Thesis (doctoral)--Freie Universität Berlin, 1979.

This dissertation discusses distal humeral epiphyseal injuries in children, i.e. lateral condylar fractures, medial condylar fractures, fracture-separation of the distal humeral epiphysis and T-condylar fractures. Medial and lateral epicondylar fractures, being apophyseal, are excluded. The research was done at the Red Cross Children's Hospital Trauma Unit. It was based on two clinical retrospective studies and one case report: a: 60 lateral condylar fractures presenting from 1984 to 1987 -were reviewed. b: 12 fracture-separations of the distal humeral epiphysis presenting from 1984 to 1989 were reviewed. c: One case report of a medial condylar fracture with associated elbow dislocation The distal humeral epiphysis is the second most commonly injured epiphysis in the body, after that of the distal radius (Peterson 1972). Supracondylar fractures are the most common fractures around the elbow in children, making up 65% of the total (Canale 1987). Lateral condyle fractures have an incidence of 17.4%, compared to 3.2% for medial condylar fractures and 0.8% for T-condylar fractures (Canale 1987). At the Red Cross Children's Hospital, 60 displaced supracondylar fractures, 20 lateral condylar fractures and 2 to 3 fracture-separations of the distal humeral epiphysis are seen every year. Medial condylar fractures are rare.

M.Med., Orthopaedic Surgery, Faculty of Health Sciences, University of the Witwatersrand, 2010

No description available.

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2007. / Härtill 4 uppsatser.

O tratamento de fraturas umerais distais em aves impõe grande dificuldade, devido a córtices muito finas dos ossos A artrodese com fixador externo da articulação úmero-rádio-ulnar é inviável para aves que se pretende reintroduzir ao meio ambiente. Doze animais foram divididos em dois grupos: cirurgias bilaterais com anquilose de uma asa (asa estática) e manutenção da articulação da outra (asa dinâmica) (grupo 1), e cirurgia unilateral, com manutenção da função da articulação (asa dinâmica), sendo a outra controle (asa intacta) (grupo 2). Foram feitas avaliações clínicas, radiológicas, morfológicas do osso, histomorfométricas (de ambos os grupos) e de capacidade de vôo (grupo 2). A 6 semanas, todos os animais apresentavam fraturas consolidadas, com excessão de dois animais do grupo 1, que somente apresentaram consolidação das asas dinâmicas às 9 semanas e das estáticas às 12 semanas. Todos os animais do grupo 2 apresentaram capacidade de vôo adequada, antes de 13 semanas após a cirurgia. No grupo 1 o úmero da asa dinâmica representava 99,1% do comprimento do da asa estática, e no grupo 2, estes eram 99,5% em relação à asa intacta. A amplitude da asa, no grupo 2, demonstrou que a relação da asa dinâmica/intacta foi de 93%, e no grupo 1 a relação asa dinâmica/estática foi de 105%. O volume do osso intacto foi de aproximadamente 29% da área estudada, enquanto o da asa estática foi de 19% e das asas dinâmicas, de 22%. Houve diferença entre o número de osteoblástos das asas intactas e dinâmicas, porém não houve diferença entre as asas estáticas e intactas e entre as dinâmicas e as estáticas, e também não houve diferença do número de osteoclástos entre nenhum tipo de asa. A razão da superfície óssea pelo volume ósseo indica a quantidade de áreas de reabsorção. Não houve diferença entre as asas estática e dinâmica, porém houve diferença entre estas e os controles. O método proposto de técnica para fixação de fraturas umerais distais, sem a anquilose da articulação úmero-rádio-ulnar, demonstrou ser efetivo em manter o comprimento ósseo, a amplitude da asa e assim, garantindo a capacidade de vôo das aves tratadas, além de demonstrar ser equivalente histológicamente à técnica tradicional e mais estável de anquilose da articulação, para este tipo de fratura, e até mesmo, no período estudado, ser equivalente ao osso são, sendo um método adequado para a reparação de fraturas distais de úmero em aves quando se pretende a reabilitação destes animais. / The treatment of humeral distal fractures in birds is very difficult, because these bones are very brittle. Ankylosis of the humeral-radio-ulnar joint with an external fixator is unviable for birds intended for re-habilitation and reintroduction. Twelve animals were used and they were divided in two groups: bilateral surgeries, with ankylosis of one wing (static wing) and maintenance of the joint function of the other wing (dynamic wing) (group 1), and unilateral surgery, with maintenance of the joint function of the wing (dynamic wing), and the other was used as control group (intact wing) (group 2). Clinical, radiographic, morphologic and histomorphometric evaluations of the wings and bones (of both groups) and of evaluations of flight capacity (in group 2) were made. At 6 weeks, all animals had healed fractures, except two animals in group 1, that only presented consolidation of the dynamic wing at 9 weeks and the static wings at 12 weeks. All animals in group 2 were capable of flying before 13 weeks after surgery. In group 1, the humerus of the dynamic wing was 99.1% the length of that of the static wing, and in group 2, these were 99.5% compared to the intact wing. Wing amplitude, in group 2, showed a dynamic/ intact ratio of 93%, and in group 1 the dynamic/ static wing ratio was 105%. The volume of the intact bone was approximately 29% of the studied area, while in the static wing it was of 19% and in the dynamic wing, 22%. There was a difference in the number of osteoblasts of the intact and dynamic wings, but there was no difference between static and intact, and between dynamic and static wings, and also, there was no difference in the numbers of osteoclasts between any wings. The bone surface/ volume ratio indicates the amount of resorption areas. There was no significant difference between static and dynamic wings, but there was a difference between static and intact wings. The proposed method of distal humeral fracture fixation technique, without ankylosis of the humerus-radius-ulna joint, demonstrated being effective in keeping bone length, wing amplitude e therefore, guaranteeing flight capacity of the birds treated, as well as being histologically equivalent to the tradicional, more stable, joint ankylosis technique, for thise kind of fracture, and even, for the studied period, being equivalent to healthy bone, being an adequate method for fracture repair for this kind of fracture in birds, when one intends rehabilitation of these animals.

Εισαγωγή: Η θεραπεία των σύνθετων καταγμάτων του άνω πέρατος του βραχιονίου είναι αμφισβητήσιμη και παραμένει ένα θέμα διαρκούς αντιπαράθεσης στη διεθνή βιβλιογραφία. Οι ιδιομορφίες των καταγμάτων αυτών, η μικρή αξιοπιστία και αναπαραγωγικότητα των υπαρχόντων συστημάτων ταξινόμησης, η έλλειψη πολυκεντρικών προοπτικών ερευνών και ο μη καθορισμός αντικειμενικών κριτηρίων αξιολόγησης του θεραπευτικού αποτελέσματος, είναι μερικές μόνο από τις αιτίες που οδηγούν σε ασυμφωνία τους ερευνητές. Η επικρατούσα τάση στη διεθνή βιβλιογραφία σήμερα, επικεντρώνεται στις ελάχιστα παρεμβατικές τεχνικές οστεοσύνθεσης, που περιλαμβάνουν περιορισμένες αποκολλήσεις γύρω από τα κατεαγότα τμήματα, προσπάθεια διατήρησης της αιμάτωσης της κεφαλής και περιορισμό των μεταλλικών υλικών που απαιτούνται για την επίτευξη σταθερής οστεοσύνθεσης. Τα βασικά πλεονεκτήματα της μεθόδου που προτείνουμε είναι η ατραυματική προσπέλαση, η αποφυγή βίαιων χειρισμών επί του κατάγματος, η μη χρησιμοποίηση μεταλλικών υλικών οστεοσύνθεσης, η αποκατάσταση της ρήξης του μυοτενόντιου πετάλου και η χιαστί συγκράτηση των αποσπασθέντων τμημάτων της κεφαλής σε ένα ενιαίο τμήμα, δίκην ταινίας ελκυσμού (tension band effect), που επιτρέπει την σταθερή οστεοσύνθεση του κατάγματος και διευκολύνει την πρώιμη κινητοποίηση του ώμου. Υλικό-Μέθοδος: Την χρονική περίοδο 1991-2003 αντιμετωπίστηκαν χειρουργικά στην κλινική μας με τη μέθοδο της οστεοσυρραφής 214 ασθενείς. Πρόκειται για 123 γυναίκες και 91 άνδρες με πρόσφατο κάταγμα του άνω πέρατος βραχιονίου και μέσο όρο ηλικίας τα 52,7 έτη (από 18 έως 82 ετών). Συνολικά, με βάση την ταξινόμηση και τα κριτήρια του CS. Neer, αντιμετωπίστηκαν 71 κατάγματα 2-τμημάτων, 75 κατάγματα 3-τμημάτων και 64 κατάγματα 4-τμημάτων (48 ενσφηνωμένα σε βλαισότητα) καθώς και 4 περιπτώσεις με κάθετο διαχωρισμό της αρθρικής επιφανείας. Ο μέσος χρόνος παρακολούθησης ήταν 5.2 έτη και αφορούσε το 92% των ασθενών. Συνολικά 13 ασθενείς δεν προσήλθαν στον τελευταίο επανέλεγχο ενώ 4 απεβίωσαν για λόγους μη σχετιζόμενους με το κάταγμα ή την θεραπεία του, αφήνοντας 197 ασθενείς για πλήρη κλινική και ακτινολογική αξιολόγηση. Μελετήθηκαν και αξιολογήθηκαν όλα τα διεγχειρητικά ευρήματα, οι προεγχειρητικές και μετεγχειρητικές ακτινογραφίες, η επάρκεια και διατήρηση της ανάταξης, οι πρώιμες και απώτερες επιπλοκές, τα στοιχεία νοσηλείας, η επίπτωση μετεγχειρητικών φλεγμονών, η συμμόρφωση με το πρόγραμμα φυσιοθεραπείας, η ικανοποίηση του ασθενούς με τη θεραπεία και το τελικό κλινικό αποτέλεσμα, με βάσει τις παραμέτρους του Constant Score. Ακτινολογικά, η εξέλιξη της πώρωσης αξιολογήθηκε με προσθοπίσθια και διαμασχαλιαία ακτινογραφία στον 1ο, 3ο, 6ο και 12ο μήνα, καθώς και στον τελευταίο επανέλεγχο. Η παρουσία πλήρους ή τμηματικής άσηπτης νέκρωσης της κεφαλής, απορρόφησης ή παρεκτόπισης των ογκωμάτων, απώλειας της ανάταξης ή πώρωσης σε πλημμελή θέση, καθώς και οι όποιες ενδείξεις παρουσίας δευτεροπαθούς οστεοαρθρίτιδας και συνδρόμου υπακρωμιακής προστριβής κατεγράφησαν σε όλους τους ασθενείς που συμπεριελήφθησαν στη μελέτη. Σε 16 κατάγματα 4-τμημάτων εκπονήθηκε επιπλέον κλινική αγγειογραφική μελέτη για την διερεύνηση της διατήρησης της αιμάτωσης της βραχιονίου κεφαλής μετά την εφαρμογή της οστεοσυρραφής. Αποτελέσματα: Όλα τα κατάγματα πωρώθηκαν σε διάστημα 10.4 εβδομάδων κατά μέσο όρο (από 6.5 έως 14.6 εβδομάδες), εκτός από τέσσερις περιπτώσεις που παρουσίασαν ψευδάρθρωση. Η μέση τιμή του Constant score κατά τον τελευταίο επανέλεγχο ήταν 80.2 (από 35 έως 100 βαθμούς) ανεξαρτήτως τύπου κατάγματος, ενώ ως ποσοστό επί της λειτουργικότητας του υγιούς ώμου κυμάνθηκε στο 87.5%. Συνολικά 61 ασθενείς (30.9%) είχαν άριστο αποτέλεσμα, 96 (48.8%) πολύ καλό, 24 μέτριο (12.2%) και 16 πτωχό (8.1%). Η συνολική επίπτωση άσηπτης νέκρωσης της βραχιονίου κεφαλής ήταν 22/197 περιπτώσεις (11.1%), με πλήρη καθίζηση της κεφαλής σε 9 ασθενείς και μερική σε 13. Η παρουσία «λύσης» του ΜΒΟ επισημάνθηκε σε 18 ασθενείς (9.1%), έκτοπης οστεοποίησης σε 21 (10.6%), συμπτωματικής οστεοαρθρίτιδας σε 9 (4.5%) και συνδρόμου υπακρωμιακής προστριβής σε 11 (5.5%). Η συνολική επίπτωση επανεγχείρησης λόγω επιπλοκών κυμάνθηκε στο 7.1%. Η ανάλυση των αποτελεσμάτων της αγγειογραφικής μελέτης κατέδειξε διατήρηση της ενδοστικής αιματικής παροχής μετά από την εφαρμογή οστεοσυρραφής στα κατάγματα 4-τμημάτων ενσφηνωμένων σε βλαισότητα. Συμπεράσματα: Προτείνουμε την ανοικτή ανάταξη και εσωτερική οστεοσύνθεση με μη-απορροφήσιμα ράμματα σε όλα τα παρεκτοπισμένα κατάγματα του άνω πέρατος του βραχιονίου που είναι επιδεκτικά οστεοσύνθεσης (2-τμημάτων ΜΒΟ, 3-τμημάτων και 4-τμημάτων ενσφηνωμένων σε βλαισότητα). Αποφεύγοντας τις πιθανές επιπλοκές των μεταλλικών υλικών μπορούμε, με την τεχνική της οστεοσυρραφής, να επιτύχουμε ικανοποιητική ανάταξη, σταθερή οστεοσύνθεση και αποκατάσταση του μυοτενόντιου πετάλου, που επιτρέπουν την πρώιμη κινητοποίηση της άρθρωσης και την επίτευξη ενός καλού τελικού κλινικού και ακτινολογικού αποτελέσματος. Σε νεαρούς ασθενείς με παρεκτοπισμένα κατάγματα 4-τμημάτων χωρίς ενσφήνωση και σε κατάγματα-εξαρθρήματα 3- και 4- τμημάτων, μπορεί να εφαρμοστεί αρχικά η οστεοσυρραφή, με σκοπό την απώτερη βιωσιμότητα της κεφαλής, αλλά η έκβαση είναι λιγότερο προβλέψιμη και η επίπτωση των επιπλοκών σημαντική. / Background: Ideal treatment of displaced proximal humeral fractures remains controversial and a matter of continuous debate in the international literature. The particularities of those fractures, the under strength reliability and reproducibility of the existing classification systems, the lack of multicenter prospective studies and the heterology definitions about the evaluation of results are only some of the reasons that bring researchers out of step. Current trends in operative treatment of these fractures are focused in minimal invasive techniques of reconstruction, involving limited soft tissue detachments, preserving blood supply of the humeral head and eliminating of necessary hard material application for stable osteosynthesis. The main advantages of our proposed technique are the minimal approach, without forced manipulations on the fracture, the avoidance of any hard material application, the repair of coexisting rotator cuff tears and the cruciate, tension-band like manner of bone fragments retention to a uniform part that allows stable internal fixation of the fracture and early shoulder joint motion. Material-Methods: Between 1991 and 2003, 214 patients underwent transosseous suturing for displaced fractures of the proximal humerus in our Department. There were 123 women and 91 men with a mean age of 52.7 years (range, 18-82). According to Neer criteria and fracture classification we managed 71 two-part fractures, 75 three-part and 64 four-part (48 of them was of valgus impacted subtype) as well as 4 splitting head fractures. Mean follow up period was 5.2 years and concerned the 92% of the patients. Overall, 13 patients were lost from the last follow up appointment and 4 died from reasons unrelated to the fracture or its treatment, leaving a total of 197 patients for full clinical and radiological evaluation. We recorded and investigated all preoperative and postoperative radiographs, intraoperative details, kind of reduction, early and late complications, hospital stay details, the incidence of infection, the cooperation with the rehabilitation program, the patient satisfaction and the objective clinical outcome according to the parameters of Constant score. Radiologically, the union progress was evaluated with anteroposterior and auxiliary views at 1st, 3rd, 6th, and 12th month as well as at the last follow up. All radiographs were investigated for the presence of partial or total collapse of the head, lysis or tuberosity displacement, loss of reduction or malunion as well as for signs of post-traumatic osteoarthritis and subacromial impingement syndrome. In 16 patients with four-part valgus impacted fractures, a digital angiographic evaluation was performed for further investigation of humeral head supply after transosseous suturing. Results: All fractures were united until the 10.4 week (range, 6.5 to 14.6 weeks), except four that developed nonunion. The mean Constant score at the last follow up was 80.2 (from 35 to 100 points) singly from fracture type, whereas the functional score as a percentage to that of the unaffected shoulder was 87.5%. Overall, 61 patients (30.9%) were rated as excellent, 96 (48.8%) very good, 24 good (12.2%) και 16 poor (8.1%). The overall incidence of avascular necrosis was 22/197 cases (11.1%); 9 patients showed total collapse and 13 partial collapse. Greater tuberosity lysis was noted in 18 patients (9.1%), heterotopic ossification in 21 (10.6%), posttraumatic osteoarthritis in 9 (4.5%) and subacromial impingement syndrome in 11 (5.5%). The overall rate of reoperation due to complications was 7.1%. The results of angiographic investigation showed conservation of endosteal blood supply of the humeral head, after transosseous suturing. Conclusions: We suggest open reduction and internal fixation in all displaced fractures of the proximal humerus that were amenable for fixation (2-part greater tuberosity, 3-part and 4-part valgus impacted fractures). Avoiding the complications of any hard material application, we are able, with the solely use of transosseous sutures, to accomplish adequate reduction, stable osteosynthesis and repair of rotator cuff tears, allowing for early shoulder joint motion and a satisfactory clinical and radiological outcome. In young patients, with displaced four-part fractures without impaction or 3- and 4-part fractures-dislocations, the transosseous suturing can be applied initially, as a head preserving treatment, but the outcome is less predictable and the rate of complications prominent.

O tratamento de fraturas umerais distais em aves impõe grande dificuldade, devido a córtices muito finas dos ossos A artrodese com fixador externo da articulação úmero-rádio-ulnar é inviável para aves que se pretende reintroduzir ao meio ambiente. Doze animais foram divididos em dois grupos: cirurgias bilaterais com anquilose de uma asa (asa estática) e manutenção da articulação da outra (asa dinâmica) (grupo 1), e cirurgia unilateral, com manutenção da função da articulação (asa dinâmica), sendo a outra controle (asa intacta) (grupo 2). Foram feitas avaliações clínicas, radiológicas, morfológicas do osso, histomorfométricas (de ambos os grupos) e de capacidade de vôo (grupo 2). A 6 semanas, todos os animais apresentavam fraturas consolidadas, com excessão de dois animais do grupo 1, que somente apresentaram consolidação das asas dinâmicas às 9 semanas e das estáticas às 12 semanas. Todos os animais do grupo 2 apresentaram capacidade de vôo adequada, antes de 13 semanas após a cirurgia. No grupo 1 o úmero da asa dinâmica representava 99,1% do comprimento do da asa estática, e no grupo 2, estes eram 99,5% em relação à asa intacta. A amplitude da asa, no grupo 2, demonstrou que a relação da asa dinâmica/intacta foi de 93%, e no grupo 1 a relação asa dinâmica/estática foi de 105%. O volume do osso intacto foi de aproximadamente 29% da área estudada, enquanto o da asa estática foi de 19% e das asas dinâmicas, de 22%. Houve diferença entre o número de osteoblástos das asas intactas e dinâmicas, porém não houve diferença entre as asas estáticas e intactas e entre as dinâmicas e as estáticas, e também não houve diferença do número de osteoclástos entre nenhum tipo de asa. A razão da superfície óssea pelo volume ósseo indica a quantidade de áreas de reabsorção. Não houve diferença entre as asas estática e dinâmica, porém houve diferença entre estas e os controles. O método proposto de técnica para fixação de fraturas umerais distais, sem a anquilose da articulação úmero-rádio-ulnar, demonstrou ser efetivo em manter o comprimento ósseo, a amplitude da asa e assim, garantindo a capacidade de vôo das aves tratadas, além de demonstrar ser equivalente histológicamente à técnica tradicional e mais estável de anquilose da articulação, para este tipo de fratura, e até mesmo, no período estudado, ser equivalente ao osso são, sendo um método adequado para a reparação de fraturas distais de úmero em aves quando se pretende a reabilitação destes animais. / The treatment of humeral distal fractures in birds is very difficult, because these bones are very brittle. Ankylosis of the humeral-radio-ulnar joint with an external fixator is unviable for birds intended for re-habilitation and reintroduction. Twelve animals were used and they were divided in two groups: bilateral surgeries, with ankylosis of one wing (static wing) and maintenance of the joint function of the other wing (dynamic wing) (group 1), and unilateral surgery, with maintenance of the joint function of the wing (dynamic wing), and the other was used as control group (intact wing) (group 2). Clinical, radiographic, morphologic and histomorphometric evaluations of the wings and bones (of both groups) and of evaluations of flight capacity (in group 2) were made. At 6 weeks, all animals had healed fractures, except two animals in group 1, that only presented consolidation of the dynamic wing at 9 weeks and the static wings at 12 weeks. All animals in group 2 were capable of flying before 13 weeks after surgery. In group 1, the humerus of the dynamic wing was 99.1% the length of that of the static wing, and in group 2, these were 99.5% compared to the intact wing. Wing amplitude, in group 2, showed a dynamic/ intact ratio of 93%, and in group 1 the dynamic/ static wing ratio was 105%. The volume of the intact bone was approximately 29% of the studied area, while in the static wing it was of 19% and in the dynamic wing, 22%. There was a difference in the number of osteoblasts of the intact and dynamic wings, but there was no difference between static and intact, and between dynamic and static wings, and also, there was no difference in the numbers of osteoclasts between any wings. The bone surface/ volume ratio indicates the amount of resorption areas. There was no significant difference between static and dynamic wings, but there was a difference between static and intact wings. The proposed method of distal humeral fracture fixation technique, without ankylosis of the humerus-radius-ulna joint, demonstrated being effective in keeping bone length, wing amplitude e therefore, guaranteeing flight capacity of the birds treated, as well as being histologically equivalent to the tradicional, more stable, joint ankylosis technique, for thise kind of fracture, and even, for the studied period, being equivalent to healthy bone, being an adequate method for fracture repair for this kind of fracture in birds, when one intends rehabilitation of these animals.

Abstract Although nonoperative treatment is recognized as an effective treatment method for humeral shaft fractures, it is associated with an approximately 10% risk of nonunion and long-term impairments of the shoulder joint. There is a growing interest to treat even simple humeral shaft fractures operatively to avoid these problems. Intramedullary (IM) nailing has proven to be very effective in the treatment of femoral and tibial shaft fractures and the same method has been adopted for humeral shaft fractures. However, the results regarding union rate and shoulder joint function after antegrade insertion of an IM nail have been very controversial. The purpose of this study was to investigate fracture union, shoulder joint function and symptoms after antegrade IM nailing of humeral shaft fractures, to assess safety and results of IM nailing in pathological fractures, to evaluate the efficacy of exchange nailing and Ilizarov's technique in the treatment of nonunion after IM nailing and to find out, by comparing shoulder joint symptoms and function after antegrade IM nailing and dynamic compression (DC) plate fixation, whether antegrade access to the medullary cavity is the main reason behind shoulder joint problems. During the years 1987-1997, 126 humeral shaft fractures were operated upon in Oulu University Hospital using antegrade IM nailing. The nonunion rate was 22% and distraction of the fracture fragments was the most important risk factor associated with nonunion. The reoperation rate, for various reasons, was 25%. Shoulder joint pain and impairment of function was present in 37% of the patients. In the treatment of 18 pathological fractures IM nailing was a rapid and safe operation, associated with good pain relief. Exchange nailing of 13 cases of nonunion after IM nailing resulted in a union rate of 47% and this method is not useful in the humerus in contrast to tibial and femoral fractures. Permanent nonunion leaves the patient with severe impairment of the shoulder joint and a loose nail may lead to severe osteolysis of cortical bone. In complicated nonunion with poor bone quality, Ilizarov's technique, although associated with a high rate of minor complications and reoperations, worked well. When IM nailing was compared with DC plating it was found that there were no significant differences in shoulder pain, function scores, range-of-motion and strength. Antegrade insertion of the nail, if carried out properly, is probably not the main reason for shoulder joint impairment after IM nailing. Antegrade IM nailing of humeral shaft fractures is associated with several problems, e.g. shoulder joint impairment and difficulties in reconstruction after nonunion, and indications for this method may be exceptional, such as comminuted and pathological fractures.