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Fat emboli may occur in patients after traumatic fractures or orthopedic procedures; however, their clinical detection is a very rare finding. Here, we describe a 77-year-old female who was admitted to the emergency department with a fracture of the right humerus. We diagnosed fat embolism after an ultrasound of the right subclavian vein. The embolism was detected by high-intensity transient signals present on the spectral Doppler. While these signals are well known for microembolization in transcranial Doppler, to our knowledge this is the first case report in the medical literature to observe and describe high-intensity transient signals seen in the upper extremities by spectral Doppler. Although it is unusual to detect a fat embolism in transit, we believe clinicians should be aware of this finding, particularly when evaluating high-risk patients.

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PURPOSE: Supracondylar humerus (SCH) fractures account for approximately 30% of injuries for those younger than 7 years of age (Cheng et al. in J Pediatr Orthop 19:344-350, 1999). Recent studies examining the association of patient age and SCH fracture outcomes have provided conflicting findings. The purpose of this study is to investigate SCH fracture outcomes in children at different ages of skeletal development. METHODS: Retrospective review of a Level I pediatric trauma center between 2010 and 2014 was conducted. 190 patients with SCH fractures, age < 14 years, fracture type Gartland III or IV (AO/OTA 13-M 3.1 III and IV) were included. Patients were sorted into age groups: < 2 years, 4-6 years, and > 8 years. Patients were treated with either a closed or open reduction with percutaneous fixation. Clinical outcomes including postoperative elbow range of motion, nerve palsy, compartment syndrome, infection, and cubitus varus were assessed. RESULTS: Patients in younger age groups were more likely to obtain postoperative full elbow flexion (< 2 years = 77%; 4-6 years = 66%; > 8 years = 43%) and full elbow extension (< 2 years = 96%; 4-6 years = 88%; > 8 years = 64%). Age was a significant predictor of nerve palsy on admission, mean operative time (< 2 years = 21.8 min; 4-6 years = 43.0 min; > 8 years = 80.7 min), and mean fluoroscopy time (< 2 years = 22.9 s; 4-6 years = 59.5 s; > 8 years = 171.9 s). There were no differences in rates of open reduction, compartment syndrome, pin tract infection, cubitus varus, or reoperation among groups. CONCLUSION: Increasing age is associated with increased elbow stiffness after percutaneous fixation of Gartland Type III and Type IV SCH fractures. Older patients with SCH fractures may benefit from formal rehabilitation. LEVEL OF EVIDENCE: III.

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The upper limb has a complex anatomy comprised of many nerve and vascular structures, making humeral shaft fractures extremely important. Injury to the humeral shaft commonly occurs due to trauma and affects younger male or older female patients. The radial nerve travels along the spiral groove of the humerus, placing it at an increased risk of damage in humeral shaft fractures. If injured, there are a variety of classifications of radial nerve injury, different indications for exploration, and treatment methods that orthopedic surgeons have available in treating these injuries. This review aims to discuss the etiology of humeral shaft fracture-associated radial nerve palsy, tools for diagnosis, and treatment.

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PURPOSE: Three-dimensional (3D) capacity for remodelling in cubitus varus deformity (CVD) after paediatric supracondylar humeral fractures (PSHFs) remains unelucidated. This study investigated remodelling patterns after PSHFs by examining 3D deformity distribution over time after injury. METHODS: Computed tomography (CT) data of 86 patients with CVD after PSHFs were analysed. The 3D deformity angles in the sagittal, coronal, and axial directions were assessed and correlated with the duration between the age at injury and CT evaluation. For the subgroup analysis, we performed the same correlation analysis in a younger (< 8 years old) and an older group (≥ 8 years old); we categorized the duration into early (< 2 years), middle (≥ 2 to < 5 years), and late periods (≥ 5 years) and compared the deformity angles of each direction among the three groups. RESULTS: Sagittal deformity showed a moderate correlation with the duration of deformity (r = -0.54; P < 0.001), while coronal and axial deformities showed a negligible correlation. Sagittal deformity showed moderate correlations with the duration in the younger group (r = -0.62; P < 0.001) and weak correlations in the older group (r = -0.37; P = 0.091). In the sagittal direction, the deformity angle in the early period was significantly larger than those in the mid and late periods (P < 0.001). However, there were no significant differences among the three groups in the coronal and axial directions. CONCLUSION: Sagittal deformities in CVDs are capable of remodelling, especially in the early period and at a younger age, whereas coronal and axial deformities are less likely to undergo remodelling.

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OBJECTIVE: This work aimed to evaluate the results of using a 2-stage surgical treatment strategy without doing anterior transposition of the ulnar nerve (ATUN) for cases with long-standing nonunited fracture lateral humeral condyle (LHC) in children, accompanied by a critical review. METHODS: A consecutive 12 children with a long-standing ">2 years" nonunited LHC with evident radiologic gross anatomic distortion of the elbow were included in this study. A 2-stage surgical treatment strategy was applied, wherein the first stage, open functional reduction, osteosynthesis, and iliac bone graft were done. Then after 6 months, the second stage surgery was carried out in the form of supracondylar humeral corrective osteotomy if the cubitus valgus angle was ≥20 degrees. ATUN was not done for any of the cases even with those having ulnar nerve dysfunction. RESULTS: Union took place in 11 out of the 12 cases after a mean follow-up period of 11 weeks (range: 8 to 14 wk; SD: 1.6). All the 7 cases showed preoperative ulnar nerve dysfunction and reported clinical recovery at the end of their follow-up. CONCLUSIONS: Two-stage surgical treatment strategy without ATUN is a convenient, reproducible, and successful line of treatment for children presented with longstanding nonunited LHC with anatomically distorted elbow. LEVEL OF EVIDENCE: Level IV-case series.

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Posttraumatic cubitus varus is a multiplanar deformity that results from an improperly reduced supracondylar humerus fracture. The prevention of posttraumatic cubitus varus hinges on the stable restoration of all 3 columns of the distal humerus while avoiding malrotation. The collapse of any column leads to varying degrees of deformity in the coronal, sagittal, and/or axial plane. The purpose of this article is to explain the pattern of the deformity and use this to summarize preventative tactics for avoiding its described sequelae. We also summarize, illustrate, and present case examples for the various osteotomies used to correct the deformity, and speculate future directions.

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CASE: We report a single case of a closed intra-articular distal humerus fracture in a 28-year-old man with a preexisting fishtail deformity characterized by concavity of the central trochlea and corresponding deformity of the olecranon. The patient was treated with open reduction and internal fixation. CONCLUSION: The case highlights the diagnosis and challenges of treatment. Conventional fixation choices and imaging techniques may need to be altered when treating a fracture with this deformity.

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The association of radial nerve palsy and humeral shaft fracture is well known. Primary exploration and fracture fixation is recommended for open fractures and vascular injury while expectant management remains the standard of care for closed injuries. In the absence of nerve recovery, exploration and reconstruction is recommended 3 to 5 months following injury. When direct repair or nerve grafting is unlikely to achieve a suitable outcome, nerve and tendon transfers are potential options for the restoration of wrist and finger extension.

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Supracondylar humerus fractures are the most common elbow fractures in children up to 10 years of age. The incidence of associated nerve injuries varies up to 15% depending on the data. Traumatic and iatrogenic lesions mainly affect the ulnar nerve. The regeneration of peripheral nerves is comparatively better in childhood. In the present study, the functional results after surgical and conservative treatment of nerve injuries in children after supracondylar fractures were compared and analyzed for influencing factors. In this retrospective comparative study, clinical data of pediatric nerve injuries following supracondylar humerus fractures treated over a period of 13 years (2008-2021) were analyzed. Children who were treated surgically (neurolysis, autologous reconstruction) due to insufficient clinical/neurophysiological improvement within 6 months after trauma or who were followed up conservatively in case of regression of symptoms within 6 months after trauma were included. All patients underwent multidisciplinary follow-up. 48 patients (26 female/22 male) with nerve injuries were included in this study. All patients had a history of surgical treatment with K- wire fixation due to severe dislocated fractures. The mean age was 7±2 years. The initial symptoms were severe motor deficits in all patients and sensory deficits in 87.5% (n=42). Isolated lesions of the ulnar nerve were most common (n=24, 50%). The nerve was neurolysed in 21 patients and additionally transferred to the volar side in 15. Nerve grafting was performed in 7 children and split repair in 2. Postoperatively, there was a significant improvement in motor function in all patients. Despite comparably severe motor deficits at initial presentation, further 20 children were treated conservatively due to the regression of neurological deficits. They showed comparably good functional results. No serious complications were recorded in either group. The average follow-up time was 377.25±524.87 days. The presented study shows excellent functional results after surgical treatment of pediatric nerve injuries without severe complications. Children with comparatively high-grade lesions at initial presentation have a good chance of complete spontaneous remission even without surgery. For this reason, the indication for surgery in children should be very carefully considered.

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INTRODUCTION: The frequency of proximal humeral fractures shows an increasing tendency, especially in the elderly, who are frequently affected by osteoporosis. The adequate treatment of complex, displaced fractures poses a serious challenge. Among surgical treatment options, osteosynthesis with an angular stable plate is preferred, however, the implant-related complication rate may be exceptionally high. In our present study, we report the short-term outcomes of our new method of valgising angular stable plate fixation which we use for multifragmentary, displaced proximal humeral fractures in elderly patients. MATERIALS AND METHODS: We retrospectively evaluated the clinical and radiological outcomes of 52 patients (46 female and 6 male, age: 71.9 ± 9.6) who suffered dislocated three- or four-part fractures and underwent valgising angular stable plate fixation. RESULTS: Mean follow-up time was 17.3 months, while the functional outcomes were as following: excellent in 26, good in 18, moderate in 5 and poor in 3 patients. The mean Constant-Murley Score was 82.5 ± 11.2. Functional outcomes only showed significant correlation (p = 0.031) with age and were proven unrelated to fracture type, BMI and known primary diseases. The cumulative complication rate was 9.6% and revision rate was 5.8%. Neurological deficit, pseudoarthrosis or avascular humeral head necrosis did not occur during the follow-up period. CONCLUSIONS: Valgising angular stable plate fixation that we apply for proximal humeral fractures provided favourable functional outcomes and a low postoperative complication rate due to the optimal head and plate placement. The method is especially effective for the treatment of displaced three- and four-part fractures with weakened, osteoporotic bone structure.

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A child sustained an ipsilateral supracondylar humerus (SCH) and distal both-bone forearm fractures bilaterally, in addition to facial injuries, following a fall from height. He was managed surgically by closed reduction and pinning for both SCH and distal end radius fractures bilaterally. At the final follow-up, all the fractures had united uneventfully, and he had no functional limitations or cosmetic concerns. We conclude that a floating elbow in the paediatric population is an uncommon injury, and the bilateral scenario is even rarer. One should be vigilant for compartment syndrome; early surgical fixation may give better results.

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INTRODUCTION: Pediatric humeral lateral condyle fractures are the second most common elbow fractures. Their treatment presents challenges due to physeal and intra-articular involvement. Postoperative stiffness is a common concern that can limit limb functionality. This study aims to identify risk factors for postoperative stiffness in a large cohort of these fractures across multiple institutions. METHODS: A large, multicenter retrospective review of medical records from 6 level I trauma centers was conducted. Data from children aged 1 to 12 years with lateral condyle fractures treated between 2005 and 2019 were collected. Elbow stiffness was defined in the present study as having a limited elbow ROM that led to requiring a physical or occupational therapy referral or needing surgical treatment to address stiffness. Relevant patient demographics, fracture characteristics, treatment approaches, and complications were analyzed. RESULTS: Six hundred sixty-five fractures were analyzed. The average patient age was 8.8 years with 21% experiencing stiffness. The stiffness group had older patients, a higher incidence of elbow dislocations, a higher rate of open reduction, and more severe fracture patterns. Multivariate regression analysis identified open reduction, increased age, and concurrent elbow dislocation as significant risk factors for stiffness. Patients with stiffness commonly utilized only physical or occupational therapy (96%), while a small percentage (4%) required surgical interventions. CONCLUSIONS: This study highlights the risk factors for postoperative stiffness in pediatric humeral lateral condyle fractures, namely increased age, concomitant elbow dislocation, and treatment with open reduction. Families of older patients or severe fracture patterns requiring open reduction and those with concurrent elbow instability should be counseled about their increased risk of stiffness. The authors recommend initially attempting a closed reduction in high-risk patients to help mitigate the risk of postoperative stiffness. Early initiation of range of motion exercises may also be beneficial for at-risk patients. LEVEL OF EVIDENCE: Level III: Therapeutic studies-Investigating the results of treatment.

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The minimally invasive plate osteosynthesis (MIPO) for proximal metaphyseal-diaphyseal humeral fracture is an effective alternative treatment with satisfactory outcomes. In this study, we described the surgical techniques and clinical results using MIPO via a lateral approach and long PHILOS plate fixation in 23 patients. All fractures were successfully united within a mean union time of 13.5 weeks (range 9-18). There was no iatrogenic radial nerve palsy. The deltoid power was grade 5 in all patients, except for 2 patients who had associated brachial plexus injury and gunshot injury at the deltoid muscle. The mean Constant-Murley score was 85.6 (range 16-98) and DASH score was 12.1 (range 1.7-85). Based on these findings, the lateral MIPO with long PHILOS plate fixation could be an alternative for the proximal metaphyseal-diaphyseal fractures of the humeral shaft.

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INTRODUCTION: Proximal humerus fractures (PHF) are common injuries that can lead to axillary artery injury, which carries the risk of not being identified during initial assessment. The aim of this study was to describe the management of suspected axillary artery injury associated with PHF according to our experience and to describe a new multidisciplinary surgical approach. METHODS: This was a single-center retrospective study. A database was created for patients admitted for PHF to the emergency department of the Hospital of Cannes between October 2017 and October 2019. Patients admitted with PHF associated with suspected ipsilateral upper limb ischemia, and/or massive diaphysis displacement, and/or upper limb ipsilateral neurological deficits were included in this study. RESULTS: In total, 301 patients diagnosed with PHF were admitted within these periods. Among these patients, 12 presented with suspected axillary artery lesions, of whom, 6 were included in the present study and treated according to our new approach. A description of these 6 cases, along with an extensive literature review is presented. CONCLUSION: Based on our experience, the endovascular approach proposed for the management of axillary artery injury associated with proximal humerus fractures is effective, feasible and reproducible.

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OBJECTIVES: Lateral humeral condyle fractures account for 12% to 17% of all distal humerus fractures in children, and usually occur as an isolated injury or are associated with radial neck and/or proximal ulna fractures. The presentation with a concomitant dislocation of the elbow is rare. Therefore, literature on young patients with this uncommon combination is sparse and mostly limited to case reports and small case series. The aim of the present study is to identify the best treatment strategy for this injury, recognize potential risk factors for the development of complications, and identify predictors of outcome. METHODS: This is a multicenter retrospective review of electronic and written medical records for skeletally immature patients who were diagnosed with a lateral condyle fracture of the humerus associated with elbow dislocation (ED). Data recorded included patient demographics, fracture classification, direction of the dislocation, treatment strategy, time to union, elbow range of motion, complications, and additional procedures. The modified Flynn criteria were used to determine the outcomes. RESULTS: We identified 23 patients who presented to 3 institutions with a concomitant lateral humeral condyle fractures and an ED. The mean age at the time of injury was 8.7 years (range: 6 to 13 y). The median time from injury to surgery was 1 day (interquartile range: 0.5, minimum to maximum: 0 to 29 d). The median follow-up was 24 weeks (interquartile range: 16, minimum to maximum: 4 to 120 wk). The injury occurred more commonly in males (79%) with Weiss type 3 fractures. The direction of the dislocation was posterior or posteromedial in most cases. Open reduction through a modified Kocher lateral approach and fixation with either Kirschner wires (N = 12) or cannulated screws (N = 9) was the preferred method of treatment. Eight patients (34.8%) developed complications, including persistent elbow stiffness (N = 5), elbow instability (N = 1), and avascular necrosis (N = 2). There were no cases of delayed union, nonunion, malunion, heterotopic ossification, neurological injury, or hardware failure. Patients treated with casting or Kirschner wire fixation had a significantly increased rate of elbow stiffness compared with screw fixation (50%, 25%, and 11%, respectively, P = 0.015). According to Flynn's criteria, 65% of the patients had good or excellent outcomes, and 35% had poor. CONCLUSION: The findings of this study demonstrate a higher than previously described rate of complications in children with lateral condyle humerus fracture associated with ED, including persistent elbow stiffness, avascular necrosis, and chronic elbow instability, leading to unsatisfactory clinical outcomes in over one-third of the cases. Our findings suggest that the internal fixation with screws, combined with a shorter postoperative immobilization period (2 wk) may lead to improved clinical outcomes. LEVEL OF EVIDENCE: Level III-therapeutic, case series.

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OBJECTIVES: The primary objective of the present study is to compare the radiographic outcomes and complications of two different techniques for lateral closing-wedge osteotomy in pediatric patients with cubitus varus. METHODS: We retrospectively identified patients treated at five tertiary care institutions: 17 underwent the Kirschner-wire (KW) technique, and 15 patients were treated with the mini external fixator (MEF) technique. Demographic data, previous treatment, pre- and postoperative carrying angle (CA), complications and additional procedures were recorded. Radiographic evaluation included assessment of the humerus-elbow-wrist angle (HEW), and the lateral prominence index (LPI). RESULTS: Patients treated with both KW and MEF achieved significant improvements in clinical alignment (mean pre-op CA -16 ± 6.1 degrees to mean post-op 8.9 ± 5.3 degrees, P < 0.001). There were no differences in final radiographic alignment or radiographic union time; however, time to achieve full elbow motion was faster in the MEF group (13.6 versus 34.3 weeks, P = 0.4547). Two patients (11.8%) in the KW group experienced complications, including one superficial infection and one failed correction that required unplanned revision surgery. Eleven patients in the MEF group underwent a planned second surgical procedure for hardware removal. CONCLUSIONS: Both fixation techniques are effective at correcting cubitus varus in the pediatric population. The MEF technique may have the advantage of shorter recovery of elbow range of motion but may require sedation for hardware removal. The KW technique may present a slightly higher complication rate.

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Transphyseal fractures of the distal humerus often occur in children younger than 4 years as a result of birth trauma, nonaccidental trauma, or falls from a low height. It is important to identify and treat these injuries in a timely manner to ensure successful management. Most transphyseal fractures of the distal humerus are treated with closed reduction and percutaneous pinning with the aid of an elbow arthrogram. The most common complication following a fracture is cubitus varus caused by growth arrest, malunion, or osteonecrosis of the medial condyle. Normal carrying angles may be restored through corrective lateral closing wedge osteotomy.

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Background: This is the first systematic review of the relationship between humeral shaft fractures and radial nerve palsy in children. The present comprehensive review is aimed at identifying important clinical findings between humeral diaphysis fractures and radial nerve injuries and assessing the effects of treatment. Methods: We searched electronic bibliographic databases, including PubMed, the Cochrane Library, Scopus, and Web of Knowledge, until March 2022. This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and the patients, interventions, comparisons, outcomes guidelines. Results: We identified 23 original papers, of which 10 were eligible for further analysis. Cases of 32 young patients with radial nerve palsy were identified and analyzed. The prevalence of radial nerve palsy was 4.34% (eight cases out of 184 patients with humeral shaft fractures). The radial nerve was most often associated with a simple transverse fracture (12A3, 17 cases (65.4%)). Conclusions: Radial nerve injury in humeral shaft fractures in children is rare, with a frequency of 4.34%. We highly recommend early surgical nerve exploration with transverse fractures in the distal third segment combined with primary radial palsy. Furthermore, we recommend making thoughtful decisions regarding early nerve exploration in the Holstein-Lewis fractures. In addition, consideration of early surgical nerve exploration in fractures resulting from high-energy trauma and open fractures despite their morphology is recommended.

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Management of children with supracondylar humeral fractures with pulseless pink hands is still controversial, whether to choose operative or conservative treatment. Proponents of conventional treatment mentioned that most patients can restore the motor and sensory function of the hand shortly after the injury without the need to restore distal pulse by surgery. Opponents of this treatment strategy claim that many patients will develop limb shortening a few years after the injury leading to functional and psychological problems. In this study, we made a comparison of the outcomes of each treatment to help in making policy for the treatment of such types of injuries in our center. This study answers the question "Which method is preferred for treating supracondylar humeral fracture with suspected vascular injury represented by pulseless pink hand, and what are the short and long-term outcomes of each treatment method. The main objective of the study is to settle a policy for the treatment of such types of injuries in our center. This study is a retrospective for the 10-year period from 2010 to 2020, it included 74 patients with blunt trauma to one upper extremity. All patients were children aged one year to fourteen years. Patients with penetrating trauma, combined penetrating and blunt trauma, victims of burns and explosions, and patients with other co-morbidities were excluded. We have two treatment strategies: Conservative (watchful waiting) and Operative exploration. We compared the outcomes of these two strategies regarding the short-term outcome (6 months follow-up) and the long-term outcome (5 years follow-up). We looked for acute and chronic limb ischemia and chronic pain syndrome as the short-term follow-up, while we took limb shortening and chronic limb ischemia and limb function as variables of the long-term follow-up. We don't have the ability to control patients for the psychological examination by a psychiatrist, therefore; we excluded this variable from our study.

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