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.

Can Only Fix Sternoclavicular Joint to Treat Bipolar Clavicle Injury?

Background: Owing to the rarity of bipolar clavicle injury, treatment remains controversial. The purpose of this study is to report treatment of bipolar clavicle injury with internal plate fixation.Methods: We present our experience of clavicle hook plating for sternoclavicular joint dislocation and anatomical plating for distal clavicle fracture for the treatment of three consecutive bipolar clavicle injuries with different injury patterns. At follow up, radiographs were assessed for joint congruity, fracture union, and implant failure. Clinical evaluation included Disability of the Arm, Shoulder, and Hand (DASH), Constant and Murley Score, Visual Analog Scale (VAS), and complications.Results：All patients had a minimum follow-up of six months. Each fracture had solid union, and each dislocation showed no sign of recurrent dislocation, the mean shoulder forward flexion was 153.3°±10.4°, the mean DASH score was 13.9±9.2 points. The mean Constant and Murley score was 82.3±12.3 points, and, the mean VAS score was 2.2±2.0 point. No complications were encountered, and each patient was highly satisfied with their treatments.Conclusion: Our experience of using internal plating for bipolar clavicle injury is positive, as it allows early mobilization and resulted in good joint function. Also, only sternoclavicular joint fixation might be sufficient for some part of bipolar clavicle injury, acromioclavicular joint fixation is not necessary unless residual instability existence.

Successful Treatment of a 15-Year-Old Nonunion of a Midshaft Clavicle Fracture Causing Brachial Plexus Compression

A 49-year-old man with a 15-year-old nonunion of a midshaft clavicle fracture suffered from progressive tingling in his entire arm and fingers for two years, due to irritation of the brachial plexus in the costoclavicular space, especially upon elevation of the arm. After open reduction and internal plate fixation, all symptoms were resolved and complete consolidation of the fracture was achieved at one-year follow-up. This case demonstrates two things: brachial plexus compression can occur even many years after a nonunion of a clavicle fracture and union can be still achieved, even in a longstanding nonunion.

Distal femoral osteotomy using a novel deformity reduction device

SummaryDistal femoral osteotomy is a surgical procedure used to correct patellar luxation, secondary to a femoral deformity. A distal femoral osteotomy using the tibial plateau levelling osteotomy-jig to temporarily provide stability of the distal femoral osteotomy, maintaining limb alignment in the frontal and axial planes prior to internal plate fixation of the osteotomy, has been described. This report describes a novel jig named Deformity Reduction Device (DRD). This device was developed with the specific aim of increasing precision and predictability during corrective osteotomy execution in order to be consistent with the preoperative planning. The distal femoral osteotomy DRD-assisted procedure is described in detail, discussing the theoretical and practical principles of the application.