Zur Diagnostik von Rupturen der Rotatorenmanschette wird häufig die im Vergleich zur Sonografie deutlich kostenintensivere Magnetresonanztomografie durchgeführt. Ein Grund hierfür ist, dass es zum Teil schwierig ist, standardisierte statische Sonografie-Bilder zu gewinnen, was die reproduzierbare, untersucherunabhängige diagnostische Information verringert. Ziel des ersten Teils der Arbeit war es einerseits, zu analysieren, ob mit der 3D-Sonografie diese Probleme verringert werden könnten und andererseits die Sensitivität mit dem 2D-Ultraschall zur Diagnostik von Komplett- und Partialrupturen zu vergleichen. Bei der Untersuchung von 114 Patienten konnten mit dem 3D-Ultraschall Rupturen der Rotatorenmanschette gut dargestellt werden. Der Vergleich zwischen 2D- und 3D-Ultraschall ergab keinen statistisch signifikanten Unterschied zwischen beiden Verfahren für die Diagnostik von Komplett- und Partialrupturen. Ein Vorteil war die Möglichkeit der untersucherunabhängigen simultanen Auswertung von drei standardisierten Schnittebenen zu einem späteren Zeitpunkt. Bei der Verwendung biodegradierbarer Anker zur Fixierung von Weichteilen können ossäre Reaktionen auftreten. Ziel war es, die frühen Reaktionen des umgebenden Gewebes auf einen Poly-(L-co-D/L-Lactid) 70/30 Anker im Vergleich zu einem Titananker im Schafsknochen zu analysieren. Innerhalb von 20 Wochen nach Implantation zeigte sich keinerlei Verlust von Knochensubstanz im Bereich des distalen Schafsfemur bei Ankern aus Titan oder aus Polylactid. Vielmehr zeigte sich eine ausgeprägte Neuformation von spongiösem Knochen in die Implantathohlräume vor allem für das biodegradierbare Material. Daher sollten neben materialbedingten Ursachen auch biomechanische Ursachen wie zyklische Belastungen für mögliche Osteolysen in Betracht gezogen werden. Die arthroskopische subacromiale Dekompression (ASD) ist ein häufig durchgeführtes Verfahren zur Therapie von Subachromialsyndromen. Es sollten die eigenen Ergebnisse seit 1993 unter Berücksichtigung von Nebendiagnosen sowie die Möglichkeit, verschiedene Scores und VAS auch telefonisch erheben zu können, analysiert werden. Die Untersuchung von 422 Schultern zwischen 1,5 und 9,5 Jahren (durchschnittlich 4,8 Jahre) nach der Operation zeigte, dass die ASD mit überwiegend guten und sehr guten subjektiven und objektiven Resultaten (ca. 75%) ein zuverlässiges operatives Verfahren ist. Im Gegensatz zu einem laufenden Rentenverfahren hatten Rupturen der Rotatorenmanschette zum Zeitpunkt der Operation keinen negativen Einfluss auf das Operationsergebnis. Bei Nichtbeachtung der Pathologie des superioren Labrums und bei Rezidivoperation kam es zu einem erhöhten Anteil an Therapieversagern. Die telefonische Erhebung verschiedener Schulter-Scores (ausgenommen Constant-Score) und der VAS lieferte valide Resultate, die eine klinische Untersuchung entbehrlich machen und insbesondere bei Langzeitstudien eine wesentlich höhere Nachuntersuchungsrate ermöglichen. Das Konzept der winkelstabilen Osteosynthese ermöglicht eine weichteilschonende, minimal-invasive Frakturstabilisierung. Um eine sichere Verankerung von winkelstabilen Schrauben zu erreichen, ist eine korrekte Positionierung der Schraube in der Platte erforderlich. In biomechanischen Testungen konnte gezeigt werden, dass bei einer geringen Abweichung des Insertionswinkels winkelstabiler Schrauben von bis zu 5° vom optimalen Winkel immer noch eine hohe Stabilität der Schrauben-/Plattenverbindung gewährleistet war. Ab einem Winkel von über 5° kam es zu einer signifikanten Abnahme der Festigkeit dieser Verbindung. Um eine optimale Festigkeit der Verbindung Schraube/Platte zu erreichen und das Risiko der Schraubenlockerung zu minimieren, ist die konsequente Benutzung eines Zielgerätes zu empfehlen. Die klinische Nachuntersuchung von 53 Patienten mit winkelstabiler Osteosynthese bei proximaler Humerusfraktur zeigte eine mit der Literatur vergleichbare Komplikationsrate bei verringertem sekundären Dislokationsrisiko. Es zeigte sich aber auch die Problematik dieser Fakturen mit langer Nachbehandlungsdauer und dem Risiko einer Humeruskopfnekrose im Verlauf. Winkelstabile Implantate ermöglichten eine sichere Stabilisierung von proximalen Humerusfrakturen, konnten jedoch eine insuffiziente Anwendung - wie eine fehlerhafte Verankerung der Kopfverriegelungsschrauben - nicht kompensieren. Erhöht war das Risiko einer Schraubenperforation durch die Sinterung des Kopfes auf das rigide Implantat. / Goal of the study was evaluation of advantages and limitations of shoulder diagnosis and different techniques of minimal invasive shoulder surgery. MRI has become the standard for diagnosis of rotator cuff lesions, since it can be difficult to obtain standardized ultrasound images. Goal of the study was analysis of sensitivity of 3D- in comparison to 2D-ultrasound. Examination of 114 patients showed excellent visualization of rotor cuff defects with 3D-ultrasound. Comparison to 2D-ultrasound showed no statistical significant difference between both methods for diagnosis of full- and partial thickness defects of the rotator cuff. Advantage of 3D-ultrasound was the possibility of simultaneous visualization of three standardized planes. For the reattachment of ligaments and tendons biodegradable implants are increasingly used today. However, with the use of biodegradable implants early and late osteolysis has been reported. Goal of this study was to analyze the early osseous integration of a newly designed suture anchor in comparison to a titanium implant. The implants made of Poly-(L-co-D/L-lactide) 70/30 or titanium were inserted into the cancellous bone of the distal femoral condyle in four sheep. The animals were followed radiographically over a period of 20 weeks in which no final implant degradation was anticipated. After sacrifice new bone formation was quantitatively and local tissue response qualitatively analyzed from microradiographs and histological sections were examined. New bone formation was seen around both implant materials within 20 weeks. Inside the recess of the polylactide suture anchor there was significantly higher bony ingrowth (p = 0.026) as compared to the titanium implant. Histologically non of the materials did show any inflammatory reaction. These data indicate that early osteolysis around Poly-(L-co-D/L-lactide) 70/30 suture anchors in cancellous bone may not be attributable to the material properties but rather to other reasons such as the mechanical situation at the implant-bone interface. Arthroscopic subacromial decompression (ASD) has become a well established procedure to treat chronic subacromial impingement syndrome. Goal of the study was to retrospectively evaluate the outcome and to evaluate the validity of data collection by telephone interview. The examination of 422 patients average 4.8 years after peration showed in 75% goog and excellent results. The average Constant score (raw score) improved from 46 to 80 Pts. Patients who had a second ASD had good results in only 25%. Patients with running workers compensation application showed no satisfying outcome. Lesions of the rotator cuff were shown to have no significant influence on the outcome in comparison to patients with intact rotator cuff. Additionally, it was shown that the assessment of various shoulder scores (except Constant Score) by telephone interview is possible. Internal fixators with angular stability have been developed in order to provide high stability without compression of the plate on to the bone. The insertion angle of the screw must correspond precisely to the axis of the screw hole. The objective of this study was to examine the relationship between the stability of the locked screw-plate on the insertion angle of the screw. Locking screws were inserted in a isolated or combined locking hole with the use of an aiming device. The screws were inserted with an axis deviation of 0°(optimal condition), 5° and 10°. The samples were tested under shear or axial (push out) loading conditions until failure occurred. Locking screws inserted in the isolated locking hole (PC-Fix) showed a significant decrease of failure load if inserted at 5° and 10° angle. Screws inserted in the combined locking hole (LCP) also showed a significant decrease of push-out force of 77% with 10° axis deviation. A locking head screw exhibits a high stability with a moderate axis deviation in the angle of insertion of up to 5°. However there is a significant decrease in stability with increasing axis deviation (>5°). A aiming device is recommended to provide an optimal fixation with angular stability. Clinical Examination of 53 patients with angular stable osteosynthesis of proximal humeral fractures showed a rate of complications, which can be compared with literature with lower risk of secondary dislocation. Implants with angular stability allow stable fixation of proximal humeral fractures however the risk of screw perforation is higher.

L’imagerie médicale et la 3D, en pleine expansion dans le champ de l'anthropologie biologique, permettent d’explorer les structures internes tout en les préservant. L’étude de la micro-architecture osseuse trabéculaire permet d’appréhender la variabilité de l'os humain à une échelle jusqu'à présent peu explorée. Dans le cadre de cette recherche, cette variabilité est analysée et caractérisée en termes de croissance et de maturation, en fonction des critères individuels d’âge et de sexe, ainsi que dans des contextes pathologiques variés. Les images microtomodensitométriques des métaphyses humérales proximales de 43 sujets immatures (provenant de 3 collections ostéologiques de référence et couvrant l’ensemble des âges du développement) et celles de 8 cas paléopathologiques (représentant 5 étiologies différentes) ont été analysées pour quantifier la micro-architecture osseuse trabéculaire. Nos résultats montrent que cette micro-architecture varie pendant et entre les différentes phases de la croissance. Des corrélations avec l’âge sont mises en évidence, si elles n’expliquent pas suffisamment la variabilité observée pour en faire des estimateurs d'âge précis, il apparaît néanmoins que les variations relevées entre les différents volumes d’intérêt pourraient caractériser différentes périodes de la croissance. Les variables mesurées présentent des différences sexuelles significatives pendant l’adolescence, mais ne peuvent pas en l'état être utilisées pour la diagnose sexuelle. L'étude de la microarchitecture trabéculaire osseuse des sujets pathologiques atteste d’un développement anormal de l’os et donc du statut pathologique de l’individu observé. / Medical imaging and 3D reconstructions are used increasingly by anthropologists; they allow both investigating and preserving internal structures. Study of trabecular bone microarchitecture allows understanding variability of human skeleton at a smaller scale. This variability is observed and characterized in terms of normal growth and maturation according to age and sex, and for several pathological conditions. μCT scans of proximal metaphysis of humerus from 43 immature individuals (coming from 3 identified skeletons collections and representing all periods of age development) and 8 paleopathological cases (corresponding to 5 different etiologies) have been analyzed to quantify bone microarchitecture. Our results show that this microarchitecture varies during and between different phases of growth. Correlations with age are highlighted, even if they do not sufficiently explain the observed variability in order to represent specific age estimators; it nevertheless appears that the variations observed between the different volumes of interest could characterize different periods of growth. The measured variables showed significant sex differences only during the adolescence period, but they cannot be used, in the present state, for sex determination. The study of the trabecular bone microarchitecture of pathological individuals attests of the abnormal development of bone and therefore of their pathological status.

There is an understanding among biological anthropologists that long bone epiphyseal shape is highly regulated by genetic and biomechanical factors. Conversely, long bone diaphyseal geometry and robusticity have been shown to respond to activity in life. The current study examined the assumption of epiphyseal consistency by exploring the relationship between a well established bony response to activity (Cross-Sectional Geometry) and shape change among the proximal humerus and femur. Long bone samples were taken from four hunter-gatherer populations: the Andaman Islanders, the Indian Knoll, Point Hope Alaskans, and the Sadlermiut. Shape was measured through landmark configurations placed on the proximal end of a total of 91 humeri and 84 femora. Cross-sectional Geometry measures (J) were taken from each specimen, as well. Principal Component Analyses were conducted on the landmark shape data to determine where the shape variation was occurring among the sample. These Principal Components were then compared via Bivariate Regression to the J values taken from the diaphysis. Significant relationships occurred between the development of the lesser tubercle and an increase in J among the humerus sample. Significant relationships were also found among the femur sample; as when J increased the proximal epiphyses were more likely to be more gracile, and the space between the femoral head and the greater trochanter increased. The humerus results indicated a more robust proximal epiphysis in groups with activities that rely heavily on the upper body, such as rowing, swimming, and harpooning. The femur results were more complex, as the relationship between activity and proximal shape is likely heavily influenced by a genetically predetermined body shape. These results indicated that there is a relationship between activity and proximal epiphyseal shape, but that it, like all relationships, is complex, and comprised of multiple factors. Ultimately, proximal long bone shape is the result of multiple influences including, activity, genetics, population adaptation, health, and many more. Future research should focus on determining if the relationship between activity and shape exists among other populations, and when and where it begins during growth and development. / Graduate

Background: Complex proximal humerus fractures with metaphyseal comminution remain challenging regarding reduction and stability. In most fracture patterns the hard bone of the bicipital groove remains intact. In this case series, we describe a novel technique of hybrid double plate osteosynthesis of complex proximal humerus fractures with metaphyseal comminution. Methods: In randomly chosen shoulder specimens and synthetic bones, pilot studies for evaluation of the feasibility of the technique were performed. Between 4/2010 and 1/2012 10 patients underwent hybrid double plate osteosynthesis. Seven patients (4 male, 3 female, mean age was 50 years (range 27–73)) were available for retrospective analysis. Based on plain radiographs (anterior-posterior and axial view), the fractures were classified according to the Orthopaedic Trauma Association classification (OTA) and by descriptive means (head-split variant (HS), diaphyseal extension or comminution (DE)). Results: Follow-up radiographs demonstrated complete fracture healing in six patients and one incomplete avascular necrosis. None of the patients sustained loss of reduction. Three patients where reoperated. The medium, not adapted, Constant score was 80 Points (58–94). Patients subjective satisfaction was graded mean 3 (range: 0–6) in the visual analog scoring system (VAS). Conclusion: The technique of hybrid double plate osteosynthesis using the bicipital groove as anatomic landmark may re-establish shoulder function after complex proximal humerus fractures in two dimensions. Firstly the anatomy is restored due to a proper reduction based on intraoperative landmarks. Secondly additional support by the second plate may provide a higher stability in complex fractures with metaphyseal comminution.

An ongoing debate concerning Neandertal ecology is whether or not they utilized long range weaponry. The anteroposteriorly expanded cross-section of Neandertal humeri have led some to argue they thrusted their weapons, while the rounder cross-section of Late Upper Paleolithic modern human humeri suggests they threw their weapons. We test the hypothesis that Neandertal humeri were built to resist strains engendered by thrusting rather than throwing using finite element models of one Neandertal, one Early Upper Paleolithic (EUP) human and three recent human humeri, representing a range of cross-sectional shapes and sizes. Electromyography and kinematic data and articulated skeletons were used to determine muscle force magnitudes and directions during three positions of spear throwing and three positions of spear thrusting. Maximum von Mises strains were determined at the 35% and 50% cross-sections of all models. During throwing and thrusting, von Mises strains produced by the Neandertal humerus fell roughly within or below those produced by the modern human humeri. The EUP humerus performed similarly to the Neandertal, but slightly poorer during spear thrusting. This implies the Neandertal and EUP human humeri were just as well adapted at resisting strains during throwing as recent humans and just as well or worse adapted at resisting strains during thrusting as recent humans. We also did not find any correlation between strains and biomechanical metrics used to measure humeral adaptation in throwing and thrusting (retroversion angle, Imax/Imin, J). These results failed to support our hypothesis and suggest they were capable of using long distance weaponry.

The humerus of a racing horse Thoroughbred is highly susceptible to stress fractures at a characteristic location as a result of cyclic loading. The propensity of a Thoroughbred to exhibit humeral fracture has made equines useful models in the epidemiology of stress fractures. In this study, a racing Thoroughbred humerus was simulated during training using a 3D finite element model in conjunction with a bone remodeling algorithm. Nine muscle forces and two contact forces were applied to the 3-dimensional finite element model, which contains four separate load cases representing fore-stance, mid-stance, aft-stance, and standing. Four different training programs were incorporated into the model, which represent Baseline Layup and Long Layup training programs along with two newly implemented programs for racing, which have an absence of a layup period, last a period of 24 weeks, and a race once every four weeks. Muscle and contact forces were rescaled for all load cases to simulate dirt, turf, and synthetic track surfaces. Bone porosity, damage, and BMU activation frequency were examined at the stress fracture site and compared with a control location called the caudal diaphysis. It was found that race programs exhibited similar remodeling patterns between each other. Damage at the stress fracture site and caudal diaphysis was reduced during all training programs for the turf and synthetic track surfaces with respect to the dirt track surface. Key findings also included changes in bone remodeling at the stress fracture site and caudal diaphysis as a result of turf and synthetic track surfaces. This model can serve as a framework for further studies in human or equine athletes who are susceptible to stress fractures.

Recent advances in the methods of skeletal age estimation have rekindled interest in their applicability to paleodemography. The current study contributes to the discussion by applying several long established as well as recently developed or refined aging methods to a subsample of 121 adult skeletons from the early medieval cemetery of Lauchheim. The skeletal remains were analyzed by 13 independent observers using a variety of aging techniques (complex method and other multimethod approaches, Transition Analysis, cranial suture closure, auricular surface method, osteon density method, tooth root translucency measurement, and tooth cementum annulation counting). The age ranges and mean age estimations were compared and results indicate that all methods showed smaller age ranges for the younger individuals, but broader age ranges for the older age groups.

INTRODUÇÃO: As fraturas da extremidade proximal do úmero são frequentes, com incidência crescente no idoso e com impacto na qualidade de vida e na função do ombro. Para os casos com desvio, a placa bloqueada é o método mais utilizado de osteossíntese. Bons resultados clínicos são obtidos tanto com a placa bloqueada como com a haste intramedular bloqueada. O objetivo do estudo foi a comparação desses métodos no tratamento das fraturas da extremidade proximal do úmero quanto aos resultados clínicos, radiográficos e à taxa de complicações. MÉTODOS: Nesse estudo clínico prospectivo e randomizado, 72 pacientes com fraturas desviadas da extremidade proximal do úmero, classificadas como em 2 ou 3 partes de Neer, foram alocados para receberem osteossíntese com placa bloqueada (36 pacientes - Grupo Placa) ou haste intramedular bloqueada (36 pacientes - Grupo Haste). Os desfechos clínicos foram avaliados aos 3, 6 e 12 meses e incluíram as escalas de Constant e Murley, Universidade da Califórnia em Los Angeles modificada (UCLA), escala visual analógica de dor (EVA) e o questionário \"Disability of Arm, Shoulder and Hand\"(DASH) e a amplitude de movimento passiva. Os desfechos radiográficos consistiram na avaliação da consolidação e do ângulo cabeça-diáfise. As complicações foram avaliadas até os 12 meses e incluíram a avaliação do manguito rotador pela ultrassonografia. O desfecho primário do estudo foi a avaliação pela escala de Constant e Murley, aos 12 meses de pós-operatório. RESULTADOS: Sessenta e cinco pacientes completaram 12 meses de seguimento, sendo 32 no Grupo Haste e 33 no Grupo Placa. A escala de Constant aos 12 meses foi de 70,3 pontos para o Grupo Haste e de 71,5 pontos para o Grupo Placa (p = 0,750). A escala de Constant Relativa Individual foi de 81% para o Grupo Haste e de 85% para o Grupo Placa (p = 0,400). Também não houve diferença entre os grupos aos 3 e 6 meses para a escala de Constant. A escala EVA e o questionário DASH também não apresentaram diferença aos 3, 6 e 12 meses, assim como os resultados radiográficos. A escala UCLA apresentou diferença de 4,0 pontos aos 3 meses, com melhores resultados para o Grupo Haste (p = 0,005), mas sem diferença significante aos 6 e 12 meses. A amplitude de movimento apresentou diferença de 2,1 pontos favorável ao Grupo Haste para a rotação medial aos 6 meses (p = 0,042), sem diferença para os demais planos de movimento nos diferentes momentos de avaliação. Foram registradas 38 complicações, sendo 28 no Grupo Haste e 10 no Grupo Placa, com diferença estatística (p = 0,001). As complicações ocorreram em 18 pacientes, sendo 11 (34%) do Grupo Haste e sete (21%) do Grupo Placa, sem diferença estatística (p = 0,137). CONCLUSÕES: A osteossíntese das fraturas da extremidade proximal do úmero com placa bloqueada ou haste intramedular bloqueada produziram resultados clínicos e radiográficos semelhantes. A fixação com haste intramedular bloqueada apresentou maior taxa de complicações e reoperações / INTRODUCTION: Fractures of the proximal humerus are common, with an increasing incidence in the elderly and with a high impact on quality of life and shoulder function. For displaced fractures, the locking plate is the most used method of osteosynthesis. Studies have shown good clinical results with the use of locking plates, but also with the fixation with locking intramedullary nail. The aim of this study was to compare the clinical outcomes, radiographic results and the complications between these two methods in patients with displaced proximal humerus fractures. METHODS: In this prospective, randomized clinical trial, 72 patients with displaced fractures of the proximal humerus, classified as Neer 2- or 3-part, were randomly assigned to receive osteosynthesis with either locking plate (36 patients - Plate Group) or locking intramedullary nail (36 patients - Nail Group). The clinical outcomes were evaluated at 3, 6 and 12 months and included the Constant and Murley, University of California at Los Angeles (UCLA) and Disability of Arm, Shoulder and Hand (DASH) scores, visual analog scale (VAS) and the passive range of motion. Radiographic findings (consolidation and head shaft angle) and complications, which included the evaluation of rotator cuff by ultrasound, were also evaluated. The primary outcome was the Constant and Murley score at 12 months. RESULTS: Sixty-five patients completed 12 months of follow-up, 32 in the Nail Group and 33 in the Plate Group. The mean Constant score at 12 months was 70.3 points for the Nail Group and 71.5 points for the Plate Group (p = 0.750) and the mean Relative Constant score was 81% for the Nail Group and 85% points for the Plate Group (p = 0.400). There was also no difference at 3 and 6 months for the Constant score. VAS, DASH and radiographic findings also did not differ at 3, 6 and 12 months. Range of motion showed a 2.1 points difference in favor of the Nail Group for medial rotation at 6 months (p = 0.042), with no difference for the other motions at 3, 6 and 12 months. The UCLA score presented a difference of 4.0 points at 3 months, with better results for the Nail Group (p = 0.005), but no significant difference at 6 and 12 months. Thirty-eight complications were recorded, 28 in the Nail Group and 10 in the Plate Group, with significant difference (p = 0.001). Complications occurred in 18 patients, 11 (34%) of the Nail Group and seven (21%) of the Plate Group, with no significant difference (p = 0.137). CONCLUSIONS: Locking plates and locking intramedullary nail yielded similar clinical and radiographic results. Locking intramedullary nail fixation has a higher risk for complications and reoperations

O objetivo deste estudo é o de comparar os resultados clínicos e radiográficos do tratamento cirúrgico das fraturas da diáfise do úmero com haste intramedular bloqueada ou placa em ponte. Quarenta fraturas da diáfise do úmero, em 39 pacientes, dos tipos A, B ou C da classificação do grupo A.O., foram tratadas no período compreendido entre junho de 2003 e dezembro de 2007. Destas, após seleção por sorteio, 21 fraturas foram submetidas à osteossíntese com placas em ponte de 4,5 mm e parafusos (grupo PP) e 19 com hastes intramedulares bloqueadas não fresadas (grupo HIB). Duas eram fraturas expostas, uma do tipo II e outra do tipo III-a de Gustilo. Vinte e cinco pacientes eram do sexo masculino (64%) e a idade variou de 19 a 75 anos (idade média de 41 anos e 10 meses). O lado direito foi acometido em 22 pacientes (55%) e a queda, o mecanismo de trauma mais freqüente (46%). O tempo mínimo de seguimento foi de seis meses e o máximo de 60 meses para o grupo PP (M=34,5 meses) e de oito e 58 meses (M=27meses) para o grupo HIB. Em apenas um caso, operado com haste intramedular bloqueada, não houve a consolidação. Houve um caso de infecção profunda no grupo PP e um de infecção superficial no grupo HIB. Dois casos do grupo PP evoluíram com capsulite adesiva e, em apenas um dos casos do grupo HIB, o parafuso distal ficou saliente. Ocorreu neuropraxia do nervo cutâneo lateral do antebraço em um dos casos do grupo HIB que regrediu em três dias. Não houve diferença entre os grupos com relação ao tempo total da cirurgia. O tempo de utilização da radioscopia no ato operatório foi maior no grupo HIB. Houve semelhança entre os dois métodos de fixação nos resultados referentes à dor, à função, à flexão ativa e à força de flexão na articulação do ombro e também com relação à dor, mobilidade, força muscular e estabilidade na articulação do cotovelo. Segundo os critérios da UCLA para o ombro, obtivemos resultados excelentes e bons em 85,7% no grupo operado com placa em ponte e 79% no grupo com haste intramedular bloqueada e de acordo com os critérios de Broberg e Morrey para o cotovelo, obtivemos resultados excelentes e bons em 85,7% no grupo operado com placa em ponte e 90,5% no grupo com haste intramedular bloqueada. Na avaliação subjetiva, duas pacientes, uma do grupo HIB e outra do PP, não ficaram satisfeitas. Conclusão: Não houve diferença no resultado clínico e radiográfico entre os dois métodos / The purpose of the study is to compare clinical and radiographic outcomes between nonreamed locked intramedullary nail and bridging plate for the treatment of humeral shaft fracture. Forty humeral shaft fractures in 39 patients, A, B or C AO types were treated between June 2003 and December 2007. The cases were randomly assigned into two groups being 21 fractures fixed by a 4.5 mm bridging plate, and 19 by nonreamed intramedullary locking nail. Two cases had open fractures, one Gustilo type II, the other type IIIa. Twenty five patients were male (64%), ages ranging from 19 to 75 years old (mean age 41 years and 10 months). The right side was treated in 22 patients (55%) and fall was the most frequent cause of fracture (46%). The minimal period of follow-up was six months and the maximum was 60 months for the bridging plate group (mean=34.5 months) and ranged from eight to 58 months (mean=27months) for the nail group. Only one case from the nail group presented a nonunion. One case, in the plate group, developed a deep infection, and another one, in the nail group, had a superficial infection. Two cases of the bridging plate group had adhesive capsulites and in one case of the nail group the distal screw became prominent. A transient neuropraxis of the antebrachial lateral cutaneous nerve was found in one case of the nail group, but it recovered in three days. There were no differences between the groups concerning pain, function, active flexion and strength of flexion of the shoulder, as well as pain, range of motion, muscle strength, and stability of the elbow. According to the UCLA score, we had 85.7% excellent and good results in the plate group and 79% in the nail group. According to Broberg and Morrey score for the elbow, we had 85.7% excellent and good results in the plate group and 90.5% in the nail group. Just one patient, from the nail group, was not satisfied with the final result, according to subjective criteria. In conclusion, there were no differences in the final clinical and radiographic results between the two methods of fixation

INTRODUÇÃO: As fraturas da extremidade proximal do úmero são frequentes, com incidência crescente no idoso e com impacto na qualidade de vida e na função do ombro. Para os casos com desvio, a placa bloqueada é o método mais utilizado de osteossíntese. Bons resultados clínicos são obtidos tanto com a placa bloqueada como com a haste intramedular bloqueada. O objetivo do estudo foi a comparação desses métodos no tratamento das fraturas da extremidade proximal do úmero quanto aos resultados clínicos, radiográficos e à taxa de complicações. MÉTODOS: Nesse estudo clínico prospectivo e randomizado, 72 pacientes com fraturas desviadas da extremidade proximal do úmero, classificadas como em 2 ou 3 partes de Neer, foram alocados para receberem osteossíntese com placa bloqueada (36 pacientes - Grupo Placa) ou haste intramedular bloqueada (36 pacientes - Grupo Haste). Os desfechos clínicos foram avaliados aos 3, 6 e 12 meses e incluíram as escalas de Constant e Murley, Universidade da Califórnia em Los Angeles modificada (UCLA), escala visual analógica de dor (EVA) e o questionário \"Disability of Arm, Shoulder and Hand\"(DASH) e a amplitude de movimento passiva. Os desfechos radiográficos consistiram na avaliação da consolidação e do ângulo cabeça-diáfise. As complicações foram avaliadas até os 12 meses e incluíram a avaliação do manguito rotador pela ultrassonografia. O desfecho primário do estudo foi a avaliação pela escala de Constant e Murley, aos 12 meses de pós-operatório. RESULTADOS: Sessenta e cinco pacientes completaram 12 meses de seguimento, sendo 32 no Grupo Haste e 33 no Grupo Placa. A escala de Constant aos 12 meses foi de 70,3 pontos para o Grupo Haste e de 71,5 pontos para o Grupo Placa (p = 0,750). A escala de Constant Relativa Individual foi de 81% para o Grupo Haste e de 85% para o Grupo Placa (p = 0,400). Também não houve diferença entre os grupos aos 3 e 6 meses para a escala de Constant. A escala EVA e o questionário DASH também não apresentaram diferença aos 3, 6 e 12 meses, assim como os resultados radiográficos. A escala UCLA apresentou diferença de 4,0 pontos aos 3 meses, com melhores resultados para o Grupo Haste (p = 0,005), mas sem diferença significante aos 6 e 12 meses. A amplitude de movimento apresentou diferença de 2,1 pontos favorável ao Grupo Haste para a rotação medial aos 6 meses (p = 0,042), sem diferença para os demais planos de movimento nos diferentes momentos de avaliação. Foram registradas 38 complicações, sendo 28 no Grupo Haste e 10 no Grupo Placa, com diferença estatística (p = 0,001). As complicações ocorreram em 18 pacientes, sendo 11 (34%) do Grupo Haste e sete (21%) do Grupo Placa, sem diferença estatística (p = 0,137). CONCLUSÕES: A osteossíntese das fraturas da extremidade proximal do úmero com placa bloqueada ou haste intramedular bloqueada produziram resultados clínicos e radiográficos semelhantes. A fixação com haste intramedular bloqueada apresentou maior taxa de complicações e reoperações / INTRODUCTION: Fractures of the proximal humerus are common, with an increasing incidence in the elderly and with a high impact on quality of life and shoulder function. For displaced fractures, the locking plate is the most used method of osteosynthesis. Studies have shown good clinical results with the use of locking plates, but also with the fixation with locking intramedullary nail. The aim of this study was to compare the clinical outcomes, radiographic results and the complications between these two methods in patients with displaced proximal humerus fractures. METHODS: In this prospective, randomized clinical trial, 72 patients with displaced fractures of the proximal humerus, classified as Neer 2- or 3-part, were randomly assigned to receive osteosynthesis with either locking plate (36 patients - Plate Group) or locking intramedullary nail (36 patients - Nail Group). The clinical outcomes were evaluated at 3, 6 and 12 months and included the Constant and Murley, University of California at Los Angeles (UCLA) and Disability of Arm, Shoulder and Hand (DASH) scores, visual analog scale (VAS) and the passive range of motion. Radiographic findings (consolidation and head shaft angle) and complications, which included the evaluation of rotator cuff by ultrasound, were also evaluated. The primary outcome was the Constant and Murley score at 12 months. RESULTS: Sixty-five patients completed 12 months of follow-up, 32 in the Nail Group and 33 in the Plate Group. The mean Constant score at 12 months was 70.3 points for the Nail Group and 71.5 points for the Plate Group (p = 0.750) and the mean Relative Constant score was 81% for the Nail Group and 85% points for the Plate Group (p = 0.400). There was also no difference at 3 and 6 months for the Constant score. VAS, DASH and radiographic findings also did not differ at 3, 6 and 12 months. Range of motion showed a 2.1 points difference in favor of the Nail Group for medial rotation at 6 months (p = 0.042), with no difference for the other motions at 3, 6 and 12 months. The UCLA score presented a difference of 4.0 points at 3 months, with better results for the Nail Group (p = 0.005), but no significant difference at 6 and 12 months. Thirty-eight complications were recorded, 28 in the Nail Group and 10 in the Plate Group, with significant difference (p = 0.001). Complications occurred in 18 patients, 11 (34%) of the Nail Group and seven (21%) of the Plate Group, with no significant difference (p = 0.137). CONCLUSIONS: Locking plates and locking intramedullary nail yielded similar clinical and radiographic results. Locking intramedullary nail fixation has a higher risk for complications and reoperations