可注射式磷酸钙骨水泥在肱骨近端骨折中应用观察

目的：对注射式磷酸钙骨水泥作为植骨材料在肱骨近端骨折中的临床疗效进行评估。方法：采用可注射式磷酸钙骨水泥（CPC）作为植骨材料治疗肱骨近端骨折复位后骨缺损21例。结果：21例患者术后获8~20个月（平均16.6个月）随访,所有患者骨折均获得骨性愈合,愈合时间10~18周,平均13.8周,术后无感染及内固定松动发生,根据Neer评分评定,优15例,良3例,可1例,差2例,优良率为85.7%。结论：注射式磷酸钙骨水泥具有安全、方便、副作用小、填充效果确实等优点,临床疗效满意。

克氏针钢丝张力带治疗肱骨小头骨折13例疗效观察

目的：探讨克氏针钢丝张力带固定治疗肱骨小头骨折临床疗效。方法 ：收集肱骨小头骨折28例,传统组15例采用无头加压螺钉固定治疗;改良组13例采用克氏针张力带固定治疗。比较了两组骨折愈合时间以及肘关节功能的恢复。结果：两组患者骨折分类无差异,术中所有骨折均达牢靠固定,所有患者均获得随访,随访时间为术后6-21月,平均11.4月。传统组、改良组骨性愈合时间分别为65.2±3.4d、45.6±2.8d;对肘关节术后功能根据Cassebaum评分系统进行评价,传统组关节功能为优10例,良3例,一般2例,优良率86.7%;改良组关节功能为优11例,良1例,一般1例,优良率92.3%;两组优良率比较有统计学意义。结论：对于肱骨小头骨折,克氏针张力带较无头加压螺钉能提供更坚强固定,允许早期功能锻炼,临床效果较好。

肱骨近端脆性骨折Neer 3/4型手术并发症分析

目的:探讨肱骨近端脆性骨折Neer 3/4型手术治疗后的并发症发生情况。方法:对肱骨近端脆性骨折Neer 3/4型的老年患者50例均采用锁定接骨板进行治疗,随访时间为3~42个月,平均为23.45个月,最后一次随访时采用视觉疼痛评分(VAS)和Constant-Murley评分对治疗结果进行评估,分析年龄、性别、手术时间、受伤原因、骨折类型等因素对并发症发生情况的影响,比较并发症是否影响患者的治疗效果。结果:治疗后患者的VAS评分为(0.87±1.03)分,ConstantMurley评分为(87.56±11.34)分;50例患者中有9例患者出现不同类型的并发症,并发症的发生率18%,其中术后大结节移位1例、骨折延迟愈合1例、感染1例,螺钉穿出2例,肱骨头坏死3例,畸形愈合1例;不同性别、年龄、手术时间、受伤原因、骨折类型等因素在并发症的发生率方面差异无统计学意义(P>0.05),发生并发症患者的VAS评分和Constant-Murley评分与没有发生并发症的患者比较,差异有统计学意义(P<0.05)。结论:锁定接骨板能够有效治疗肱骨近端脆性骨折Neer3/4型,但仍发生一定的并发症,出现的并发症主要有术后大结节移位、骨折延迟愈合、感染、螺钉穿出、肱骨头坏死和畸形愈合,并发症的发生会影响患者的功能活动,因此术前要进行合理的评估和计划,手术操作时要严格规范操作,尽量避免并发症的发生。

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.

Nickel-Titanium swan-like memory connector: a new tool to treat humeral shaft nonunion

Objective: To explore a new strategy to treat humeral shaft nonunion efficiently. Methods: In the light of mechanical characteristics of Nickel Titanium memory and the anatomic morphology of humeral shaft, we designed the swan like shape memory alloy connector (SMC). SMC was clinically applied in treating 55 cases of humeral shaft nonunion. Success rate of nonunion repair, reinterventions, complications, range of motion, and patient satisfaction were evaluated. Results: Fifty five humeral shaft nonunion patients were treated with autogenous bone grafting and SMC internal fixation. The average follow up period was 32 months. In 50 patients with complete follow up data, 49 were recovered from nonunion by lamellar bone healing. The excellent and good rate was 98%; one patient suffering from re fracture in a fall refused further treatment. Neither infection nor re fracture after SMC extraction or joint dysfunction was found in the whole group. Conclusion: SMC facilitates safe internal fixation and bone grafting; its memory biomechanic properties promote osteosynthesis, resulting in accelerated and high quality healing of humeral shaft nonunion. SMC internal fixation with bone grafting is creative, efficient and promising in treating humeral shaft nonunion.

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

Unilateral external fixator in the treatment of lower third humeral shaft fractures

Objective: To retrospectively analyze the effect of unilateral external fixators in the treatment of lower third humeral shaft fractures.Methods: From October 1997 to October 2003, 33 patients aged 15 -70 years (average 31 years) with lower third humeral shaft fractures were treated with unilateral external fixators. There were 9 spiral fractures (type A1), 1 oblique fracture (type A2), 3 transverses fractures (type A3) and 20 comminuted fractures (11 type B1, 9 type B2) according to AO classification. Fifteen cases were treated with open reduction and limited internal fixation and fixation with external fixators, 10 cases treated with open reduction and fixation with external fixators, and 8 cases treated with closed reduction and fixation with external fixators. Nerve exploration was undertaken in 9 cases with preoperative radial nerve injury. External fixators were removed after bone healing. The average follow-up was 18 months with a range from 8 to 24 months. Results: The time of bone healing ranged 11-22 weeks (average 14 weeks). The latest follow-up showed the functions of 9 cases of preoperative radial nerve injury and of 2 cases postoperative radial nerve injury and the function of elbow were recovered to normal. There were only 7 cases of superficial infection at pin hole, which was subsided by using oral antibiotics and pin-hole care with mild disinfectants.Conclusions: Fixation with unilateral external fixators combined with open reduction and limited internal fixation has a good effect in the treatment of lower third humeral shaft fractures.

Open reduction and internal fixation for displaced supracondylar fractures of the humerus in children with crossed K-wires via lateral approach

Objective： To assess the therapeutic results of open reduction and internal fixation with crossed K-wires via lateral approach for displaced supracondvlar fractures of the humerus in children. Methods： We prospectively followed 52 children who presented with Gartland type 3 displaced supraeondylar fractures of the humerus and were managed by open reduction and internal fixation with crossed K-wires via lateral approach.There were 37 male and 15 female patients; average age was 7.39 years. The most common mechanism of trauma was fall while playing （n=23）, followed by fall from height （n=20）, road traffic accidents （n-5） and fall from standing height （n=2）. In 2 cases, mode of injury was not available. The mean follow-up was 12 months and patients were assessed according to Flynn＇s criteria. Results： Lateral approach provided an excellent view of the lateral column between two nervous planes and enabled an anatomical reduction in all cases. Immobilizing the elbow at 90 degrees or more of flexion was not needed after cross K-wire fixation. Majority of patients regained full range of motion within 6 weeks of pin removal. Two patients had postoperative ulnar nerve injuries that resolved after pin removal. The common late complication of cubitus varus was not seen in any patient. Delayed presentation to the emergency department, repeated manipulations by bone setters and massage with edible oil were responsible for stiffness in 5 patients. Superficial pin tract infection was noted in 5 patients that resolved with dressings and antibiotics. No deep infection occurred. A detailed clinical examination and radiographic analysis was done at final follow-up. They included measurement of carrying angle and range of movements of both operated and normal sides, and radiographs of both upper limbs for comparison. According to Flynn＇s criteria, 90.4% patients showed satisfactory results. Conclusion： Lateral approach for open reduction and internal fixation of the widely-displaced supracondylar fracture of the humerus is safe and straightforward, ensuring anatomical reduction and excellent function. The approach is easy and familiar to most orthopedic surgeons in our setup.

Proximal humeral fractures treated with arthroplasty

Objective: To explore arthroplasty in treating 3- and 4-part fractures of the proximal humerus. Methods: A total of 132 patients with proximal humeral fractures were treated in our hospital from July 1997 to February 2003. According to Neer’s classification, the fractures of 45 patients (14 males and 31 females, aged 31-78 years, 56.1 years± 7.8 years on an average) belonged to 3- or 4-part fractures (10 patients with 4-part fracture and 35 with 3-part comminuted fracture) and they were treated with shoulder joint arthroplasty. Unipolar prosthesis replacement of the head of humerus was made in 28 cases, while bipolar prosthesis replacement in 2 cases and total shoulder joint replacement in 15 cases. Results: During the follow-up period (range: 12-72 months, mean: 37.3 months± 4.1 months), among the 45 patients who suffered from fractures of the proximal humerus and underwent arthroplasty surgery, 44 patients ( 97.8%) had no postoperative pain and were satisfied with the active range of motion and with the whole treatment results. And radiography showed that the prostheses were at their good position. One patient had postoperative pain because he had so narrow medullary cavity that the humeral prosthesis could not be put deeply enough and the prosthesis head was a little higher over the anatomic level. He did not have good postoperative active range of motion, either. Then he received a review surgery and got satisfied results. Temporary shoulder stiffness was observed in one patient. Manual release of these adhesions improved the shoulder function. No evidence of nonunion of the fracture segments around the humeral prosthesis stem was found. Conclusions: Shoulder arthroplasty is a dependable method to restore the comfort and function of the should joints of the patients with 3- or 4-part fractures of the proximal humerus.

Coupled exofixator for comminuted fracture of humeral shaft

Objective: To report and assess the efficacy of a coupled exofixator in the treatment of comminuted fracture of the humeral shaft.Methods: From June 1999 to September 2003, 24 patients with comminuted fracture of the humeral shaft were treated in our department, in whom 11 were involved in left humerus fractures and 13 in right humerus fractures. Closed reduction or open reduction with a small incision as well as a coupled exofixator was used to treat these patients. Results: All cases got anatomical reduction after 6-12 months follow-up. The time for fracture union averaged 5.8 months with a good functional recovery of the shoulder-elbow joints. Conclusions: The coupled exofixator is favorable to the treatment of comminuted humeral shaft fractures. It can shorten union time and avoid nonunion occurrence.

Closed reduction and percutaneous pinning of displaced supracondylar fractures of humerus in children with delayed presentation

Objective： Supracondylar fractures of the humerus account for 60% of all the fractures around the pediatric elbow and even in developed countries 18% of patients undergo surgery 48 hours or longer following presentation in the hospital. Management guidelines are not clear yet for these patients who present late. The aim of this prospective study was to evaluate the clinical, radiological and functional outcome following closed reduction and percutaneous pinning of widely displaced supracondylar fractures of the humerus presenting 12 hours or more after injury.Methods： We reviewed the functional and radiological results of closed reduction and percutaneous pinning using crossed K-wires in 40 patients with displaced extension type supracondylar fracture of the humerus （Gartland type Ⅲ） with a delay of more than 12 hours in presentation. The average age of patients was 4.5 years and the mean delay in presentation was 17.55 hours.Results： Closed reduction and percutaneous pinning was successful in 90% of patients. The mean follow up period was 15 months. The Baumann＇s angle was restored within 4 degrees of the unaffected side in all patients. Use of a small medial incision in patients with severe swelling helped us avoid ulnar nerve injury. Using Flynn＇s criteria,38 patients （95%） had an excellent result. Two patients had mild myositis and both had a poor result. None of the patients developed cubitus varus.Conclusion： Closed reduction and crossed pinning of displaced supracondylar fractures of humerus in children is a safe and effective method even with delayed presentation.

Bilateral traumatic proximal humerus fractures managed by open reduction and internal fixation with locked plates

Fractures of the proximal humerus are uncommon in young patients.Although bilateral fracture of proximal humerus itself is rare,association with epilepsy and electrocution is frequent.Only one case of traumatic bilateral proximal humerus fracture has been reported in the literature.We report a rare case of bilateral traumatic displaced proximal humerus fractures in a 40 years old male patient,which was treated by means of open reduction and internal fixation with proximal humerus locked pates on both sides and obtained a good functional outcome.

Treatment of nonunions of humeral fractures with interlocking intramedullary nailing

Objective： To introduce the experience of treating nonunions of humeral fractures with interlocking intramedullary nailing. Methods： Twelve patients with humeral nonunions were treated with interlocking intramedullary nailing. The time interval between trauma and surgery was 10.5 months on average. Open reduction with anterograde approach was performed. Axial compression was specially applied to the fracture site with humeral nail holder after insertion of distal locked screws. Iliac bone grafting was added. Results： The average follow-up period was 21 months （ranging 9-51 months）. All patients achieved osseous union 5.8 months after treatment on average. Eleven patients hadgood functions of the shoulder joints and the upper extremities. No patient experienced any permanent neurological deficit. Refracture of the original ununited region occurred in one patient after removal of the internal fixator one year later, but union was achieved after closed re-intramedullary nailing fixation. Conclusion： Humeral interlocking intramedullary nailing is an effective alternative treatment for humeral nonunion.

A severely displaced metaphyseal fracture of the proximal humerus with dislocation of the shoulder in a child

Fracture of the proximal humerus meta- physis with coexistent dislocation of the shoulder in chil- dren is a rare injury. The injury often occurs as a conse- quence of high velocity trauma. Most fractures of the proxi- mal humerus commonly associated with the epiphysis in children can be treated with closed reduction. We presented a case of 5-year-old girl who sustained this type of fracture-dislocation of the shoulder. Open reduction and internal fixation with multiple smooth K-wires was performed. At two years follow-up, the patient was pain free and regained full range of motion.

latrogenic brachial artery injury during anterolateral plat- ing of humeral shaft fracture

There are several well defined indications for surgical management of humeral shaft fractures.Operative procedures on the humerus are associated with their own complications.Iatrogenic brachial artery injury as a complication of humeral shaft plating has not been reported previously.We report a case of a 48 years old femalewho received operation at a district hospital and was referred to us when the surgeon could not palpate the pulse.CT angiogram showed that there was segmental non-opacification of the brachial artery.There was distal reformation and the thrombosis was decided to be managed conservatively.We believe that the arterial injury was a result ofimproper surgical technique and the segmental block might be due to improper use of plate holding forceps.This case report makes us aware of a rare complication of operative management of humeral shaft fractures and that basic principles of surgery must be always followed to prevent such injuries.

Surgical treatment of proximal humerus fractures using PHILOS plate

Objective：To evaluate functional outcome and complications of open reduction and internal fixation with proximal humeral internal locking system （PHILOS） plate for proximal humerus fractures.Methods：We reviewed 51 patients who underwent open reduction and internal fixation with PHILOS plate between the years 2007 to 2012.There were 35 men and 16 women with a mean age of 38 years （range 24-68）.There were 41 patients in the age group of ＜60 years and 10 patients in the age group of ＞60 years.According to Neer classification system,8,15 and 23 patients had 2-part,3-part,and 4-part fractures,respectively and 5 patients had 4-part fracture dislocation.All surgeries were carried out at our tertiary care trauma centre.Functional evaluation of the shoulder at final follow-up was done using Constant-Murley score.Results：The mean follow-up period was 30 months （range 12-44 months）.Two patients were lost to followup.Of the remaining 49 patients,all fractures were united clinically and radiologically.The mean time for radiological union was 12 weeks （range 8-20 weeks）.At the final follow-up the mean Constant-Murley score was 79 （range 50-100）.The results were excellent in 25 patients,good in 13 patients,fair in 6 patients and poor in 5 patients.During the follow-up,four cases of varus malunion,one case of subacromial impingement,one case of deep infection,one case of intraarticular screw penetration and one case of failure of fixation were noted.No cases of avascular necrosis,hardware failure,locking screw loosening or nonunion were noted.Conclusion：PHILOS provides stable fixation in proximal humerus fractures.To prevent potential complications like avascular necrosis,meticulous surgical dissection to preserve vascularity of humeral head is necessary.

Missed posterior shoulder dislocation with malunited proximal humerus fracture

Posterior dislocation of the shoulder may be missed or neglected at initial presentation especially in developing countries.We present a case of 40-year-old Indian man who had 3-month missed posterior dislocation of the right shoulder along with malunited fracture of the anatomical neck of the humerus.Open reduction and stabilization with modified McLaughlin procedure was performed.Rotational osteotomy of proximal humerus had to be performed as supplementary procedure to keep the humeral head stable in glenoid cavity during functional range of movements.The patient had excellent result of the shoulder at 3 years follow-up.

Epidemiologic pattern of paediatric supracondylar fractures of humerus in a teaching hospital of rural India： A prospective study of 263 cases

Purpose： This prospective study aimed to investigate the epidemiologic parameters of supracondylar humeral fractures in children admitted to a teaching institution of a developing country primarily catering to rural population, to find any preventable cause of such injuries. Methods： All suspected cases of supracondylar humeral fracture reporting to emergency or outpatients department were analysed for various epidemiologic parameters including age, sex, laterality, time of presentation, associated injuries, neurovascular complications and classification over a period of four years. Results： We analysed a total of 263 patients and most of the fractures were seen in 5-8-year age group with a mean of 7.9 years. A total of 157 cases were males and non-dominant extremity was involved in 65% of fractures in our series. Fall on outstretched hand was the predominant cause of injury and fall from rooftop was the predominant mode. In all patients, 36.12% reported to our hospital 1 week after injury, 39.92% presented to hospital within 48 h after trauma and the remaining 23.95% presented 48 h to 1 week after trauma. None had a bilateral injury. Gartland type 3 fractures constituted 54.37% of patients, followed by type 1 （23.95%） and type 2 （21.67%）. Conclusion： Almost one fourth of supracondylar humeral fractures in children can be prevented by installing railing of rooftops and stairs. It is necessary to educate people on hazards of treatment by traditional bonesetters. Moreover, the children with supracondylar humeral fractures should be screened for associated injuries.

Combined radial and median nerve injury in diaphysea fracture of humerus： a case report

Radial nerve palsy is the most common neurological involvement in humeral shaft fractures.But combined radial and median nerve injury in a closed diaphyseal fracture of the humerus is rare.Combined injury to both radial and median nerve can cause significant disability.A detailed clinical examination is therefore necessary following humeral shaft fractures.We report a patient with closed diaphyseal humeral fracture （AO 12A-2.3） together with radial and median nerve palsy,its management and review of the literature.As the patient had two nerves involved,surgical exploration was planned.Fracture was reduced and fixed with a 4.5 mm narrow dynamic compression pla te.There was no external injury to both radial and median nerves on surgical exploration.Neurological recovery started at 3 weeks＇ follow-up.Complete recovery was seen at 12 weeks.Careful clinical examination is of the utmost importance in early diagnosis of combined nerve injuries,which allows better management and rehabilitation of the patient.

Selection of approach and fixation in the treatment of type C fracture of distal humerus in adults

Objective：To study the surgical treatment for distal humeral fractures in adults according to the follow-up results.Methods： Twenty-one cases （16 males and 5 females）of distal humeral fracture were included in this study. The average age was 42.5 years （range： 37-52 years）. Fractures were classified according to the AO classification system.Nine cases of C1,8 C2 and 4 C3-type fractures were identified.Open reduction and internal fixation were performed in all cases. A tricep-reflecting approach was adopted, and either the AO orthogonal plating or parallel plating technique was chosen,based on the fracture type. The plaster cast was removed 3 weeks after operation. Rehabilitation was encouraged during this period and afterwards. The average follow-up time was 12.2 months （range： 8-28 months）. The outcome was scored according to Aitken and Rorabeek system.Results：No nerve injury,nonunion or failure of fixation was encountered during the operation and follow-up.However, ossifying myosifis occurred in one case.Conclusions：A triceps-reflecting approach can provide adequate exposure to the joint. The use of AO orthogohal plating or parallel plating techniques based on the type of fractures can provide rigid fixation for the fracture.