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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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BACKGROUND: Control of humeral torsion can present a challenge, especially intraoperatively during closed reduction and fixation of humeral shaft fractures or 2-part surgical neck fractures of the proximal humerus. The objective of this study is to develop and validate an indirect method for the assessment of humeral torsion using an index that is linearly correlated with rotational arm position and can be derived from only a single plain radiographic image of the proximal humerus. METHODS: The Humeral Head Offset Index (HHOI) is calculated as the ratio of the medial and lateral offset of the humeral head measured from the outer cortices of the shaft on a plain radiographic or fluoroscopic image. The relationship of HHOI with humeral torsion was first verified on a sawbone model with radiopaque characteristics under fluoroscopic control. Different degrees of retroversion were simulated through manual rotation of the humerus with a digital protractor in 5° increments until 40° internally rotated and then in 5° increments until 40° externally rotated from the neutral position. The same procedure was subsequently performed digitally on Digitally Reconstructed Radiographs (DRRs) from computed tomography (CT) dataset of the sawbone. Next, the HHOI index was applied to eight randomly selected patients with total humerus CT using the same method. Spearman's rho was calculated for the bivariate analysis of correlation between the simulated degree of retroversion and the HHOI. Strength of correlation was classified according to Koo and Li. Interrater and intrarater reliability of three blinded observers with repetition of measurement after three months were analyzed by assessing the intraclass correlation coefficient (ICC). RESULTS: Both in the sawbone model and in DRRs, we demonstrated a high to very high significant linear correlation between simulated retroversion and the HHOI. ICC values demonstrated excellent interrater reliability and excellent intrarater reliability for measurement of the HHOI. CONCLUSIONS: The HHOI is a new, simple, reliable index that has a linear relationship to the rotation of the humerus and can therefore allow an indirect control of humeral torsion in comparison to the contralateral side.

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PURPOSE: The radial nerve may be painfully irritated or damaged by open reduction and internal fixation (ORIF) of humeral fractures. Secondary radial nerve lesions after ORIF of humeral shaft fractures are described in up to 16%. Not only peripheral nerves but also orthopaedic instruments and osteosynthesis material are well visible by ultrasound. The aim of this study was to evaluate the accuracy of ultrasound in assessing the relation between the bone overlapping screw tips and the radial nerve close to the humeral bone. METHODS: Ultrasound-guided drilling was used to place screws as close as possible to the radial nerve in 8 humeral bones of four cadavers. The relation between the radial nerve and the screw tips was assessed by high-resolution ultrasound, and the overlap of all screw tips over the bone was measured by ultrasound and fluoroscopy. Thereafter, the findings were validated by anatomical dissection. RESULTS: We could correctly identify all screw tips and their relation to the radial nerve by ultrasound. In 7 of 8 cases, the screw tip had direct contact with the radial nerve. The overlaying length of the screw tip was accurately measured by using ultrasound in all cases. In contrast fluoroscopy underestimated this length in 50% of cases. CONCLUSION: With this study, we show that ultrasound can reliable visualize the screw tips and its relation to the radial nerve. Ultrasound is a promising diagnostic tool to evaluate patients with radial nerve irritations or lesions after ORIF of humeral fractures. Furthermore, ultrasound could be an adequate tool to guide drilling.

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Distal humerus intra-articular comminuted open fracture is a challenging injury, with nonunion, infection and stiffness considered as major concerns. We report a 58-year-old woman who was admitted to the emergency department from a car accident, sustaining an open wound with severe comminution of distal humerus and complete articular fracture, classified as AO/OTA 13C2 and Gustillo Anderson type IIIA. Debridement and external fixation was done first, followed by open reduction and internal fixation with fibular strut allograft. The patient showed excellent results in radiological and functional outcomes. Level of Evidence: Level V (Therapeutic).

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PURPOSE: Comminuted coronal shear fractures of the distal humerus represent rare injuries and are difficult to treat, especially comminuted capitellum and trochlear fractures (Dubberley Type III). The on-table reconstruction technique of comminuted articular fractures may be an option, although it has not been reported in the coronal shear fracture of the distal humerus. The aim of the present case series is to determine the functional and radiological outcomes of on-table reconstructed Dubberley III fractures. METHODS: A retrospective review was conducted of 10 patients with Dubberley type III fractures in coronal shear fractures of the capitellum and trochlea who underwent an 'on-table' reconstruction technique between January 2009 and October 2019. All patients were evaluated using the disabilities of the arm, shoulder, and hand (DASH) score, American Shoulder and Elbow Surgeons(ASES) score, Mayo Elbow Score Performance Index (MEPI) score and at least 4 years later. RESULTS: All cases achieved union. At the final follow-up, the mean range of elbow motion was 11.5°of flexion contracture and 131.9° of further flexion. The mean DASH score was 21.2 (5.7) points (range 13.3-32.5). The mean ASES score was 88.6 ± 7.4 (range, 77 to 100). The mean MEPI score was 87 (10) points (range 70-100). In complication, partial osteonecrosis of capitellum is developed in one patient. One patient had heterotopic ossification without functional impairment. CONCLUSION: The on-table reconstruction technique can be a reliable option in the surgical treatment of complex distal humerus fractures. This technique allows anatomical reduction of comminuted capitellum and trochlea, with a low risk of avascular necrosis over 4 years of follow-up. LEVEL OF EVIDENCE: Level IV, retrospective case series.

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OBJECTIVE: In this study, we investigated the efficacy of percutaneous poking reduction and Kirschner wire fixation in older children with irreducible supracondylar flexion-type fractures of the humerus. METHODS: This retrospective investigation included 27 children, comprising 15 males and 12 females, aged between 10 years and 3 months to 14 years and 11 months, all diagnosed with a flexion-type supracondylar fracture of the humerus within one week of trauma. All patients underwent surgery under general anesthesia. Following unsuccessful manual reduction, percutaneous poking reduction with Kirschner wires was performed under C-arm fluoroscopy to achieve fracture reduction. Following successful reduction, three 2.0 mm Kirschner wires were inserted in a cross pattern to secure the fracture ends. Postoperatively, the elbow joint was immobilized in a functional position with a plaster cast for four weeks. RESULTS: Follow-up in the outpatient department ranged from 9 to 36 months. Clinical functional assessment using Flynn's criteria rated 24 cases as excellent, 2 as good, and 1 as fair, yielding an overall efficacy of 96.3%. No cases of fracture re-displacement, fracture fragment necrosis, or other complications such as nonunion, iatrogenic nerve injury, myositis ossificans, or long-term elbow joint dysfunction were observed during the postoperative follow-up. CONCLUSION: The percutaneous poking reduction and Kirschner wire fixation technique is a simple and reliable procedure for treating irreducible flexion-type supracondylar fractures of the humerus in older children, with minimal trauma. This technique offers substantial stability for the fracture and results in excellent long-term recovery of joint function.

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Greater tuberosity fractures of the humerus can be challenging to manage due to their complex anatomy and the potential for compromised shoulder function. We present a novel technique for treating greater tuberosity fractures utilizing specialized anatomical plates and rotator cuff reinforcement. The technique involves the use of an anatomically T-shaped plate designed specifically for the greater tuberosity region of the humerus, allowing for precise fixation and stability. Additionally, rotator cuff reinforcement is performed using sutures to enhance structural integrity and promote early mobilization. The simplified process is as follows: After administering anesthesia, a 3 cm incision is made along the lateral aspect of the shoulder to precisely expose the fracture site of the greater tuberosity. A suture of size 5 is skillfully threaded through the tough rotator cuff tendon to securely attach the proximal humerus to the anatomical plate after the greater tuberosity has been reduced. Intraoperative fluoroscopy is utilized to verify the accurate positioning of plates and screws. After ensuring everything is correct, the surgery concludes.

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OBJECTIVE: The aim of the operation is to replace the articular surface of the distal humerus in cases of nonreconstructible fractures of the distal humerus. INDICATIONS: Active patients with high functional requirements, in whom weight limitation of total elbow arthroplasty should be avoided. CONTRAINDICATIONS: Contraindications include fractures with irreconstructible epicondyles and/or irreconstructible collateral ligaments, as well as ulnohumeral, or radiohumeral osteoarthritis. SURGICAL TECHNIQUE: Following subcutaneous anterior transposition of the ulnar nerve, surgical dislocation of the elbow joint is achieved through a paratricipital approach with release of the soft tissue structures from the humerus. After resection of the trochlea, the intramedullary canal of the humerus is prepared using rasps in order to implant the hemiprosthesis with retrograde cementing. Finally, the medial and lateral collateral ligaments as well as the flexors and extensors are repaired. POSTOPERATIVE MANAGEMENT: Early functional rehabilitation in a hinged elbow orthosis while avoiding varus/valgus stress after wound healing is completed. RESULTS: Between 2018 and 2022, 18 patients with coronal shear fractures were treated with elbow hemiarthroplasty. The mean Mayo Elbow Performance Score (MEPS) was 79 (70-95) after a mean follow-up of 12 months. The mean range of motion was 99° (70-130°) in extension-flexion and 162° (90-180°) in pronation-supination.

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CASE: A 10-year-old, postmenarchal girl presented to the emergency department with a closed, displaced, intercondylar T-type distal humerus fracture. Open reduction and internal fixation was performed 3 days following initial presentation. The patient healed but experienced elbow stiffness in the 7 months following the procedure. Implant removal and capsular release were performed at that time. At the 31-month follow-up, the patient reported satisfactory elbow functionality. CONCLUSION: There is limited literature available discussing optimal management and associated outcomes of intercondylar T-type distal humerus fractures in the young-adolescent population. This report presents a possible method for management of the initial injury and the most common associated complication.

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Shape of supracondylar fracture of the humeral of pediatric patients is analysed with Procrustes method. XR-images of fractures are considered both in anterio-posterior (AP) view and in a lateral (L) view. Applying Procrustes method for both views mean images are constructed and compared. Variability of shapes is quantified with a shape principal component analysis. Possibility of predictions of typical shape of humeral fracture and its variability using statistical shape analysis offers additional information on injury characteristics important in preoperative planning. Non-parametric tests (permutational and bootstrap) do not indicate statistical difference between Procrustes mean shapes in anterio-posterior and lateral projections. It is shown, however, that AP and L shapes of humeral fractures differ in their variability quantified by shape principal components.

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BACKGROUND: Use of postoperative radiographs after surgical management of supracondylar humerus (SCH) fractures is often based on rote practice rather than evidence. The purpose of this study was to determine the frequency with which 3-week postoperative radiographs at the time of pin removal altered management plans in pediatric SCH fractures that were intraoperatively stable after closed reduction and percutaneous pinning (CRPP). METHODS: We prospectively recruited pediatric patients with SCH fractures managed by CRPP at our institution from June 2020 until June 2022, and reviewed retrospective data on pediatric SCH fractures managed surgically at our institution between April 2008 and March 2015. Patients were assessed for post-CRPP fracture alignment and stability. For prospective patients, we asked clinicians to document their management decision at the 3-week follow-up visit before evaluating the postoperative radiographs. Our primary outcome was change in management because of radiographic findings. RESULTS: Overall, 1066 patients in the retrospective data and 446 prospectively recruited patients met the inclusion criteria. In the prospective group, radiographic findings altered management for 2 patients (0.4%). One patient had slow callus formation and 1 patient was identified as having cubitus varus. Altered management included prolonged immobilization or additional radiographic follow-up. Radiographic findings altered management in 0 (0%) of 175 type II fractures, in 2 (0.9%) of 221 type III fractures, and in 0 (0%) of 44 type IV fractures. We obtained similar findings from retrospective data. CONCLUSION: Rote use of 3-week postoperative radiographs after surgical management of SCH fractures that are intraoperatively stable has minimal utility. Eliminating rote postoperative radiographs for SCH fractures can decrease the time and financial burdens on families and health care systems without affecting patient outcomes.

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The aim of this study was to construct a classification model for the automatic diagnosis of pediatric supracondylar humerus fractures using radiomics-based machine learning. We retrospectively collected elbow joint Radiographs of children aged 3 to 14 years and manually delineated regions of interest (ROI) using ITK-SNAP. Radiomics features were extracted using pyradiomics, a python-based feature extraction tool. T-tests and the least absolute shrinkage and selection operator (LASSO) algorithm were used to further select the most valuable radiomics features. A logistic regression (LR) model was trained, with an 8:2 split into training and testing sets, and 5-fold cross-validation was performed on the training set. The diagnostic performance of the model was evaluated using receiver operating characteristic curves (ROC) on the testing set. A total of 411 fracture samples and 190 normal samples were included. 1561 features were extracted from each ROI. After dimensionality reduction screening, 40 and 94 features with the most diagnostic value were selected for further classification modeling in anteroposterior and lateral elbow radiographs. The area under the curve (AUC) of anteroposterior and lateral elbow radiographs is 0.65 and 0.72. Radiomics can extract and select the most valuable features from a large number of image features. Supervised machine-learning models built using these features can be used for the diagnosis of pediatric supracondylar humerus fractures.

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Tension band wiring (TBW) is one of the most commonly used fixation techniques to fix olecranon osteotomies. Hardware prominence has been the most commonly reported complication of TBW. However, distal migration of Kirschner (K)-wire after TBW fixation for olecranon osteotomy has not been reported. In this case report, we presented distal migration of K-wire detected nine months after initial surgery in a 46-year-old male patient. The patient was operated on for an intraarticular distal humerus fracture using an olecranon osteotomy. The osteotomy was fixed with TBW fixation. The patient missed routine follow-ups and presented to the outpatient clinic with a complaint of skin irritation at the elbow nine months after the surgery. On radiological examination, distal migration of one K-wire was detected. The K-wire was surgically removed without any complication. Physicians should be aware of possible complications of TBW and remove fixation after fracture union to avoid unexpected complications.

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We report the treatment of two patient with humeral fractures with one or more risk factors for nonunion. The first patient was elderly with a previously diagnosed central nervous sys-tem injury. The second elderly patient previously sustained a cerebral vascular accident affecting the fractured arm. The fracture was oblique in the proximal third of the humerus. We achieved bone healing non-operatively utilizing a spe-cialized plastic orthosis that included a deforming element made of dense foam. This device asymmetrically increases the soft tissue pressure around the fracture.

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BACKGROUND: The modified Gartland classification is the most widely accepted grading method of supracondylar humeral fractures among orthopedic surgeons and is relevant to identifying fractures that may require surgery. OBJECTIVE: To assess the interobserver reliability of the modified Gartland classification among pediatric radiologists, pediatric orthopedic surgeons, and pediatric emergency medicine physicians. MATERIALS AND METHODS: Elbow radiographs for 100 children with supracondylar humeral fractures were retrospectively independently graded by two pediatric radiologists, two pediatric orthopedic surgeons, and two pediatric emergency medicine physicians using the modified Gartland classification. A third grader of the same subspecialty served as a tie-breaker as needed to reach consensus. Readers were blinded to one another and to the medical record. The modified Gartland grade documented in the medical record by the treating orthopedic provider was used as the reference standard. Interobserver agreement was assessed using kappa statistics. RESULTS: There was substantial interobserver agreement (kappa = 0.77 [95% CI, 0.69-0.85]) on consensus fracture grade between the three subspecialties. Similarly, when discriminating between Gartland type I and higher fracture grades, there was substantial interobserver agreement between specialties (kappa = 0.77 [95% CI, 0.66-0.89]). The grade assigned by pediatric radiologists differed from the reference standard on 15 occasions, pediatric emergency medicine differed on 19 occasions, and pediatric orthopedics differed on 9 occasions. CONCLUSION: The modified Gartland classification for supracondylar humeral fractures is reproducible among pediatric emergency medicine physicians, radiologists, and orthopedic surgeons.

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BACKGROUND: Fractures of the lateral condyle of the humerus in children are articular fractures with difficult diagnostics due to the incompletely ossified elbow joint. The aim of this study was to evaluate the method of treatment at initial presentation and to analyze the frequency of subsequent displacement during follow-up. MATERIAL AND METHOD: Retrospective analysis of the frequency of primary fracture dislocation and subsequent displacement of fractures of the lateral condyle of the humerus in children under 16 years of age between 2004 and 2021. Conventional radiographs in two planes at the time of the accident and in the follow-up after 5-7 days were evaluated. RESULTS: A total of 285 fractures of the lateral condyle of the humerus were evaluated. The average age was 5.3 years. Of the fractures 109 (38.3%) were directly surgically treated in cases of primary displacement and 176 fractures (61.7%) were not primarily displaced and were initially treated conservatively. During follow-up, subsequent displacement was evident in 46 fractures (26.1%). A total of 130 fractures (45.6%) were treated conservatively and 155 fractures (54.4%) were treated surgically using open joint visualization and screw osteosynthesis or K­wire osteosynthesis. CONCLUSION: Fractures of the lateral condyle of the humerus occur more frequently in a certain age group and require targeted radiological diagnostics. Nondisplaced fractures can be treated conservatively but essential radiological follow-up shows a high number of subsequent displacements, so that open surgical stabilization is often necessary.

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OBJECTIVES: To assess the treatment and outcomes of supracondylar humeral fractures (SHFs) in children older than 10 years of age at the time of injury. METHODS: The study analyzed clinical data from 60 patients who sustained SHF, all over the age of 10 years, were analyzed. The patients included 49 males and 11 females with a mean age of 10.9 ± 0.9 years (range, 10 to 14.5). All patients underwent surgical treatment under general anesthesia. Closed reduction (CR) and percutaneous fixation were the primary treatment, with open reduction and internal fixation being employed only in cases CR was unsuccessful. The study assessed the healing of fractures by measuring the radiographic angles, including the carrying angle (RCA), Baumann's angle (BA), and metaphyseal-diaphyseal angle (MDA) on anteroposterior radiographs of the elbow joint. In addition, the study evaluated whether the anterior humeral line (AHL) appropriately passed through the middle third of the capitellum. The final follow-up visit used the Mayo Elbow Performance Index score (MEPI) and Flynn's criteria to analyze the recovery of elbow function. RESULTS: There were 15 (25%) SHF type II, 17 (28.3%) type III and 28 (46.7%) type IV. Of the 60 patients, 56 (93.3%) underwent successful CR, whereas 4 (6.7%) required open reduction and internal fixation because of an unsuccessful CR. The final follow-up showed the average BA as 72° ± 5.3°, the average MDA as 88.3° ± 2.8°, and the average RCA as 9.6° ± 3.9°. The AHL bisected accurately the capitellum in 59 cases (98.3%). The average range of elbow flexion-extension was 146.6° ± 8.6°, whereas the average MEPI score was 99.9 ± 0.6; 98.3% (n=59) were rated as excellent and 1.7% (n=1) were rated as good. According to Flynn's criteria, 86.7% had an excellent outcome (n=52), 10% had a good outcome (n=6), and 3.3% had a poor outcome (n=2). Only 1 patient (1.7%) experienced redisplacement. Eight cases of nerve injury were reported, with 7 involving the radial nerve and 1 involving the ulnar nerve; all resolved spontaneously. CONCLUSIONS: CR and percutaneous fixation have been shown to be effective in treating SHF in 93.3% of children aged 10 years old and older at the time of injury, with favorable radiographic and functional outcomes and a low risk of secondary displacement. Open reduction should only be considered when CR is ineffective.

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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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