William Min

Proximal humeral malunion treated with reverse shoulder arthroplasty

BACKGROUND The purpose of this study was to determine the outcomes of patients with proximal humeral malunions treated with reverse shoulder arthroplasty (RSA). MATERIALS AND METHODS Sixteen patients were treated with RSA for sequelae of a proximal humeral fracture with a malunion. Clinical outcomes (American Shoulder and Elbow Surgeons [ASES] score, Simple Shoulder Test, visual analog scale [VAS] score for pain and function, range of motion, and patient satisfaction) and radiographs were evaluated at a minimum follow-up of 2 years. Wilcoxon signed-rank tests were used to analyze preoperative and postoperative data. RESULTS All patients required alteration of humeral preparation with increased retroversion of greater than 30°. The total ASES score improved from 28 to 63 (P = .001), ASES pain score from 15 to 35 (P = .003), ASES functional score from 15 to 27 (P = .015), VAS pain score from 7 to 3 (P = .003), VAS function score from 0 to 5 (P = .001), and Simple Shoulder Test score from 1 to 4 (P = .0015). Forward flexion improved from 53° to 105° (P = .002), abduction from 48° to 105° (P = .002), external rotation from 5° to 30° (P = .015), and internal rotation from S1 to L3 (P = .005). There were no major complications reported. Postoperative radiographic evaluation showed 2 patients with evidence of notching and 1 patient with proximal humeral bone resorption. CONCLUSION RSA is indicated for treating the most severe types of proximal humeral fracture sequelae. The results of RSA for proximal humeral malunions with altered surgical technique yield satisfactory outcomes in this difficult patient population.

Staged versus acute definitive management of open distal humerus fractures.

BACKGROUND Open distal humerus fractures are associated with soft tissue and bony injury. This study compares the results of a staged protocol using initial joint spanning external fixation and delayed definitive fixation to acute definitive fixation. METHODS Treated open distal humerus fractures were retrospectively reviewed, with patients examined at 2 weeks, 6 weeks, 12 weeks, 26 weeks, and 52 weeks after definitive surgery. Outcomes were determined radiographically by union rate and clinically by range of motion, Short Musculoskeletal Function Assessment, Short Form-36, and Mayo Elbow Performance Index. RESULTS Fourteen treated patients with open AO/OTA type 13-C3 distal humerus fractures, with average patient age 52.7 years and average follow-up 98.6 weeks, were identified. All fractures were treated with initial irrigation and debridement emergently and either spanning external fixation in eight patients or primary definitive internal fixation in six patients. All fractures healed, with average time to osseous healing, in 25.7 weeks versus 23.4 weeks (p=0.7) in staged versus primary definitive treatment, respectively. Elbow range of motion on final follow-up was 73.75° versus 94.17° (p=0.22). Complications included nonunions, heterotopic ossification, infection, and persistent ulnar nerve deficit. Average functional outcomes scores for staged management versus primary internal fixation were Short Form-36, 50.2 versus 68.2 (p=0.065); Short Musculoskeletal Function Assessment, 33.5 versus 12.5 (p=0.078); and Mayo Elbow Performance Index, 55.6 versus 84.2 (p=0.011), respectively. CONCLUSIONS Open distal humerus fractures had poor outcomes relative to normative functional scores; however, this is possibly due to more severe soft tissue injuries that were felt better managed with staged management at the time of presentation.

Young and Burgess Type I Lateral Compression Pelvis Fractures: A Comparison of Anterior and Posterior Pelvic Ring Injuries

The goals of this study were to find associations between anterior and posterior ring injuries, provide a descriptive comparison of pelvic ring disruptions as assessed by plain radiography, and compare the value of computed tomography (CT) over plain radiography in evaluating anterior and posterior structures. A retrospective review of radiographic reports and records identified 142 patients with pubic ramus fractures as observed by plain radiography. A statistical analysis was performed to test the associations between anterior ring injury as assessed by plain radiography and posterior ring injury as assessed by CT. Forty-five point five percent of patients with bilateral ramus fractures and 42.0% of patients with dual-ramus fractures had concomitant sacral fractures not observed on plain radiographs. These occult sacral fractures were found in only 11.1% of patients with inferior ramus fractures. The type of pubic injury on plain radiographs may be predictive of posterior ring injury, and therefore may help determine injury energy and severity, determine the need for further imaging studies, and help guide clinical management. Although CT is highly sensitive in identifying both anterior and posterior pubic ring injuries, elderly patients with simple fractures of a single pubic ramus are less likely to suffer from pelvic instability and thus may not benefit from CT.

Stress radiographs in orthopaedic surgery

&NA; Stress radiographs are useful in determining the amount of ligamentous laxity present following trauma. The results may be helpful in determining diagnosis, surgical indications, and the type and timing of rehabilitation. Some techniques for obtaining stress radiographs involve specific patient positioning or manually applied force; others require use of a particular testing device. Stress radiographs may be obtained for a variety of anatomic areas and joints. The parameters that define abnormality on stress radiographs should be compared with those of clinical findings. The use of common and novel methods to obtain stress radiographs has led to improved identification and diagnosis of many orthopaedic pathologies. Some of these techniques have been developed with the aim of reducing patient discomfort or minimizing the clinicians exposure to radiation.

Hypoplasia of the Trapezius and History of Ipsilateral Transient Neonatal Brachial Plexus Palsy

We present two children with hypoplasia of the left trapezius muscle and a history of ipsilateral transient neonatal brachial plexus palsy without documented trapezius weakness. Magnetic resonance imaging in these patients with unilateral left hypoplasia of the trapezius revealed decreased muscles in the left side of the neck and left supraclavicular region on coronal views, decreased muscle mass between the left splenius capitis muscle and the subcutaneous tissue at the level of the neck on axial views, and decreased size of the left paraspinal region on sagittal views. Three possibilities can explain the association of hypoplasia of the trapezius and obstetric brachial plexus palsy: increased vulnerability of the brachial plexus to stretch injury during delivery because of intrauterine trapezius weakness, a casual association of these two conditions, or an erroneous diagnosis of brachial plexus palsy in patients with trapezial weakness. Careful documentation of neck and shoulder movements can distinguish among shoulder weakness because of trapezius hypoplasia, brachial plexus palsy, or brachial plexus palsy with trapezius hypoplasia. Hence, we recommend precise documentation of neck movements in the initial description of patients with suspected neonatal brachial plexus palsy.

Orthopaedic Trauma in the Elderly

Injuries to the musculoskeletal system in the elderly can be devastating. Many medical and social factors specific to older patients require special consideration when dealing with these injuries both acutely and throughout their rehabilitation. The geriatric segment of the population is rapidly growing and sustains a disproportionate number of fractures compared to others [1–3]. The specific goal of all orthopaedic care is to restore patient function to a preinjury level. Decreased bone stock, muscular weakness, systemic disease, and poor mentation are some challenges that make a return to independent living status difficult following such injuries. Immobilization and the use of devices to assist in ambulation (crutches, walkers, and wheelchairs) may require an elderly patient to be subjected to institutional care for an extended period of time. The following is an overview of the etiology, pathophysiology, and treatment considerations in treating geriatric patients with fractures and associated injuries.