Chris Huber

Proximal humeral fractures: The role of calcium sulphate augmentation and extended deltoid splitting approach in internal fixation using locking plates

UNLABELLED The aim of our study is to analyse the results of our surgical technique for the treatment of proximal humeral fractures and fracture dislocations using locking plates in conjunction with calcium sulphate bone-substitute augmentation and tuberosity repair using high-strength sutures. We used the extended deltoid-splitting approach for fracture patterns involving displacement of both lesser and greater tuberosities and for fracture-dislocations. Optimal surgical management of proximal humeral fractures remains controversial. Locking plates have become a popular method of fixation. However, failure of fixation may occur if they are used as the sole method of fixation in comminuted fractures, especially in osteopenic bone. METHODS We retrospectively analysed 22 proximal humeral fractures in 21 patients; 10 were male and 11 female with an average age of 64.6 years (range 37-77). Average follow-up was 24 months. Eleven of these fractures were exposed by the extended deltoid-splitting approach. Fractures were classified according to Neer and Hertel systems. Preoperative radiographs and computed tomography (CT) scans in three- and four-part fractures were done to assess the displacement and medial calcar length for predicting the humeral head vascularity. According to the Neer classification, there were five two-part, six three-part, five four-part fractures and six fracture-dislocations (two anterior and four posterior). Results were assessed clinically with disabilities of the arm, shoulder and hand (DASH) scores, modified Constant and Murley scores and serial postoperative radiographs. RESULTS The mean DASH score was 16.18 and the modified Constant and Murley score was 64.04 at the last follow-up. Eighteen out of twenty-two cases achieved good clinical outcome. All the fractures united with no evidence of infection, failure of fixation, malunion, tuberosity failure, avascular necrosis or adverse reaction to calcium sulphate bone substitute. There was no evidence of axillary nerve injury. Four patients had a longer recovery period due to stiffness, associated wrist fracture and elbow dislocation. The CaSO4 bone substitute was replaced by normal appearing trabecular bone texture at an average of 6 months in all patients. CONCLUSION In our experience, we have found the use of locking plates, calcium sulphate bone substitute and tuberosity repair with high-strength sutures to be a safe and reliable method of internal fixation for complex proximal humeral fractures and fracture-dislocations. Furthermore, we have also found the use of the extended deltoid-splitting approach to be safe and to provide excellent exposure facilitating accurate reduction for fixation of the fracture patterns involving displacement of both lesser and greater tuberosities and for fracture-dislocations.

Challenges and solutions in the fixation of a hip fracture in the presence of a contralateral ankylosed hip: a case report

Background An intracapsular femoral neck fracture is a common orthopaedic presentation and requires expedient fixation in a young adult. This case demonstrates how patient-specific factors, namely an ankylosed contralateral hip, can make a common operation challenging. Case Description A 22-year-old man with osteogenesis imperfecta and multiple bony deformities was brought to A&E after being involved in a motor vehicle collision. Plain radiographs and clinical examination demonstrated a right intracapsular femoral neck fracture, ipsilateral femora vara and a contralateral ankylosed hip secondary to protrusio acetabuli. The intraoperative patient and fluoroscopic positioning were technically challenging. Clinical Relevance Preoperative literature review revealed no operative strategy or case report describing how best to perform closed reduction and internal fixation of a femoral neck fracture with a co-existing contralateral ankylosed hip joint. We hope our experience will aid other surgeons who find themselves in a similar clinical scenario. We will present the difficulties faced and the adaptations made to our surgical technique which we utilised to achieve an anatomical fixation.

Lateral meniscal cyst presenting as Medial Compartment Knee Swelling: A case report and literature review

INTRODUCTION Meniscal cysts are relatively uncommon orthopaedic lesions usually arising from the meniscus. They present as clinically palpable masses and dull pain. PRESENTATION OF CASE We report on a 33-year-old male patient who presented clinically with a medial knee swelling that arose from a lateral meniscal cyst. DISCUSSION No similar cases were cited in the literature. The cyst was removed surgically with a good result obtained and no recurrence after 12 months. Typically, a clinically palpable mass corresponds to a meniscal cyst arising from the ipsilateral meniscus. CONCLUSION Magnetic resonance imaging is vital to exclude such anomalies prior to surgical intervention.