Acromion-axillary Nerve Distance and Its Relation to the Humeral Length in the Prediction of the Axillary Nerve Position During the Anterolateral Deltoid-splitting Approach in the Treatment of Proximal Humerus Fractures: a Clinical Study

Background Because of the broad anatomical variation in the course of the axillary nerve, several cadaveric studies have investigated the acromion-axillary nerve distance and its association with the humeral length to predict the axillary nerve location. This study aimed to analyze the acromion-axillary nerve distance (AAND) and its relation to the arm length (AL) in patients who underwent internal plate fixation for proximal humerus fractures.Methods The present prospective study involved 37 patients (15 female, 22 male; the mean age = 51 years, age range = 19 to 76) with displaced proximal humerus fractures who were treated by open reduction and internal fixation. After anatomic reduction and fixation was achieved, the following parameters were measured in each patient before wound closure without making an extra incision or dissection: (1) the distance from the anterolateral edge of the acromion to the course of axillary nerve was recorded as the acromion-axillary nerve distance and (2) the distance from the anterolateral edge of the acromion to the lateral epicondyle of the humerus was recorded as arm length. The ratio of AAND to AL was then calculated and recorded as the axillary nerve index.Results The mean AAND was 6 ± 0.36 cm (range = 5.5–6.6), and the mean arm length was 32.91 ± 2.9 cm (range = 24–38). The mean axillary nerve ratio was 0.18 ± 0.02 (range = 0.16 to 0.23). There was a significant moderate positive correlation between AL and AAND (p = 0.006; r = 0.447). The axillary nerve location was predictable in only 18% of the patients.Conclusion During the anterolateral deltoid-splitting approach to the shoulder joint, 5.5 cm from the anterolateral edge of the acromion could be considered as a safe zone for the prevention of possible axillary nerve injury.

Outcomes of Mini-Invasive Arthroscopic Arthrolysis Combined with Locking Screw and/or Intramedullary Nail Extraction after Osteosynthesis of the Proximal Humerus Fracture

Data on the effectiveness of arthroscopic arthrolysis and extraction of osteosynthetic material after osteosynthesis of the proximal humerus in patients with persisting problems are rare and insufficient. In this study, we performed arthroscopic arthrolysis and extraction of fixation screws, and, where protruding, extraction of the nail in 34 patients with problems persisting 12 months after osteosynthesis of the proximal humerus using an intramedullary nail. The effectiveness of the treatment was assessed using the Constant–Murley shoulder score and forward flexion difference between the treated arm and the contralateral one. A median increase of 16 points in CMS score and 30 degrees reduction in the arm forward flexion difference was recorded 12 months after the arthroscopy. The improvement was significantly higher in the patient group with intramedullary nail extraction (however, this group had worse pre-operative values and the screw was only extracted where likely to cause problems). The median time to heal was 11 weeks; no serious peri- or post-procedural complications occurred. Mini-invasive arthroscopic arthrolysis combined with extraction of osteosynthetic material proved to be a safe and effective method for treatment of patients after osteosynthesis of the proximal humerus using an intramedullary nail with persisting pain and/or mobility limitation.

Glenohumeral joint dislocation is rare in children with proximal humeral fractures: a descriptive study and literature review

Background Glenohumeral dislocation combined with fracture of the proximal humerus is extremely rare in children, and this study aims to investigate its incidence in the pediatric population and review the treatment strategy for this condition. Methods Between Jan 2014 and Jan 2019, 280 patients with unilateral proximal humeral fractures were retrospectively reviewed. Imaging and follow-up notes were reviewed for patients with a predilection for glenohumeral joint dislocation. Six (2.14%) patients between the ages of 5 and 10 years were confirmed as glenohumeral joint dislocation and included in the study. All these patients underwent closed reduction and external fixation under general anesthesia. Results Out of 280 patients with proximal humeral fractures, only 6 patients, including 4 males and 2 females, were confirmed as glenohumeral joint dislocation. ROM was normal compared with the contralateral shoulder in every patient at the last follow-up. There was no case of radiological abnormality, including avascular necrosis or devascularization of the humeral head. Conclusions Glenohumeral dislocation is a rare entity associated with the proximal humerus fracture in children, with an overall incidence in our case series was 2.14%. Reduction and stabilization of such injury using an external fixator is a suitable choice for pediatric patients that failed closed reduction.

Outcomes associated with secondary implant removal and arthrolysis in patients with a painful stiff shoulder after proximal humeral fracture fixation

Aims Open reduction and plate fixation (ORPF) for displaced proximal humerus fractures can achieve reliably good long-term outcomes. However, a minority of patients have persistent pain and stiffness after surgery and may benefit from open arthrolysis, subacromial decompression, and removal of metalwork (ADROM). The long-term results of ADROM remain unknown; we aimed to assess outcomes of patients undergoing this procedure for stiffness following ORPF, and assess predictors of poor outcome. Methods Between 1998 and 2018, 424 consecutive patients were treated with primary ORPF for proximal humerus fracture. ADROM was offered to symptomatic patients with a healed fracture at six months postoperatively. Patients were followed up retrospectively with demographic data, fracture characteristics, and complications recorded. Active range of motion (aROM), Oxford Shoulder Score (OSS), and EuroQol five-dimension three-level questionnaire (EQ-5D-3L) were recorded preoperatively and postoperatively. Results A total of 138 patients underwent ADROM; 111 patients were available for long-term follow-up at a mean of 10.9 years (range 1 to 20). Mean age was 50.8 years (18 to 75);79 (57.2%) were female. Mean time from primary ORPF to ADROM was 11.9 months (6 to 19). Five patients developed superficial wound infection; ten developed symptomatic osteonecrosis/post-traumatic arthrosis (ON/PTA); four underwent revision arthrolysis. Median OSS improved from 17 (interquartile range (IQR) 12.0 to 22.0) preoperatively to 40.0 (IQR 31.5 to 48.0) postoperatively, and 39.0 (IQR 31.5 to 46.5) at long-term follow-up (p < 0.001). Median EQ-5D-3L improved from 0.079 (IQR -0.057 to 0.215) to 0.691 (IQR 0.441 to 0.941) postoperatively, and 0.701 (IQR 0.570 to 0.832) at long-term follow-up (p < 0.001). We found that aROM improved in all planes (p < 0.001). Among the variables assessed on multivariable analysis, a manual occupation, worsening Charlson Comorbidity Index and increasing socioeconomic deprivation were most consistently predictive of worse patient-reported outcome scores. Patients who subsequently developed ON/PTA reported significantly worse one-year and late OSS. Conclusion ADROM in patients with persistent symptomatic stiffness following ORPF can achieve excellent short- and long-term outcomes. More deprived patients, those in a manual occupation, and those with worsening comorbidities have worse outcomes following ADROM. Cite this article: Bone Joint J 2022;104-B(1):157–167.

Functional Outcome of Proximal Humerus Fracture Managed Surgically by Joshi's External Stabilizing System

INTRODUCTION: The ideal management of proximal humerus fracture is still controversial despite various treatment options. Conservative treatment with slab is fraught with shoulder stiffness and malunion while surgical treatment with plates and nail is fraught with infection and blood loss. Therefore, Joshi External Stabilization System (JESS) being a minimally invasive percutaneous procedure can be the ideal treatment for these fractures. MATERIAL AND METHODS: This prospective and observational hospital based study was carried out in Orthopedics Department, Universal College of Medical Sciences Teaching Hospital (UCMS-TH) from December 2018 to January 2021. All patients with traumatic proximal humerus fracture who fulfilled the inclusion criteria were enrolled in the study and were treated with JESS. Fracture was classified according to Neer classification and functional outcome was assessed according to Constant Murley Score (CMS) system. Post-operatively patients were regularly followed at 6 weeks, 3 months and 6 months. RESULTS: There was statistically significant difference in VAS score (p<0.05) measured at six weeks, three months and six months; and CMS (p<0.05) at three months and six months. There was statistically significant difference between fracture type (Neer type) and fracture union (p<0.05). But the association between functional outcome and type of fracture was statically insignificant (p>0.05). CONCLUSION: Displaced proximal humerus fracture when treated surgically with JESS has good functional and radiological outcome. It produces less pain, less stiffness and greater Range of Motion (ROM).

A Case Report: Post-Operative Physiotherapy Rehabilitation Program for a Patient with Tibial Osteosarcoma

Tumour or bone tumour can occur in any bone and called it as a Osteosarcoma. It is more prone in the long bones of the body especially at metaphyseal growth plate of the bone. Femur, Tibia and Humours are the most common bone for the osteosarcoma and in some research pelvis bone and skull or jaw bone also involved. There are many factors which cause the sarcoma might be due lack of physical activity. The Chondroblastoma as Giant Cell Tumour of the Humours of Epiphysial Chondromatous in nature. Proximal humerus and Knee are the most common and most affected bone by the Chondroblastomas at the level of epiphyses of the longer bone. 62% cases show the thinning of the Subchondral structure and 33% cases shows the collapse and chondral breach Mostly (90%) it is found in the age group of 5 to 25 years of age with the male and female ratio is of 2:1. Psychological and physical improvement is seen in the patient of sarcoma and enhances participation in the exercise with great enthusiasm and help in the reduction the impact of symptoms of diseases. Physical therapy exercise protocol starts from low to moderate intensity which involved resistance exercise, aerobic exercise and combination of both exercises. Conclusion: Physiotherapy has been demonstrated to be useful in post-operative osteosarcoma patients in our case study. Physiotherapy assists the patient in de-stressing from both mental and physical stress. The goal of improving function through health-care management and goal-setting was met on schedule. Taking excellent care of yourself after surgery can help you avoid issues.