Humeral medial epicondyle fractures in the pediatric population account for up to 20% of elbow fractures, 60% of which are associated with elbow dislocation. Isolated injuries can occur from either ...direct trauma or avulsion. Medial epicondyle fractures also occur in combination with elbow dislocations. Traditional management by cast immobilization increasingly is being replaced with early fixation and mobilization. Relative indications for surgical fixation include ulnar nerve entrapment, gross elbow instability, and fractures in athletic or other patients who require high-demand upper extremity function. Absolute indications for surgical intervention are an incarcerated fragment in the joint or open fractures. Radiographic assessment of these injuries and their true degree of displacement remain controversial.
•Open reduction internal fixation is sometimes impossible in distal humerus fractures in adults due to extensive comminution and bone loss.•Elbow Hemi-Arthroplasty (EHA) is a reasonable option for ...unreconstructible intra-articular distal humerus fractures in patients over the fifth decade.•The implant removes complications related to the ulnar component such as wear of the hinge or aseptic loosening of the ulnar component. It does bring potential disadvantages such as risk of instability with possible wear and progressive joint osteoarthrosis.
The surgical management of distal humerus fractures in adults generally consists in open reduction internal fixation (ORIF) or total elbow arthroplasty (TEA). Hemi humeral hemiarthroplasty (EHA) is a treatment option for unreconstructable intra-articular distal humerus fractures. It is a reasonable option in patients over the fifth decade and its potential advantages are to eliminate the complications related to the ulnar component such as wear of the hinge (busching wear) or the aspetic loosening of the ulnar component. The potential disadvantages are the risk of instability with the possibility of a wear and progressive joint osteoarthrosis. The aims of this manuscript are to evaluate the indications in which we used the EHA, analyzing the correct surgical technique and describe the outcomes in medium and long-term follow-ups. Between 2006 and 2019, we performed 51 EHAs at the Hesperia Hospital in Modena and at the Rizzoli Orthopedic Institute. Taking into consideration only the cases of acute fractures, 27 patients (27 elbows) with a minimum follow-up of 12 months were identified. The patient's mean age at the time of surgery was 64 years old (range from 45 to 78 years old) and they were 78% female (21 out of 27). The Latitude Tornier implant was used in all the patients of our group. The mean MEPS was 89.3 points (from 50 to 100 pts) with excellent results in 19 patients, good in 5, one fair and 2 poor;the mean DASH was 12.6 (from 3.3 to 45.8); the mean OES was 42.3 (from 22 to 47). Complications, were found in 12 patients and any patients required a TEA conversion. Distal humerus hemiarthroplasty from our experience is a good option for the surgical management of unrecostructible distal humeral fractures in selected patients. It is important to perform a precise surgical technique; preserve the triceps insertion, preserve or repair the collateral ligaments, fix the condylar bones implant the prosthesis at the correct size, depth and rotation. The majority of the complication that we observed are related to the stiffness and not to the progressive degenerative changes of the articular surface
The 'pink, pulseless hand' is often used to describe the clinical situation in which a child with a supracondylar fracture of the humerus has normal distal perfusion in the absence of a palpable ...peripheral pulse. The management guidelines are based on the assessment of perfusion, which is difficult to undertake and poorly evaluated objectively. The aim of this study was to review the available literature in order to explore the techniques available for the preoperative clinical assessment of perfusion in these patients and to evaluate the clinical implications. A systematic literature review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered prospectively with the International Prospective Register of Systematic Reviews. Databases were explored in June 2022 with the search terms (pulseless OR dysvascular OR ischaemic OR perfused OR vascular injury) AND supracondylar AND (fracture OR fractures). A total of 573 papers were identified as being suitable for further study, and 25 met the inclusion criteria for detailed analysis. These studies included a total of 504 patients with a perfused, pulseless limb associated with a supracondylar humeral fracture. Clinical examination included skin colour (23 studies (92%)), temperature (16 studies (64%)), and capillary refill time (13 studies (52%)). Other investigations included peripheral oxygen saturation (SaO2) (six studies (24%)), ultrasound (US) (14 (56%)), and CT angiogram (two studies (8.0%)). The parameters of 'normal perfusion' were often not objectively defined. The time to surgery ranged from 1.5 to 12 hours. A total of 412 patients (82%) were definitively treated with closed or open reduction and fixation, and 92 (18%) required vascular intervention, ranging from simple release of entrapped vessels to vascular grafts. The description of the vascular assessment of the patient with a supracondylar humeral fracture and a pulseless limb in the literature is variable, with few objective criteria being used to define perfusion. The evidence base for decision-making is limited, and further research is required. We were able, however, to make some recommendations about objective criteria for the assessment of these patients, and we suggest that these are performed frequently to allow the detection of any deterioration of perfusion.
Operative fixation is indicated for most type-II and III supracondylar humeral fractures in order to prevent malunion. Medial comminution is a subtle finding that, if treated nonoperatively, is ...likely to lead to unacceptable varus malunion. Angiography is not indicated for a pulseless limb, as it delays fracture reduction, which usually corrects the vascular problem. A high index of suspicion is necessary to avoid missing an impending compartment syndrome, especially when there is a concomitant forearm fracture or when there is a median nerve injury, which may mask symptoms of compartment syndrome. Lateral entry pins have been shown, in biomechanical and clinical studies, to be as stable as cross pinning if they are well spaced at the fracture line, and they are not associated with the risk of iatrogenic ulnar nerve injury.
Supracondylar humeral fractures are the most common elbow fractures in children and represent 3 % of all paediatric fractures. The most common cause is a fall onto an outstretched hand with the elbow ...in extension, resulting in an extension-type fracture (97–99 % of cases). Currently, the Gartland classification is used, which has treatment implications. Diagnosis is based on plain radiographs, but accurate imaging could be limited due to patient pain. Based on fracture type, the definitive treatment could be either non-operative (type I) or operative (type III/IV); however, when handling type II fractures controversy remains. Neither pin configuration have shown higher efficacy over the other. Complications are ~1 %, the most common being pin migration, with compartment syndrome as the most devastating. Overall, functional outcomes are good, and physical therapy does not appear to be necessary.
The incidence of osteoporotic distal humeral fractures (DHF) is on the rise. Their operative management is demanding. Fixation with non-locking reconstruction plates was associate with a high number ...of complications. Elbow arthroplasty (total or hemi) has been proposed as an alternative treatment, in spite of lifetime activity restrictions, and risk of complications, unknown implant survival and problematic revision surgery. Precontoured anatomical locking plates have increased the strength of the fixation in complex fractures.
double plating ORIF with precontoured anatomical locking plates is a safe and reliable treatment option for the management of AO/OTA type C3 DHF in patients aged 75 and older.
A retrospective case series study of patients aged 75 years old and older with an AO/OTA type C3 DHF treated with ORIF with double precontoured anatomical locking plates between 2007 and 2021. Pathologic fractures were excluded. Patients' demographic, surgical, clinical, and radiological data were reviewed.
A total of 27 women and 3 men, mean age of 80.1 years (range 75-93 years), were included. Mean Charlson index was 5 (range 3-8). Out of 30 patients, 19 had already died. Mean survival time after the surgical treatment was 72.3 months. Mean Mayo elbow performance score was 88.9 (range 60-100); 23 patients scored excellent or good. All fractures healed with no cases of delay union or non-union, hardware failure or loss of reduction. No patient needed a revision surgery to arthroplasty. The total number of complications was 12 (40%), mainly ulnar neuropathy (5) and cerclage removal (4).
ORIF with double pre-contoured locking plates may be a safe and reliable treatment for type C3 DHF in patients aged 75 years and older, with a good functional outcome. Complications are expected but not related to loss of reduction, fixation failure or revision to elbow arthroplasty.
Outbreaks of humeral fractures in dairy cows have been reported in New Zealand for several years. Gross, histologic, and histomorphometric findings in the humerus from primiparous cows with ...spontaneous humeral fracture were compared to age-matched control cows. Affected cows had a complete nonarticular spiral fracture of the humerus. Histologically affected humeri had a thicker growth plate with abnormal architecture, thinner cortex with increased abnormal resorption, increased resorption in the distal humerus, decreased trabecular density, abnormal trabecular architecture, presence of growth arrest lines and woven bone formation. Histomorphometry showed reduction in bone volume, trabecular perimeter, and trabecular width. Cows grazed on fodder beet had thicker growth plates with an abnormal appearance compared with cows grazed on pasture, and cows with low/marginal liver copper concentration had more resorption cavities in the distal humerus and thinner cortical bone compared with cows with adequate liver copper concentration. Decreased trabecular density (OR = 249.5), abnormal cortical resorption (OR = 54.2), presence of woven bone formation in the proximal metaphysis (OR = 37.2), and the number of resorption cavities in the distal humerus were significantly associated with a high probability of fracture. Ribs had enlargement of the costochondral junction with fractures in different stages of healing. Histology of the ribs revealed abnormal growth plate appearance, presence of fracture lines, callus tissue, fibrosis, and microfractures. Cows with humeral fracture have osteoporosis due to decreased bone formation and increased bone resorption, likely associated with inadequate feed quality and perhaps copper deficiency leading to a reduction in bone strength and fracture.
Acute osteomyelitis in children Peltola, Heikki; Pääkkönen, Markus
The New England journal of medicine,
01/2014, Letnik:
370, Številka:
4
Journal Article
