Treatment of the surgical neck fracture of the humerus with a novel external fixator in the elderly with osteoporosis: biomechanical analysis

Bone cemented K-wire fixation versus elastic stable intramedullary nailing fixation of paediatric proximal humerus fractures: A prospective cohort study

BACKGROUND

The objective of this study is to compare the treatments of pediatric displaced proximal humerus fractures with external-fixation technique using the combination of K-wires and bone-cement versus close reduction and internal fixation technique using elastic stable intramedullary nail.

METHODS

From April 2016 to March 2020, 72 children with proximal humeral fractures were allocated to group A and 44 children with proximal humeral fractures were allocated to group B. Patients in group A were treated with bone-cemented K-wire fixation, and patients in group B were treated with elastic stable intramedullary nailing. The function of the upper limb was assessed using the Shortened Version of the Disabilities of the Arm, Shoulder and Hand questionnaire and Neer score. Patient satisfaction was assessed using the 10-cm visual analogue scale.

RESULTS

Bone healing was achieved in group A and B after a mean time of 6.1 ± 1.2 and 6.4 ± 1.1 weeks, respectively. The mean surgical time of groups was 33 ± 9 and 54 ± 12 minutes, respectively. The mean Quick Disabilities of the Arm, Shoulder and Hand questionnaire score of groups were 0.5 ± 1.4 and 0.7 ± 1.5, respectively. Based on Neer score, we obtained 69 excellent and 3 good results in group A, and 41 excellent and 3 good results in group B. There were significant differences regarding duration of operation, cost of treatment, and postoperative angle at bone healing (P < .05).

CONCLUSIONS

The external cemented K-wire fixation is a useful and reliable alternative technique for the treatment of severely displaced proximal humerus fractures in children. The technique is a minimally invasive procedure with minimal complications.

Readmission, Reoperation, and Non-home Discharge Rates in Patients Receiving Surgical Treatment for Proximal Humerus Fractures

Background

Proximal humerus fractures (PHFs) are generally surgically treated with open reduction internal fixation (ORIF), hemiarthroplasty (HA), or total shoulder arthroplasty (TSA). Diverse fracture patterns and a high prevalence in the elderly population make it difficult to establish objective guidelines for the decision to undergo surgical treatment. The purpose of this study was to investigate risk factors associated with readmission, reoperation, and nonhome discharge following ORIF, HA, and TSA for PHFs.

Methods

Data on all patients who underwent ORIF, TSA, or HA for treatment of closed PHF between 2015 and 2017 were obtained by querying the American College of Surgeons National Surgical Quality Improvement database. Rates of postoperative readmission, nonhome discharge, and reoperation within 30 days were collected. Multivariate logistic regression was employed to identify predictors of readmission, nonhome discharge, and reoperation.

Results

A total of 2825 patients were included in this study: 1829 underwent ORIF, 707 underwent TSA, and 289 underwent HA. The significant predictors for readmission were having an American Society of Anesthesiologists class ≥ 3 (odds ratio [OR] 1.95, P = .003) and being of dependent functional status (OR 3.15, P < .001). The significant predictors for reoperation were male sex (OR 2.41, P < .001) and dependent functional status (OR 2.92, P = .006). The significant predictors for nonhome discharge were age 66-80 years (OR 7.00, P < .001), age ≥ 81 years (OR 16.31, P < .001), American Society of Anesthesiologists ≥3 (OR 2.34, P < .001), dependent functional status (OR 2.48, P < .001), and inpatient status (OR 3.32, P < .001). TSA showed slightly higher rates of nonhome discharge than HA and ORIF.

Conclusion

Significant risk factors for readmission, reoperation, and nonhome discharge within 30 days following surgical treatment for PHF were identified. Additionally, TSA was significantly associated with nonhome discharge compared with HA and ORIF.

Surgical Management of Proximal Humerus Fractures in Patients With Common Injury-Specific Comorbidities

When evaluating a humeral neck fracture for surgical intervention, it is prudent to evaluate the patient for the common injury-specific comorbidities of alcoholism and osteoporosis, as the presence of either of these conditions, require additional considerations to prevent complications.

This case presents a 63-year-old female who presented for evaluation after multiple falls. She was discharged from an outside facility one week prior with a left (nondominant extremity) humeral neck fracture. Her condition was complicated by alcohol use disorder with recent heavy alcohol use. On hospital stay day one, orthopedic surgery performed an initial assessment and deemed her fracture to be nonoperative due to medical comorbidities. On hospital stay day three, the patient requested a second opinion from orthopedic surgery due to continued increased pain and concern for the long-term function of her left upper extremity. The second opinion found that the fracture would be best managed by surgical intervention now that she had been medically optimized since admission. On hospital stay day five, she was taken to the operating room for planned percutaneous intramedullary nail placement with closed reduction of the fracture. Intraoperatively, the percutaneous procedure had to be converted to an open procedure due to the difficult nature of her osteoporotic bone in terms of performing a closed reduction. This case discusses the various methods for surgical management and guidelines for optimizing patients with the fracture-specific common comorbidities of alcohol use disorder and osteoporosis. The novelty of this case includes the rarity of a patient with both the major predisposing factors to proximal humerus fractures and includes a literature review of the latest recommendations for surgical management.

The use of external fixation in the emergency department: applications, common errors, complications and their treatment

The use of an external fixator (EF) in the emergency department (ED) or the emergency theatre in the ED is reserved for critically ill patients in a life-saving attempt. Hence, usually only fixation/stabilization of the pelvis, tibia, femur and humerus are performed. All other external fixation methods are not indicated in an ED and thus should be performed in the operating room with a sterile environment.

Anterior EF is used in unstable pelvic lesions due to anterior-posterior compression, and in stable pelvic fractures in haemodynamically unstable patients.

Patients with multiple trauma should be stabilized quickly with EF.

The C-clamp has been designed to be used in the ED to stabilize fractures of the sacrum or alterations of the sacroiliac joint in patients with circulatory instability.

Choose a modular EF that allows for the free placement of the pins, is radiolucent and is compatible with magnetic resonance imaging (MRI).

Planning the type of framework to be used is crucial.

Avoid mistakes in the placement of EF.

Cite this article: EFORT Open Rev 2020;5:204-214. DOI: 10.1302/2058-5241.5.190029