Results of transosseous suture fixation in four-part valgus impacted fractures of the proximal humerus.

BACKGROUND: The osteonecrosis ratio in valgus impacted fractures of the proximal humerus is low (<10 %), giving osteosynthesis all its meaning. However, the optimal fixation technique remains controversial. After recentering the humeral head, osteosuture is stable enough to allow bone healing in an adequate position as well as a good long-term shoulder functionality. METHODS: Our cohort included 22 patients with a mean age of 65 (28-83). Patients were placed in a beach-chair position. Surgical exposure was done through an anterolateral, transdeltoid approach. Stay sutures were placed on both tuberosities. Elevation of the humeral head was obtained for 9 patients using iliac crest bone graft, for 7 patients using bone substitutes, for 6 without any graft needed. Both tuberosities were approximated and tied together using two horizontal non-absorbable double-threaded sutures. The whole head was also tied to the humeral metaphysis by cerclage wiring using the same suture. Patients were immobilized in a sling for 4 weeks with no passive or active mobilization; then began rehabilitation starting with passive and active-assisted mobilization. Functional outcome was assessed with the Constant score. Radiographic follow-up was used for fracture healing and osteonecrosis signs. RESULTS: All fractures united within the first 3 months. One patient had radiographic signs of osteonecrosis and one had a secondary displaced fracture without osteonecrosis. At an average follow-up of 35 months, the median Constant score was 83.7 % (63-100) in comparison to the uninjured side. DISCUSSION: A preserved posteromedial periosteal hinge in a valgus impacted fracture of the proximal humerus is key to the success of osteosuture. This hinge provides mechanical stability to the humeral head once elevated, as well as blood-supply from the branches of the posterior circumflex humeral artery. Computed Tomography with Three-Dimensional reconstructed images allow for a precise analysis of this hinge as well as the vascularity of the humeral head. Osteosuture being a minimally invasive surgical procedure plays a predominant role in sparing the remaining vascularization of the humeral head. CONCLUSION: Osteosuture in four-part valgus impacted fractures of the proximal humerus is a minimally invasive procedure as well as a reliable technique yielding good long-term results.

Comparison of classical and minimally invasive superolateral approach for reconstruction of proximal humerus fractures with locking plates.

CONTEXT: Minimally invasive (MI) approaches are purported to present advantages for osteosynthesis when compared with conventional approaches. This study aimed to compare the medium-term clinical and radiological outcomes of patients with proximal humerus fractures treated by plate osteosynthesis with conventional and MI superolateral approaches. METHOD: The study carried out was a retrospective monocentric comparative analysis. Forty-three cases were followed up - 18 were treated with an MI approach and 25 with a conventional approach. Constant-Murley, DASH and SSV scores were established and standard complications were investigated. RESULTS: No significant differences in functional scores or complications were found between the 2 groups. The only significant difference was for pain which was significantly lower for the MI group. The overall revision rate was 18.3 %. The mean adjusted Constant-Murley for the entire population was 80.1 ± 20.2; the mean DASH score was 17.8 ± 15.9 and the mean SSV was 73.2 ± 19.5. CONCLUSION: This study did not demonstrate any significant differences between the 2 approaches. Given the low patient population in our series, the superiority of the MI approach - as indicated in the literature - was not proven.

Assessment of Functional Outcome and Postoperative Complications in Proximal Humerus Fracture Patients Managed With Proximal Humerus Internal Locking System (PHILOS) Plating.

BACKGROUND: Proximal humerus fractures are primarily common in the old age group. The appropriate approach to managing such displaced and comminuted fracture patterns is often questionable. Hence, this study was conducted to assess the functional outcome of proximal humerus fractures following treatment with a proximal humerus locking plate and to assess the frequency of complications in such patients. METHODOLOGY: In this robust study, 33 cases of proximal humerus fractures underwent surgical management at a prestigious teaching hospital from February 2021 to August 2022 utilizing a proximal humerus internal locking system (PHILOS) plate. The NEER classification was employed to categorize the fractures, and the NEER score was used for functional assessment. It's crucial to note that individuals with pathological fractures, associated injuries in the ipsilateral limb, nerve injuries, and cases of open fracture were rigorously excluded from the study. RESULTS: The mean age was 47 ± 5.2 years. Based on NEER's classification, the distribution of fractures was as follows: two-part fractures accounted for 18.18% (n = 6) of cases, three-part fractures for 54.54% (n = 18) of cases, and four-part fractures for 27.27% (n = 9) of cases. A history of road traffic accidents and falls was reported in 54.54% (n = 18) and 45.45% (n = 15) of cases, respectively. Functional outcome assessment utilizing NEER's score revealed a minimum score of 48 and a maximum of 96, with an average score of 82.96 ± 12.73. Notably, 39% of patients demonstrated excellent results, 27% exhibited satisfactorily, 21% manifested unsatisfactorily, and 12.12% presented failure outcomes. Of the 33 operated cases, 81.8% (n = 27) exhibited no complications during follow-up. The predominant complication observed was shoulder stiffness (9.09%, n = 3), followed by Varus mal-union (6.06%, n = 2), and superficial surgical site infection (3.03%, n = 1), managed with debridement and antibiotics leading to subsequent resolution. CONCLUSIONS: Managing proximal humerus fractures has consistently posed a formidable challenge. Our study indicates that using the PHILOS plate represents a reliable option for addressing such fractures. This plate provides sturdy fixation, facilitates early mobilization, and culminates in exceptional functional outcomes. The insights gained from this study can inform clinical decision-making and guide orthopedic surgeons in selecting the appropriate treatment strategy for proximal humerus fracture patients.

Minimally invasive techniques utilizing the "Joy Stick" method for managing irreducible flexion-type supracondylar fractures of the humerus in older children.

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

Complications and Outcomes of Surgically Treated Pediatric Supracondylar Humerus Fractures.

This study describes the outcome of supracondylar humerus fractures in children using crossed K-wires after closed or open reduction with the medial, lateral or bilateral approach. Patients treated between January 2000 and December 2019 were classified according to the Von Laer classification, complications were classified according to the Sink classification and clinical outcomes were classified according to modified Flynn criteria. In total, 364 patients with a mean age of 5.23 ± 2.45 years were included. The majority were type IV fractures (156; 42.9%) and 94 (60.3%) needed an open reduction for which the medial approach (53; 56.4%) was predominantly used. Overall, of 50 complications (31 using closed reduction, 19 open reduction), 17/50 (34%) needed revision surgery. An excellent clinical outcome was achieved in 348/364 (95.6%) patients. The approach used for open reduction as such had no influence on the complication rate or clinical outcome. For severely displaced fractures, the data showed that an open approach for crossed K-wires tended to result in fewer complications and better clinical outcomes than a closed reduction. If an open reduction is indicated, the required approach (medial, lateral or bilateral) should be primarily selected according to the requirements of the fracture pattern and eventual cosmetic considerations.

Reverse Shoulder Arthroplasty for Proximal Humerus Fractures: A Review of Current Evidence.

PURPOSE OF REVIEW: The aim of this review is to summarize information published in the recent peer-reviewed literature on reverse shoulder arthroplasty (RSA) for proximal humerus fractures. RECENT FINDINGS: Although there is still some debate regarding which may be the best treatment for proximal humerus fractures in certain age ranges, RSA seems to offer more predictable results than other surgical treatments for elderly patients. Successful tuberosity healing seems to correlate with better outcomes. Recent trends indicate interest in cementless fixation, fracture-specific stems and a 135-degree polyethylene opening angle. RSA provides a successful surgical solution for selected proximal humerus fractures. Indications, design features, and surgical execution have continued to evolve over the last few years.

Superior functional outcome following reverse shoulder arthroplasty compared to hemiarthroplasty for displaced three and four-part fractures in patients 65 and older: Results from a prospective multicentre randomised controlled trial - The Shoulder Hemiarthroplasty or Reverse Polarity Arthoplasty (SHeRPA) trial.

BACKGROUND: Acute unreconstructible 3- or 4-part proximal humerus fractures can be treated with hemiarthroplasty or reverse polarity shoulder arthroplasty. Randomized trials using implants from multiple different companies or uncemented implants have found superior results with reverse polarity arthroplasty. AIMS: This study aims to determine whether cemented reverse polarity arthroplasty produces a superior outcome compared to cemented hemiarthroplasty using one implant system in patients aged 65 years and over at 12 months follow-up as measured with the Constant score. METHODS: A prospective patient and assessor blinded multicenter randomized controlled trial was conducted of shoulder hemiarthroplasty or reverse polarity arthroplasty in patients aged 65 years and older with acute 3- and 4-part proximal humerus fracture not amenable to osteosynthesis. The primary outcome was the Constant score at 12 months with total follow-up to 24 months. Block randomization by site was undertaken using random number generation and sealed envelopes. Power analysis indicated that 17 patients were required in each arm to achieve 80% power with an alpha-value of 5%. Secondary outcome measures were the difference in the mean Constant Score, Quick Disabilities of the Arm Shoulder and Hand Questionnaire (QuickDASH), Oxford Shoulder Score (OSS), American Shoulder and Elbow Surgeons (ASES) Score and EQ5D-5L up to two years; differences in complication rate at one and two years; differences in revision and implant failure at one and two years. RESULTS: 18 patients were randomized to hemiarthroplasty and 18 to reverse polarity arthroplasty across 4 sites. The primary outcome as measured by the Constant score at 12 months was better in the reverse polarity shoulder arthroplasty (RSA) group (Mean 51.1, s.d. 14.9) compared to the hemiarthroplasty (HA) group (mean 35.0, s.d. 13.5) (p=0.004). No significant difference was reported at 24 months but this may be due to high rates of attrition (22%). The mean EQ-5D-5L patient rated health status score was significantly higher in the RSA group compared to the HA group at 12 months. One hemiarthroplasty was revised due to implant uncoupling and one reverse polarity shoulder replacement was revised due to instability. No other complications were recorded. DISCUSSION: Treatment of unreconstructible 3- or 4-part proximal humerus fractures with reverse polarity shoulder arthroplasty results in a superior outcome compared to shoulder hemiarthroplasty at 12 months measured with the Constant score with no increased risk of failure up to 24 months in patients age 65 years and over. High attrition rates are observed in this older population due to cognitive decline and death from other causes.

Use of light activated intramedullary device for revision of a proximal humerus fracture: a case study.

BACKGROUND: Post-operative non-compliance is a risk factor for fracture fixation failure and presents a challenge for revision surgery planning. We present a patient who underwent revision surgery for a proximal humerus fracture with lateral locked plating augmented with a UV light activated intramedullary implant. CASE: A 45-year-old woman with a history of alcoholism presented with a proximal humerus fracture. After undergoing open reduction internal fixation with a lateral locking plate, the patient suffered a fall secondary to delirium tremens. New radiographs demonstrated displacement of the fracture with failure of screws. Revision surgery consisting of removal of the initial construct as well as open reduction internal fixation via lateral locking plate, augmented with a UV-activated intramedullary cement implant, was performed. CONCLUSION: This is the first case report describing the use of a UV-activated intramedullary cement implant to augment the use of lateral locked plating for proximal humerus fractures. This case illustrates the successful management using UV-activated intramedullary cement to augment fixation, specifically in a patient with risk factors and post-operative non-compliance that predispose to fixation failure.

[Elbow hemiarthroplasty for coronal shear fractures of the distal humerus]. / Ellenbogenhemiprothese bei koronaren Abscherfrakturen des distalen Humerus.

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

Clinical outcomes for linked fixation of distal humerus fractures: a multi-center study.

BACKGROUND: O'Driscoll popularized the principle of linked column fixation for distal humerus fractures. Despite the linked column concept being widely accepted, there are few reported techniques to accomplish this goal. A novel device was designed based on the principles of linked columns. An interlocking beam is used to connect the medial and lateral plates, creating a unified fixed angle construct. Our primary objective was to report clinical outcomes across multiple institutions for a linking beam used in distal humerus fracture fixation. METHODS: A retrospective series was collected from five institutions for the TiBeam (Skeletal Dynamics, Miami, FL, USA) with a minimum follow-up of six months. Acute and chronic treatment of distal humerus fracture patterns, and all plate configurations were included for analysis. RESULTS: A total of 36 cases were collected at a mean age of 52 years and a mean follow-up of 19.3 months. AO C-type fractures were 56% of the series. The median MEPS was 85 (IQR 76.3 to 90), the median DASH was 21.4 (IQR 15.9 to 30), and the median VASa was 3.5 (IQR 2 to 5). An olecranon osteotomy was used in 86% of cases and an anatomic plate was used for fixation of the osteotomy in 94% of those cases. There were three cases of olecranon plate removal for a rate across the series of 13.7%. DISCUSSION: Our short-term results demonstrate satisfactory clinical outcomes with low rates of revision for distal humerus fracture fixed with a linking beam. Further, the rate of removal for the olecranon osteotomy plate was lower than historical reports for aggregate methods of osteotomy fixation.

Primary Reconstruction Using Fibular Strut Allograft for Distal Humerus Intra-articular Comminuted Open Fracture (AO/OTA13C2, G-A type IIIA): A Case Report.

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

Posterolateral Locked Plate and Percutaneous Medial Screw Fixation for Distal Humerus Fractures in Elderly.

Background: A high incidence of ulnar nerve-related complications has been reported in open reduction and internal fixation for distal humerus fractures (DHFs). To minimise ulnar nerve damage, we used a percutaneous medial screw combined with a posterolateral plate in the elderly. The aim of this study was to evaluate the postoperative complications and functional outcomes of this method. Methods: Data from patients aged over 65 who underwent this surgical procedure for DHFs at a single Level I trauma centre from 2013 to 2021 were extracted. Postoperative complications, reoperations, mean range of motion, Mayo Elbow Performance Index (MEPI) scores and Hand20 scores were retrospectively evaluated. All patients in this study received postoperative rehabilitation by hand therapists at our hospital. Results: We identified 28 patients treated with this method. The mean follow-up period was 8.6 ± 3.7 months. The median intraoperative time was 125 minutes (interquartile range: 105-157 minutes). None of the patients developed ulnar nerve neuropathy, but one patient (3.7%) experienced radial nerve dysfunction. Two patients (7.4%) had nonunion. Implant failure occurred in three patients (11.1%) due to migration of the medial screw. One patient (3.7%) amongst them underwent reoperation. The mean flexion to extension arc was 97 ± 18°, 116 ± 19°, and 116 ± 19° at 1-, 3- and 6-month follow-ups, respectively. According to the MEPI, 20 patients achieved excellent results, seven patients achieved good results and one patient achieved a fair result at the last follow-up. The median Hand20 score was 4.3 (interquartile range: 2.1-14.0) at the 6-month follow-up. Conclusions: The posterolateral plate and medial screw method showed good functional outcomes and few nerve-related complications. This modified method might be a better option for DHFs in elderly patients. Level of Evidence: Level IV (Therapeutic).

Neglected Bicondylar Fracture of the Distal Humerus Treated With Total Elbow Arthroplasty.

A 69-year-old woman suffered a distal humerus fracture including the medial and lateral condyles. She received conservative treatment with a posterior arm splint at a local healthcare center where she was evaluated by a non-specialist physician. Eight months later, she presented to our department complaining about severe instability. An upper limb specialist examined the patient at the time, and after thoroughly explaining the condition, he suggested a surgical approach with total elbow arthroplasty (TEA), which was then performed. At the one-year follow-up, the patient had a full range of motion without any complications or pain complaints. TEA in neglected fractures of the distal humerus is a poorly researched topic in the field of upper limb surgery with only scarce literature available. In this case report, we present the excellent outcomes of the procedure performed on an elderly patient after non-union regaining her quality of life and suggest that TEA can be a viable solution in elderly patients with complicated or non-united elbow fractures.

Incidence of four major osteoporotic fragility fractures among older individuals in Sado, Japan, in 2020.

INTRODUCTION: This study compared the 2020 incidence of fragility fractures in Sado City with those from 2004 to 2015. MATERIALS AND METHODS: Data from patients aged ≥ 60 years living in Sado City with fragility fractures in the hip, vertebral, distal radius, and proximal humerus between January 1 and December 31, 2020, were collected. We examined the number and incidence of four types of osteoporotic fractures in the older population aged ≥ 60 years living in Sado City in 2020. We compared the results with those of the 2004, 2010, and 2015 surveys, examining the temporal change and trend in the incidence of the four fracture types in this population. We investigated the use rate of anti-osteoporotic medications and the relationship between their administration and the occurrence of fragility fractures. RESULTS: The age-specific incidence of hip fractures slightly decreased from 2015. However, the incidence of the other three fractures slightly increased, although the difference was not statistically significant. The incidence of hip fractures markedly increased in the 80 s. In 2020, the percentage of patients taking anti-osteoporotic agents before the occurrence of fractures decreased to 12.4% from 14.5% in 2015; it increased from 4% in 2004 to 7.6% in 2010. CONCLUSION: The 2020 incidence of the four fractures did not decrease, and the percentage of patients receiving anti-osteoporotic agents did not increase. A higher frequency of osteoporosis treatment is necessary to reduce the incidence of fragility fractures. We recommend using anti-osteoporotic agents to prevent hip fractures among individuals in their mid-70 s and above.

Biomechanical Design Optimization of Distal Humerus Fracture Plates: A Review.

The goal of this article was to review studies on distal humerus fracture plates (DHFPs) to understand the biomechanical influence of systematically changing the plate or screw variables. The problem is that DHFPs are commonly used surgically, although complications can still occur, and it is unclear if implant configurations are always optimized using biomechanical criteria. A systematic search of the PubMed database was conducted to identify English-language biomechanical optimization studies of DHFPs that parametrically altered plate and/or screw variables to analyze their influence on engineering performance. Intraarticular and extraarticular fracture (EAF) data were separated and organized under commonly used biomechanical outcome metrics. The results identified 52 eligible DHFP studies, which evaluated various plate and screw variables. The most common plate variables evaluated were geometry, hole type, number, and position. Fewer studies assessed screw variables, with number and angle being the most common. However, no studies examined nonmetallic materials for plates or screws, which may be of interest in future research. Also, articles used various combinations of biomechanical outcome metrics, such as interfragmentary fracture motion, bone, plate, or screw stress, number of loading cycles to failure, and overall stiffness (Os) or failure strength (Fs). However, no study evaluated the bone stress under the plate to examine bone "stress shielding," which may impact bone health clinically. Surgeons treating intraarticular and extraarticular distal humerus fractures should seriously consider two precontoured, long, thick, locked, and parallel plates that are secured by long, thick, and plate-to-plate screws that are located at staggered levels along the proximal parts of the plates, as well as an extra transfracture plate screw. Also, research engineers could improve new studies by perusing recommendations in future work (e.g., studying alternative nonmetallic materials or "stress shielding"), clinical ramifications (e.g., benefits of locked plates), and study quality (e.g., experimental validation of computational studies).

A case report of primary Kaposiform hemangioendothelioma of the humerus.

To examine the clinicopathological and immunohistochemical features of Kaposiform hemangioendothelioma (KHE) and discuss its differential diagnosis and prognosis. A patient with KHE was examined; the patient's clinical and histopathological features were observed, and the expression levels of CD31, CD34, ERG, D2-40, SMA, GLUT-1, and LANA-1 were assessed. The patient was a four-year-old child with primary KHE of the humerus. She was admitted to the hospital because of pain in the right elbow joint and limited movement for more than 2 years. Imaging revealed Langerhans cell histiocytosis. The child was not diagnosed with Kasabach-Merritt phenomenon (KMP). The tumor consists of multiple hemangiomatous nodules with infiltrative growth separated by fibrous connective tissue. The proliferating hemangiomatoid nodules consisted of crisscrossing short spindle-shaped cell bundles and erythrocyte-containing lacunar or crescentic vessels. Immunohistochemical staining showed that the tumor cells diffusely expressed CD31, CD34, ERG, and other vascular endothelium-derived markers; further, the tumor cells expressed neither GLUT-1 nor LANA-1. The patient's general condition improved after surgical resection. There was no tumor recurrence after more than 8 months of follow-up. Primary KHE of the humerus is a rare vasculogenic tumor. It presents with morphological features that require an accurate differential diagnosis.

Ultrasound-guided localization of the radial nerve along the humerus: providing reference points for safer upper arm surgery.

PURPOSE: The close proximity of the radial nerve to the humerus poses a risk during upper arm surgery. Although the general course of the radial nerve is well-known, its exact position in relation to anatomical reference points remains poorly investigated. This study aimed to develop a standardized protocol for the sonographic and clinical identification of the radial nerve in the upper arm. The ultimate goal is to assist surgeons in avoiding iatrogenic radial nerve palsy. METHODS: A total of 76 measurements were performed in 38 volunteers (both sides). Ultrasound measurements were performed using a linear transducer (10 MHz) to identify the radial nerve at two key points: RD (where the radial nerve crosses the dorsal surface of the humerus) and RL (where the radial nerve crosses the lateral aspect of the humerus). Distances from specific reference points (acromion, lateral epicondyle, medial epicondyle, olecranon fossa) to RD and RL were measured, and the angle between the course of the nerve and the humeral axis was recorded. Humeral length was defined as the distance between the posterodorsal corner of the acromion and the lateral epicondyle. RESULTS: The distance from the lateral epicondyle to RD was on average 15.5 cm ± 1.3, corresponding to 50% of the humeral length. The distance from the lateral epicondyle to RL was on average 6.7 cm ± 0.8, corresponding to 21% of the humeral length. The course of the nerve between RD and RL showed an average angulation of 37° to the anatomical axis of the humerus. Gender, BMI, dominant hand, and arm thickness did not correlate with the distances to RD or RL. Measurements were consistent between the left and right side. CONCLUSION: The radial nerve can typically be identified by employing a 1/2 and 1/5 ratio on the dorsal and lateral aspects of the humerus. Due to slight variations in individual anatomy, the utilization of ultrasound-assisted visualization presents a valuable and straightforward approach to mitigate the risk of iatrogenic radial nerve palsy during upper arm surgery. This study introduces an easy and fast protocol for this purpose.

Comparing and characterizing scapular muscle activation ratios in males and females during execution of common functional movements.

Background: The shoulder complex relies on scapular movement controlled by periscapular muscles for optimal arm function. However, minimal research has explored scapular muscle activation ratios during functional tasks, nor how they might be influenced by biological sex. This investigation aims to characterize how sex impacts scapular muscle activation ratios during functional tasks. Methods: Twenty participants (ten females, ten males) were assessed with surface electromyography (EMG) and motion tracking during seven functional tasks. Activation ratios were calculated from normalized EMG for the three trapezius muscles and serratus anterior. Scapular angles were calculated using a YXZ Euler sequence. Two-way mixed methods ANOVAs (p < .05) were used to assess the effects of sex and humeral elevation level on ratios and angles. Results: Sex-based differences were present in the Tie Apron task, with males exhibiting higher upper trapezius/lower trapezius and upper trapezius/middle trapezius ratios than females. Males also demonstrated decreased internal rotation in this task. Other tasks showcased significant sex-based differences in scapular upward rotation but not in activation ratios. Humeral elevation generally demonstrated an inverse relationship with scapular muscle activation ratios. Conclusions: This study highlights sex-based differences in scapular muscle activation ratios during specific functional tasks, emphasizing the need to consider sex in analyses of shoulder movements. Normative activation ratios for functional tasks were provided, offering a foundation for future comparisons with non-normative groups. Further research is warranted to confirm and explore additional influencing factors, advancing our understanding of shoulder activation and movement in diverse populations.

Comparison of clinical outcomes and complications in 2-part vs. 3- or 4-part proximal humerus fractures treated using an intramedullary nail designed to capture the tuberosities.

Background: Intramedullary nail fixation for proximal humerus fractures has been shown to provide satisfactory results. The quality of reduction correlates with clinical outcomes, the rate of complications, avascular necrosis, and postoperative loss of fixation. The purpose of this study was to evaluate the clinical outcomes and complications of 2-part proximal humerus fractures compared to 3- or 4-part proximal humerus fractures. Methods: A single-center retrospective review was carried out of patients who underwent an intramedullary nail for a proximal humerus fracture by one of three surgeons between the years of 2009 and 2022, and who had a minimum of 12-months follow-up. Fracture pattern, American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score, satisfaction, pain score, range of motion, and complications were recorded. The mechanism of injury (high energy vs. low energy), method of reduction (open vs. percutaneous), and evidence of radiographic healing were assessed. A P value of <.05 was considered to be statistically significant. Results: The study included 78 patients (62 female, 16 male). The number of patients in each group (2-part, N = 32 vs. 3- or 4-part, N = 46), mean age (2-part, 64 vs. 3- or 4-part,61), follow-up (2-part, 42.5 months vs. 3- or 4-part, 34.5 months), injury type (2-part, 88% low energy vs. 3- or 4-part, 78% low energy), and method of reduction (2-part, 81% percutaneous vs. 3- or 4-part 72% percutaneous) were similar among the two groups. There was fracture union in all patients. All patients demonstrated satisfactory patient-reported outcome measures. However, 2-part fractures did have a significantly lower pain score, higher Single Assessment Numeric Evaluation score, and higher percentage of patients being satisfied or very satisfied when compared to 3- or 4-part fractures. The rate of subsequent procedures was 13% (n = 4) in 2-part fractures compared to 19% (n = 9) in 3- or 4-part fractures but was not statistically significant (P = .414). The overall rate of conversion to arthroplasty was 3.2% in 2-part fractures and 10.4% in 3- or 4-part fractures. Conclusion: Multipart proximal humerus fractures remain difficult to treat. However, this study demonstrates an overall acceptable outcome with improvement in range of motion, patient-reported outcomes, and similar complication rates between 2-part and 3- or 4-part proximal humerus fractures treated with an intramedullary nail. However, the improvement in certain parameters is not as marked in 3- or 4-part fractures as 2-part fractures.

Proximal humerus open reduction internal fixation with and without biceps tenodesis: assessment of early clinical outcomes.

Background: The role of biceps tenodesis (BT) during open reduction internal fixation (ORIF) of proximal humerus fractures (PHFs) remains unclear. A subset of patients undergoing ORIF have persistent pain with unclear etiology. The purpose of our study was to compare outcomes of ORIF of PHFs with and without concomitant BT. We hypothesize patients undergoing BT at the time of ORIF will have improved patient-reported outcome scores with fewer secondary procedures related to treatment of the biceps. Methods: In this retrospective cohort study, all patients undergoing ORIF for a PHF at a single level one trauma center from January 2019 to June 2022 were reviewed. Patients under the age of 18 were excluded. Primary outcomes were patient-reported outcomes measurement information system physical function, depression, and pain interference scores at 5 time points up to final follow-up. Secondary outcomes included total operative time, complications, subsequent procedures, steroid injections, and range of motion. Chi-square tests were performed for categorical values and paired t-tests for continuous variables. Results: 71 patients met inclusion criteria: 41 undergoing ORIF without BT and 30 undergoing ORIF with BT. Average follow-up was 11 months. There were no statistically significant differences in patient demographics between groups. There were no differences in patient-reported outcomes measurement information system scores at any time point postoperatively. At final follow-up patients in the ORIF with BT group had higher forward flexion than those who did not undergo BT (142 vs. 123 degrees, respectively, P < .02). There were no differences in surgical time, revision rates, postsurgical complications, or postoperative injections between groups. Conclusion: BT performed during ORIF of PHFs did not result in significantly different functional or patient-reported outcomes between groups, except for greater forward flexion at final follow-up. Although BT was done more commonly in severe PHFs, patients in both groups had similar rates of subsequent biceps-related procedures and revision surgery.