados direito e esquerdo, tanto para o ângulo a (p = 0,141), quanto para o ângulo beta (p = 0,117). O ângulo de retroversão da cabeça do úmero diminui, em média, 5,50 graus (variando de 0 grau a 8 graus) quando se usa como parâmetro distal uma linha passando pelos epicôndilos do úmero (ângulo a), em vez de usar uma linha tangente à superfície articular anterior do cotovelo (ângulo beta); essa diferença é estatisticamente significativa (p < 0,001). Conclusão: No material de observação os valores da média do ângulo a de RCU (22,26 graus) e a do ângulo beta (27,76 graus) estão entre os 15 graus e 35 graus relatados na literatura