The epidemiology of proximal humeral fractures

We present a 5-year prospective study of the epidemiology of 1,027 proximal humeral fractures. These fractures, which tend to occur in fit elderly persons, have a unipolar age distribution and the highest age-specific incidence occurs in women between 80 and 89 years of age. The commonest was the B1.1 impacted valgus fracture, found in one-fifth of the cases in this series, a type that is not included in the Neer classification. We used both Neer and AO classifications. The AO classification proved to be more comprehensive because in the Neer classification, half of the fractures are minimally displaced and almost nine-tenths fall into only three categories. In the AO classification, the B1.1, A2.2, A3.2 and A1.2 sub-groups comprise over half of all proximal humeral fractures, while the AO type C fractures occur in only 6%. We suggest that the literature does not adequately reflect the spectrum of proximal humeral fractures.     

The epidemiology of proximal humeral fractures

We present a 5-year prospective study of the epidemiology of 1,027 proximal humeral fractures. These fractures, which tend to occur in fit elderly persons, have a unipolar age distribution and the highest age-specific incidence occurs in women between 80 and 89 years of age. The commonest was the B1.1 impacted valgus fracture, found in one-fifth of the cases in this series, a type that is not included in the Neer classification. We used both Neer and AO classifications. The AO classification proved to be more comprehensive because in the Neer classification, half of the fractures are minimally displaced and almost nine-tenths fall into only three categories. In the AO classification, the B1.1, A2.2, A3.2 and A1.2 sub-groups comprise over half of all proximal humeral fractures, while the AO type C fractures occur in only 6%. We suggest that the literature does not adequately reflect the spectrum of proximal humeral fractures.     

The epidemiology of fractures of the proximal femur

Between 1980 and 1989, reports on 21,145 fractures of the proximal part of the femur (15,428 women and 5,717 men) were collected by AO Documentation and are analysed in the present paper. The number of fractures increases exponentially with age for women and for men. Up to 50, the number of fractures is higher for men than for women and vice versa after 55 years. The exponential increase in the number of fractures with age appears for all the types A1 to B3 for both women and men. No special increase has been identified for women after 50 (expected age of menopause).     

The epidemiology of fractures of the proximal humerus

Summary Sevenhundred and thirty proximal humeral fractures, taken from a 5-year period, were entered in this study. We found a higher total incidence rate than that previously seen: 73/100000 population. Twenty-nine percent of the patients required hospitalization; 75% of these were over 60 years old. Only 21% of these were operated on, the majority of admissions being for social reasons. A total of 583 bed-days were used each year in the Aarhus City area (250000 inhabitants). The majority of fractures resulted from falls on level ground. The elderly fell at home, while the younger people fell in public areas. Traffic accidents and work accidents were seldom seen. The accidents occurred typically around midday and before midnight, and mostly in December and January. Half of the fractures were two-part fractures of the surgical neck, while fractures of the greater tubercle and threepart fractures accounted for 21% and 17%, respectively. Based on current developments in the population average life span, it can be expected that proximal fractures will increase the hospital workload significantly in the future.     

Fractures of the proximal ulna olecranon and coronoid fractures

Fractures of the proximal ulna present unique challenges to the surgeon because of the complexity of the elbow joint. It is important not to underestimate the potential difficulty of these cases and to give each one thorough preoperative consideration before embarking on a surgical course. The primary principles of treatment are to restore joint congruity and stability while permitting early range of motion. A logical and consistent approach, based on the fracture characteristics and concomitant injuries, should produce predictable results.     

The anatomy of the proximal ulna

The posterior border of the ulna is the most important bony landmark for all dorsal surgical approaches and the guideline for open reduction, internal fixation of displaced comminuted fractures of the proximal ulna. We examined 74 cadaveric specimens to evaluate the anatomy of the proximal ulna, especially the course of the posterior border, the point of varus angulation, the width of the shaft, and the relationship of the posterior border to the interosseous and anterior ones. In 63 specimens, the mean point of varus angulation was 85.4 mm, and the average angulation angle was 17.7 degrees. In 11 specimens, the posterior border was either radially bowed or the bow was poorly defined and not localized to a specific area along the length of the bone. In conclusion, the variations of the proximal ulna have to be considered if dorsal plates and intramedullary screws are used.     

Treatment of proximal fifth metatarsal fractures with an ulna hook plate

IntroductionFractures of the base of the fifth metatarsal bone present one of the commonest fractures of the metatarsal bones. Conventionally intramedullary screws and tension band wiring have been used as internal fixation methods. Lately hook plates have also served as an alternative fixation method. We hereby report on our experience with the hook plate used in treating fractures of the proximal fifth metatarsal.Methods21 patients treated with the hook plate for proximal fifth metatarsal fractures were assessed clinically and radiologically.ResultsAverage time to union in primarily treated fractures (n = 18) was 7.7 weeks (range 4.5-16 weeks). Average time to return of activities of daily living (ADLs) was 10.3 weeks (range 4.5-37 weeks). The average AOFAS midfoot score was 30.4 preoperatively and 95.2 postoperatively (p < 0.01).ConclusionThe ulna hook plate presents a suitable and adequate method of osteosynthesis used to primarily treat proximal fifth metatarsal fractures requiring surgical intervention with satisfactory post-operative outcomes.     

不同类型尺骨近端骨折的内固定选择和疗效分析

目的探讨不同类型尺骨近端骨折的临床特点、内固定选择、手术策略和临床疗效。 方法回顾性分析2014年6月至2017年6月收治的45例尺骨近端骨折患者资料，男26例、女19例；年龄19~65岁，平均40.8岁；致伤原因：摔伤25例，高处坠落伤12例，交通伤8例。所有患者均行手术治疗，根据骨折的特点和类型分别选择克氏针张力带、解剖钢板或两者联合的方法固定骨折，恢复骨性结构的稳定性。合并尺骨冠状突骨折采用袢钢板固定。合并桡骨头骨折采用微型钢板固定或金属桡骨头置换。合并韧带损伤时均采用带线锚钉缝合固定修补。 结果45例患者获15.6个月（12~24个月）随访。随访结果：所有患者均获骨性愈合，愈合时间平均为11.2周（8~16周）。末次随访：肘部屈曲活动80°~135°，平均121°；肘部伸直活动0~30°，平均8°。Mayo肘关节功能评分为50~100分，平均88.2分，其中优26例，良15例，可2例，差2例，优良率为91.1％。 结论尺骨近端骨折形态各异，应该根据受伤机制、骨折特点及患者情况进行骨折严重程度的评估和分型，选择合理的内固定方式，积极进行术后康复，恢复良好的肘关节功能。     

Types of fractures of the proximal part of the ulna bone in children and youth

In this paper, authors present the forms of fractures of proximal part of ulna bone. Research is based on the completed data of 34 child and young patients in the age of 9–17 years treated in the Clinic of Pediatric Surgery and Traumatology, Medical University of Lublin and Clinic of Traumatology, Medical University of Lublin, in the years 1986–2005. In those years we had 1,048 children and youth with various elbow’s fractures in age between 4 and 17 years. Fractures have been singled out according to the age and gender as well as the side of the fracture. In our material, we separated two main types of injuries of the proximal part of the ulna bone on the basis of the analysis of the course of the crack in the fracture which is the main difference from fractures of proximal part of ulna bone in older patients where we have an occasion to meet plenty of various forms of injuries predominately caused by higher energy. We proposed unambiguous naming of these childhood injuries on the strength of international anatomical nomenclature. During statistic analysis the relationships between the number of individual forms of fractures and the patient’s development period have been shown. We did not find a crucial statistical relationship between the development period and side of the fracture and any essential relationship between development period and gender of our patients. We affirmed that in the treatment of those kinds of fractures surgical methods predominate. Taking into account the presented results of applied treatment, we would like to emphasize the specificity of child’s skeletal system and risk of appearance of severe complications in case of inappropriate medical proceedings.     

Atrophic nonunions of the proximal ulna

Ten consecutive patients were treated by one surgeon for an atrophic nonunion of the proximal ulna. There were six men and four women with an average age of 47 years. Nine of the initial injuries were fracture-dislocations (seven posterior Monteggia lesions and two transolecranon fracture-dislocations) and one was a fracture of the proximal ulnar and radial diaphysis. The nonunion was associated with failed operative fixation in nine patients and occurred after treatment in cast in one patient. Three patients had synovial pseudarthroses and eight had bony defects. Debridement of the nonunion, autogenous cancellous bone grafting, and contoured limited-contact plate fixation were done at an average of 36 months after the original injury. The patients were followed up for an average of 39 months. Union was achieved in all 10 patients. The average arc of ulnohumeral motion was 105 degrees and the average arc of forearm rotation was 130 degrees. According to the system of Broberg and Morrey five patients had an excellent result, four had a good result, and one had a fair result. The fair result was attributable to proximal radioulnar synostosis and severe ulnohumeral arthrosis. Atrophic nonunion of fractures of the proximal ulna usually follow a complex injury treated with inadequate fixation. Stable plate fixation and autogenous bone graft predictably lead to union, but the functional result may be limited by associated problems.     

Intraosseous neurilemmoma of the proximal ulna

INTRODUCTION

Neurilemmoma is a benign nerve sheath neoplasm commonly located in the soft tissue. Intraosseous neurilemmoma is rare, constituting less than 1% of primary bone tumors.

PRESENTATION OF CASE

A 21 year-old woman was presented with left elbow pain of 1-month duration. Plain radiographs showed a well-defined, lytic and expansile lesion of the proximal ulna. Computed tomography revealed cortical destruction and soft tissue extension. Because the tissue of origin for the tumor was uncertain, an open biopsy was performed. The specimens demonstrated a benign spindle cell tumor suggestive of a neurilemmoma, similar to a soft tissue neurilemmoma. The diagnosis of intraosseous neurilemmoma was established. Marginal excision of the soft tissue component and curettage of the lesion in the bone were performed. After 3.5 years of follow up, there is no clinical or radiographic finding to suggest any recurrence.

DISCUSSION

The major site of intraosseous neurilemmoma is the mandible. Occurrence in the long bone is particularly rare. Only two cases of intraosseous neurilemmoma involving the bones around the elbow have been reported to our knowledge; these cases arose in the distal humerus. We describe the first case of intraosseous neurilemmoma of the proximal ulna of the left elbow. The recommended treatment is conservative resection and bone grafting, as malignant change is extremely rare.

CONCLUSION

Although very rare, intraosseous neurilemmoma should be taken under consideration in the differential diagnosis of painful, radiographically benign-appearing osseous tumor around the elbow.     

Trends in epidemiology and patho-anatomical pattern of proximal humeral fractures

Purpose

Proximal humeral fractures are common and frequently associated with osteoporosis. Little is known about the association between the patho-anatomical fracture pattern of proximal humeral fractures and patient characteristics. The purpose of this six year longitudinal registry analysis of proximal humeral fractures was to study overall numbers, certain predefined pathoanatomical patterns and distribution compared with specific patient characteristics.

Methods

Data of patients treated between 2006 and 2011 in a country hospital that provides care >95 % of the city’s hospitalised patients with fractures was retrospectively reviewed. Data were analysed according to patient characteristics of age, gender, comorbidity, accompanying injuries and radiological analysis of pathoanatomical fracture patterns based on Neer and Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification.

Results

Eight hundred and fifteen proximal humeral fractures (67 % women/33 % men; mean age 66 years, range 19–99) were analysed. During the study period, an overall increase of 42.5 % was found: according to AO classification, 46 % were type A, 22 % type B and 32 % type C. Based on the Neer classification, 86 % were displaced, and 49 % were complex with more than three parts. Of complex fractures, 57 % were female patients >60 years. The number of complex fractures was five times higher in women >60 years than in men of the same age group.

Conclusions

An overall increase of inpatients with displaced proximal tibial fractures was documented. Interestingly, complex displaced proximal humeral fractures, especially in older women with comorbidities, accounted for the majority of cases. These results suggest that health-care planning and hospital-based therapeutic strategies should focus on this patient group.     

The treatment of isolated fractures of the distal ulna

The integrity of the periosteum and the interosseous membrane determine the stability of fractures of the distal ulna; this is indicated by the initial displacement. In fractures displaced by less than 50% the periosteum and interosseous membranes are largely intact; these fractures are stable and require only below-elbow immobilisation for protection and relief of pain. In fractures displaced by more than 50% the membranes are disrupted; these fractures are unstable and require above-elbow immobilisation for stability. As most fractures are displaced by less than 50%, immobilisation of the elbow, which significantly increases morbidity, is usually unnecessary. I report the results of a cadaveric study on the pathomechanics of fractures of the distal ulna, and of a prospective clinical trial in which the type of cast used for immobilisation was determined by the stability of the fracture.     

Reconstruction of Monteggia-like proximal ulna fractures using different fixation devices: A biomechanical study

BackgroundComminuted proximal ulna fractures are rare and reconstruction of these fractures is discussed controversially. The aim of this study was to test three currently available plate devices in a standardized comminuted four-part fracture model created in proximal ulna sawbones.Material and methodsA standardized four-part fracture of the proximal ulna was created in 80 sawbones. Reconstruction was performed by five experienced test surgeons according to a standardized reconstruction protocol. Each surgeon reconstructed 4 fractures with a 3.5 mm eight-hole reconstruction plate, 4 fractures with seven-hole third-tubular double plates and 4 fractures with a 3.5 mm anatomical seven-hole locked angle proximal ulna plate. 4 more fractures were reconstructed with simple K-wires as a reference construct for further experiments. Outcome measurements were time for reconstruction, quality of reconstruction and stability of the reconstruction. Stability testing was done in 90° and 30° flexion of the elbow. Testing in 30° flexion was done to test the anteroposterior stability regarding the fixed coronoid process.ResultsTime for reconstruction was significantly less for K-wire fixation than for the plate devices. Time for reconstruction plating and locked angle plating was significantly lower than for double plating (p < 0.005). Quality of reduction did not differ between the three plate systems (p < 0.05). K-wire fixation showed the best quality of reduction (p < 0.005). In 90° of elbow flexion the anatomic locked angle olecranon plate showed a significantly higher stability compared to the other devices. Furthermore the tubular double plating was significantly more stable than reconstruction plating or K-wire fixation (p < 0.05). In anteroposterior loading at 30°, the stability did not differ between the 4 different fixation techniques (p > 0.05). For all devices the testing in 30° flexion showed a significantly higher rigidity compared to 90° flexion.ConclusionThe locked angle plate system showed the highest stability in 90° of elbow flexion. Each implant was more stable in 30° flexion than in 90° flexion. Testing of the anterior stability of the elbow did not show any differences between the different implants. Because of the superior stability of this device, we conclude that locked angle plating should be preferred for reconstruction of monteggia like complex proximal ulna fractures.