Simple bone cysts of the proximal humerus presented with limb length discrepancy:A case report

BACKGROUND Simple bone cysts(SBC)are benign tumor-like bone lesions typically identified in children.While SBC may lead to growth disturbances or growth arrest,such cases are uncommon.The mechanisms behind these observations remain unclear.Additionally,research on the etiology of SBC remains inconclusive,and there has been no consensus on the appropriate timing and methodology for treatment.CASE SUMMARY Here,we present our experience in the successful surgical management of a 10-year-old girl with SBC,who presented with a pathological fracture complicated by malunion of the displaced fracture,varus deformity,and limb length discrepancy.We hypothesized two possible etiologies for the patient’s growth arrest and subsequent humerus varus deformity:(1)Direct disruption of the physis by fluid from the cyst itself;and(2)damage to the epiphysis due to repetitive pathological fractures associated with SBC.In addressing this case,surgical intervention was undertaken to correct the proximal humerus varus deformity.This approach offered the advantages of simultaneously correcting angular abnormalities,achieving mild limb lengthening,providing definitive SBC treatment,and reducing the overall treatment duration.CONCLUSION As per current literature,acute correction of acute angular deformity in proximal humeral SBC is not well comprehended.However,in this specific case,acute correction was considered an optimal solution.

Epidemiologic investigation of pediatric distal humerus fractures: An American insurance claims database study

BACKGROUND Distal humerus elbow fractures are one of the most common traumatic fractures seen in pediatric patients and present as three main types:Supracondylar(SC),lateral condyle(LC),and medial epicondyle(ME)fractures.AIM To evaluate the epidemiology of pediatric distal humerus fractures(SC,LC,and ME)from an American insurance claims database.METHODS A retrospective review was performed on patients 17 years and younger with the ICD 9 and 10 codes for SC,LC and ME fractures based on the IBM Truven MarketScan®Commercial and IBM Truven MarketScan Medicare Supplemental databases.Patients from 2015 to 2020 were queried for treatments,patient age,sex,length of hospitalization,and comorbidities.RESULTS A total of 1133 SC,154 LC,and 124 ME fractures were identified.SC fractures had the highest percentage of operation at 83%,followed by LC(78%)and ME fractures(41%).Male patients were,on average,older than female patients for both SC and ME fractures.CONCLUSION In the insurance claims databases used,SC fractures were the most reported,followed by LC fractures,and finally ME fractures.Age was identified to be a factor for how a pediatric distal humerus fractures,with patients with SC and LC fractures being younger than those with ME fractures.The peak age per injury per sex was similar to reported historic central tendencies,despite reported trends for younger physiologic development.

Time of surgery and surgeon level in supracondylar humerus fractures in pediatric patients:A retrospective study

BACKGROUND Supracondylar humerus fractures account for more than 60%of all elbow fractures and about 1/5 of all pediatric fractures.Unfortunately,these fractures can be associated with risk of complications including neurovascular injuries,malunions and limb deformities.Controversy exists regarding the effect of time of surgical intervention and/or level of surgeon performing the surgery on outcome of these fractures.AIM To determine whether time of surgical intervention and/or surgeon level influence the outcomes of surgically managed pediatric supracondylar humerus fractures.METHODS We retrospectively studied 155 pediatric patients presenting with a supracondylar humerus fracture in a level 1 trauma center from January 2006 to December 2019.The data extracted included demographic data,fracture characteristics,surgical data,and follow-up outcomes.The collected data was analyzed and P values of<0.05 were considered statistically significant.RESULTS Of the cohort,11%of patients had documented post-operative complications,of which the majority occurred in surgeries performed after day time working hours and in fractures requiring open reduction.While the lowest complication rate was found in surgeries performed by pediatric orthopaedic surgeons,this did not reach statistical significance.CONCLUSION In pediatric patients undergoing surgery for supracondylar fractures,we found a higher complication rate when surgeries were not performed during working hours.Surgeon level and training had no significant effect on the risk of post-operative complications.

Osteosarcoma of the Humerus Developing as Second Malignancy in the Irradiation Field Outside the Primary Tumor: 11 Years after Ewing Sarcoma of the Scapula and 29 Years after Breast Cancer

Purpose: Development of sarcoma is a known late rare negative side effect of radiotherapy. We add two cases to emphasize the need for open-end follow-up and critical evaluation to avoid misinterpretation. Patients, Methods, and Results: Two patients developed osteosarcoma as a second malignancy in the humerus after adjuvant radiotherapy of a primary tumor not directly involving the later affected bone. The first patient had a Ewing sarcoma of the scapula at age 13 years. Though after neoadjuvant chemotherapy the resected specimen showed only fibrotic necrotic areas within clear resection margins, the study group indicated adjuvant radiotherapy in a field including the shoulder joint. At age 24 years she developed an osteosarcoma of the humeral head, which was resected and reconstructed with a proximal humerus endoprosthesis. She is alive without disease at age 32 years. The second patient presented with an osteosarcoma of the proximal humerus 29 years after irradiation for breast cancer including the shoulder joint. The sarcoma was misinterpreted as radiation-induced necrosis and the patient was treated with a reverse shoulder endoprosthesis. Pathologic examination of the resected humeral head then showed a typical osteosarcoma. Two years later the humeral reverse shoulder implant was resected and a proximal humerus tumor prosthesis implanted leaving the original glenosphere. Conclusions: In both cases radiation-induced osteosarcoma developed in bone not affected by the primary cancer. Protecting uninvolved structures must be warranted in the planning of radiotherapy. The long latency between the primary and second cancer mandates long-term—best indefinite—follow-up, as with appropriate treatment of a radiation-induced osteosarcoma good healing rates comparable to those of primary osteosarcoma can still be achieved.

Blount Method in the Management of Supracondylar Fractures of the Humerus in Children

Supracondylar fractures of the humerus are the most common traumatic elbow injury in children. Several techniques are described in their support. Blount’s method is one of the widely used orthopedic means. The objective of our study was to evaluate the results of supracondylar fractures of the humerus treated by this method in our department. This was a descriptive, longitudinal study with the prospective collection over a period of 12 months from May 2018 to April 2019. It focused on children aged 0 to 15 years treated in the Orthopedic Traumatology Department of the CHU of Kati for a supracondylar fracture of the humerus in extension. A minimum follow-up period of 6 months was necessary for inclusion. 12 patients were collected. The sociodemographic, anatomopathologic, therapeutic and evolutionary aspects were studied. The results were evaluated according to Flynn’s criteria. The male sex was predominant with a ratio of 2. The average age was 5.5 years. The average admission time was 12.5 hours. Domestic accidents were the main etiology (66.66%) and Type II fracture was the most frequent with 58.33%. The duration of immobilization was 42 days for 11 patients. Complications were 1 case of secondary displacement and 1 case of 12&#730 flexion deficit. The average Baumann angle was 72&#730. The result was satisfactory for all our patients. Supracondylar fractures of the humerus are common in children, especially boys. The method of Blount when it is well carried out by respecting the indications gives good results.

Management of proximal humerus fractures in adults

The majority of proximal humerus fractures are lowenergy osteoporotic injuries in the elderly and their incidence is increasing in the light of an ageing population. The diversity of fracture patterns encountered renders objective classification of prognostic value challenging. Non-operative management has been associated with good functional outcomes in stable, minimally displaced and certain types of displaced fractures.Absolute indications for surgery are infrequent and comprise compound, pathological, multi-fragmentary head-splitting fractures and fracture dislocations, as well as those associated with neurovascular injury. A constantly expanding range of reconstructive and replacement options however has been extending the indications for surgical management of complex proximal humerus fractures. As a result, management decisions are becoming increasingly complicated, in an attempt to provide the best possible treatment for each indi-vidual patient, that will successfully address their specific fracture configuration, comorbidities and functional expectations. Our aim was to review the management options available for the full range of proximal humerus fractures in adults, along with their specific advantages, disadvantages and outcomes.

Coronal shear fractures of distal humerus: Diagnostic and treatment protocols

Coronal shear fractures of distal humerus involving the capitellum and the trochlea are rare injuries with articular complexity, and are technically challenging for management. With better understanding of the anatomy and imaging advancements, the complex nature of these fractures is well appreciated now. These fractures involve metaphysealcomminution of lateral column and associated intraarticular injuries are common. Previously, closed reduction and excision were the accepted treatment but now preference is for open reduction and internal fixation with an aim to provide stable and congruent joint with early range of motion of joint. Various approaches including extensile lateral, anterolateral and posterior approaches have been described depending on the fracture pattern and complexity. Good to excellent outcome have been reported with internal fixations and poor results are noted in articular comminution with associated articular injuries. Various implants including headleass compression screws, minifragment screws, bioabsorbable implants and column plating are advocated for reconstruction of these complex fractures. Inspite of articular fragments being free of soft tissue attachments the rate of osteonecrosis and osteoarthritis is reported very less after internal fixation. This article summarizes the diagnostic and treatment strategies for these rare fractures and recommendations for management.

Clinical significance of three dimensional finite element analysis on humerus fracture

Objective: To treat humerus fracture with three dimensional pattern and finite element analysis, providing mechanical basis for treating humerus fracture. Methods: Humerus pattern was established based on the CT images, and calculation was done by ANSYS5. 6 software. Three dimensional ten-node tetrahedron unit was selected and were divided into 2 729 nodes, 49 041 units. Distribution and amount of axial compression of humerus were analyzed when clip angle was 30°, 45°, 90° between fracture face and axial line with fixed X, Y, Z directions. Results: The distribution of stress was greatly different between fracture face and non fracture face. Stress in fracture part was fairly concentrated with incomplete symmetric distribution around the center of fracture face; Greater stress distributed in the regions 10 mm from fracture face, which was 2-3 times that of other stress regions. Conclusion: Required load must be estimated under various conditions as to select the suitable internal fixation implants during the treatment of humerus fracture, which can provide helpful stress environment for fracture healing.

Embolization of an unusual metastatic site of hepatocellular carcinoma in the humerus

Hepatocellular carcinoma （HCC） is the fish most common cancer in the world. This case documents an unusual metastatic presentation of HCC in the humerus. Preoperative palliative arterial embolization of the tumor was performed to arrest severe tumor bleeding caused by the biopsy. Embolization turned out to be useful also in limiting/preventing potential uncontrolled bleeding during subsequent amputation.

Endosteal Fibular Strut Graft with Proximal Humeral Locking Plate in Delayed and Neglected Fractures of the Proximal Humerus

Purpose: The purpose of this study was to define a treatment protocol in which a non-vascularized endosteal fibular strut graft, a corticocancellous grafts and a locking plate construct are used for stabilization of the delayed and neglected proximal humerus fractures and to report its outcome. Patients & Methods: Eleven patients (6 females and 5 males) with delayed, neglected proximal humerus fractures were included in this study, conducted between March 2015 and December 2019. Average age of the patients was 57 years (range: 41 to 67 yrs). All patients were treated with the debridement, decortication and shingling of the bone at the site of the fracture followed by using an endosteal fibular strut graft, corticocancellous bone grafts and stabilization with locking plate. The patients were followed up for a mean time of 16.3 months (range: 13 to 40 months). The patient outcomes were evaluated using the Disabilities of the Arm, Shoulder, and Hand Questionnaire, and the modified scoring system of Constant and Murley. Results: Union at the fracture site was achieved in all patients at a mean of 8.5 months (range: 6 to 11 months). The DASH score improved from an average pre-operative score of 71.1 (range: 64 to 78) to an average post-operative score of 25.2 (range: 21 to 35) at the final follow-up. Albeit with a small sample size of n = 11, this difference was found to be statistically significant (p < 0.05). The CM score improved from an average pre-operative score of 33.2 (range: 20 to 48) to an average post-operative score of 66.8 (range: 59 to 72) at the final follow-up. This difference was also found to be statistically significant in this patient cohort (p < 0.05). The results were excellent in 3 patients, good in 6 and moderate in 2. Conclusions: An endosteal fibular strut, subperiosteally placed cortico-cancellous grafts with a locking plate fixation helps in biological healing of neglected fractures of proximal humerus.

Modified Closed Reduction and Percutaneous Kirschner Wires Internal Fixation for Treatment of Supracondylar Humerus Fractures in Children

Objective Supracondylar humerus fractures are the most frequent fractures of the paediatric elbow.The present study introduced a modified surgical procedure for treatment of supracondylar humerus fractures in children.Methods From February 2015 to August 2019,73 patients with Gartland’s type II and III supracondylar fractures were treated with this modified method.Totally,68 of all patients were followed up for 3–12 months(mean 8.25 months).The evaluation results included fracture nonunion,ulnar nerve injury,pin track infection,carrying angle and elbow joint Flynn score.Results The results showed that bone union was observed in all children,one case had an iatrogenic ulnar nerve injury,and the symptoms were completely relieved in 4 months after removing of the medial-side pin.All children had no cubitus varus deformity and no pin track infection,and the rate of satisfactory results according to Flynn’s criteria score was 100%.Conclusion The modified closed reduction and Kirschner wires internal fixation could effectively reduce the rate of open reduction,the risk of iatrogenic ulnar nerve injury,and the incidence of cubitus varus deformity in treatment of supracondylar humerus fractures in children.

The Effect of Weather Conditions on Pediatric Supracondylar Humerus Fractures

Background: Environmental conditions are effective on childhood supracondylar humerus fractures. In this study, we evaluated the relationship between weather conditions and these fractures. Materials and Methods: We started this study following the approval of a non-interventional research ethics committee. Patients (<16 years) who applied to the hospital between January 2013 and July 2018 with supracondylar humerus fractures were included in the study. The hospital’s PROBEL system was used to diagnose (International Classification of the Diseases, ICD, S42.4) radiological images and patient information. Information on the weather conditions in the day and time period, in which supracondylar humerus fracture occurred, was obtained from TR (Turkey) Ministry of Agriculture and Forestry General Directorate of Meteorology. The relationship between supracondylar fracture and daily weather conditions (wind, air temperature, cloudiness, and season) was analyzed. Results: Most of the patients (n = 76, 40.6%, p < 0.05) were fractures occurring under cloudless weather conditions. Fractures were concentrated with a second frequency in cloudy weather over 60%, except for cloudless weather conditions (n = 51, 27.3%, p < 0.05). In the summer months when the air temperature was high, the number of fractures was higher (n = 62, 33.2%, p < 0.05) and less in the winter months (n = 24, 12.8%, p < 0.05). In hot weather conditions where the daily average temperature was above 20°C, supracondylar humerus fractures were observed more (n = 101, 54%) and less than 10°C (n = 43, 23%, p < 0.05). Increased incidence of fractures was observed in the presence of wind (n = 4, 2.1%, p < 0.05). Conclusion: Supracondylar humerus fractures are common in children. Environmental conditions (temperature, wind, and season) can be effective in the occurrence of these fractures.

Two-level reconstruction of isolated fracture of the lesser tuberosity of the humerus

Fractures of the lesser tuberosity of the humerus are typically met in combination with other injuries of the shoulder. Case reports of isolated lesser tuberosity fractures are particularly rare and, consequently,therapeutic protocols have not yet been completely clarified. Conservative as well as surgical treatment has been recommended, while several operative techniques have been applied. We present a case of a 39-yearold man with an isolated lesser tuberosity fracture who was treated surgically in our institution. Due to fracture comminution, a two-level reconstruction technique with headless screws and buttress plate was applied. As far as we know, this method of fixation of this type of fracture has not been previously described in the literature.The patient tolerated the procedure well and excellent results were obtained at the latest follow-up.

Lateral epicondyle osteotomy approach for coronal shear fractures of the distal humerus:Report of three cases and review of the literature

BACKGROUND Coronal shear fractures of the distal humerus are rare injuries and are technically challenging to manage.Open reduction and internal fixation(ORIF)has become the preferred treatment because it provides anatomical reduction,stable internal fixation,and early motion,but the optimal surgical approach remains controversial.CASE SUMMARY We report three cases of coronal shear fractures of the distal humerus treated successfully by ORIF via a novel surgical approach,in which lateral epicondyle osteotomy was performed based on the extended lateral approach.We named the novel surgical approach the lateral epicondyle osteotomy approach.All patients underwent surgical treatment and were discharged successfully.All patients had excellent functional results according to the Mayo elbow performance score.The average range of motion was 118°in flexion/extension and 172°in pronation/supination.Only case 2 had a complication,which was implant prolapse.CONCLUSION We demonstrated that the lateral epicondyle osteotomy approach in ORIF is effective and safe for coronal shear fractures of the distal humerus.

CLOSED REDUCTION AND PERCUTANEOUS K-WIRES FIXATION OF DISPLACED SUPRACONDYLAR HUMERUS FRACTURES IN CHILDREN

To observe the effects of closed reduction and percutaneous K wires fixation of displacd supracondylar humerus fracture in children MethodsRetrospective review of fourteen patients who sustained displaced supracondylar fracture of distal humerus treated by closed reduction and percutaneous K wires fixation Results. All patients’ K wires were removed at 4 weeks post operation Their elbow function regained at 8 weeks The average period of followed up was 10 month (varies from 6 to 18 month), all fractures healed very well without any permanent complications Two transient nerves palsy,ulnar and radial nerve each, recovered completely at 12 weeks and 16 weeks post operation respectively Conclusion. Closed reduction and percutaneous K wires fixation is a safe and efficient treatment for displaced humerus surpracondylar fracture in children

Derotational osteotomy and internal fixation of a 180°malrotated humerus:A case report

BACKGROUND Humeral shaft fractures are relatively common in adults.Rotational malalignment is reported as one complication but severe rotational deformity of the humerus is extremely rare.To our knowledge,only three cases of symptomatic humeral malrotation have been reported.There are sparse literature reports of humeral reconstruction correction.CASE SUMMARY We present a case of extreme rotational deformity of the humerus(180°)after humeral shaft fracture.The patient complained of pain and difficulties with activities of daily living.In addition,she found the deformity cosmetically unacceptable.Therefore,she was searching for surgical correction.Neurolysis of the radial nerve followed by derotational osteotomy of the humerus and internal fixation were performed.Postoperatively,the patient demonstrated transient iatrogenic radial nerve palsy which recovered completely during postoperative follow-up.The Disabilities of the Arm,Shoulder,and Hand score improved from 55 preoperatively to 16 at the final 2-year follow-up.CONCLUSION Single-stage radial neurolysis,derotational osteotomy and stable fixation is a feasible option to improve anatomic and functional problems of severely malrotated humeral shaft fractures.

Mortality following combined fractures of the hip and proximal humerus

BACKGROUND Hip fractures and proximal humerus fractures are known to be associated with increased mortality,but the impact on mortality of combining these two common injuries is not well known.AIM To compare mortality,inpatient stay and discharge destination for patients with combined hip and proximal humerus fractures with those sustaining isolated hip fractures.METHODS Using the United Kingdom national hip fracture database,we identified all hip fracture patients over the age of 60 admitted to a single trauma unit from 2010-2016.Patients sustaining a proximal humerus fracture in addition to their hip fracture were identified using hospital coding data.We calculated the 30-d and one-year mortality for both the hip fracture cohort and the combined hip and proximal humerus fracture cohort.Other variables recorded included age,gender and whether the proximal humerus was treated with or without an operation.RESULTS We identified 4131 patients with hip fractures within the study period and out of those 40 had sustained both a hip and a proximal humerus fracture.Mean age in the hip fracture cohort was 80.9 years and in the combined fracture group 80.3 years.Out of the 40 patients in the combined group four were treated operatively.The 30-d mortality for our hip fracture cohort was 7.2%compared to the mortality of our combined cohort of 12.5%(P=0.163).The one-year mortality for our hip fracture cohort was 26.4%compared to 40%for the combined fracture cohort(P=0.038).We also found patients with combined injuries were less likely to return to their own home.CONCLUSION The 30-d and one-year mortality is higher for those patients who have sustained a combined hip and proximal humerus fracture when compared to those with a hip fracture alone.

Reduction of postoperative bleeding following operative treatment of proximal humerus fractures using a collagen sponge

Aim of the present study is to investigate the efficacy and safety of TachoSil? to reduce afterbleeding and hematoma following operative treatment of proximal humerus fractures. In a prospective randomized study we included a consecutive series of 40 patients with a proximal humeral fracture in this study. All fractures were stabilized surgically with a fixed-angle “Philos plate” from May 2008 through May 2009. All patients were divided in two groups: Group I with plate osteosynthesis without TachoSil, Group II with plate osteosynthesis with TachoSil. For statistical analysis Chi2- Test and U- Test were used. There were 4 perioperative complica- tions in group II and one complication in group I (Chi2-Test: p=0.233). In group II one hardware failure occurred due to osteoporosis requiring revision and reosteosynthesis. Another patient suffered from paralysis of the radial nerve which healed uneventfully. One superficial postopera-tive infection and one superficial hematoma re-quired revision surgery, too. In this group no subfascial hematoma developed. One subfascial hematoma which required no revision occurred in group I. Blood transfusion was required 2 times in group I and 3 times in group II (Chi2-Test: p = 0.549). In sum in group II there was a sig-nificant lower blood loss for the subfascial drain, the region where TachoSil was applied. No ad-verse affects related to TachoSil could be de-tected. TachoSil was found to be safe and effective for reduction of postoperative bleeding following operative treatment of proximal hume-rus fractures. Further studies with larger sample size are required to confirm the efficacy of TachoSil? in orthopedic surgery.

Anteromedial Plating of Humerus—An Easier and Effective Approach

Plate osteosynthesis of humeral shaft fractures is an established surgical procedure. Iatrogenic radial nerve palsy appears to be common complication in treating these fractures. A case series of 20 fracture shafts of humerus were treated with anteromedial plating through anterolateral approach. There was no radial nerve palsy in any of the cases and all achieved fracture union.

Pediatric Supracondylar Humerus Fractures: Are Medial Pins Indicated?

Background: Pediatric supracondylar humerus fractures are the most common elbow fractures in children. Operative management includes closed reduction and placement of 2 to 3 laterally based pins. Occasionally, a medial pin is used to create a crossed fixation pattern, despite risk of nearly 10% iatrogenic ulnar nerve injury. The objective of this study was to assess the trends and outcomes in the operative management of pediatric supracondylar humerus fractures at a level one academic trauma center. Materials & Methods: A retrospective review was performed on all children sustaining a Gartland type II or III supracondylar humerus fractures treated by closed or open reduction and percutaneous pinning in 2006-2008 and 2009-2011 at a level one academic trauma center by two of the authors (JTR, LMT). Pin placement patterns were evaluated and compared based on year performed. Outcomes measured were rates of ulnar nerve symptoms, non-union, re-operation, and varus malalignment. Data analysis was performed using a Fisher exact test on STATA software. Results: A total of 49 patients met inclusion criteria. Of 22 patients treated in 2006-2008, 5 (23%) were type II and 17 (77%) were type III. From 2009-2011, 16 (59%) were type II and 11 (41%) were type III. Comparison of pinning pattern in type II fractures between 2006-2008 and 2009-2011 did not indicate statistical significance (p = 0.429). Comparison of pinning pattern in type III fractures during the same time period did show that there was a statistically significant decrease (p = 0.010) in the number of cross pin fixations. There were no ulnar nerve injuries, non-unions, re-operations, or varus malalignment in any patient on final follow-up. Conclusion: This study shows that there has been a significant decrease in cross pin fixation for pediatric type III supracondylar humerus fractures with equivalent clinical outcomes at a Level I trauma center. Furthermore, performing lateral pinning for type III fractures has eliminated the risk of iatrogenic ulnar nerve injury. Level of Evidence: Level III—Retrospective cohort study.