Post-traumatic stiffness and malunion after supracondylar humerus fracture in an adolescent patient

The following case illustrates a high degree of post-traumatic complexity due to the malunion of the distal humerus and osteophyte formation with bony block in motion. This was the sequela of a supracondylar humerus fracture on a patient who was close to skeletal maturity. Flexion extension was from 45 to 90 degrees. An attempt for arthroscopic osteoplasty was performed which was unsuccessful because there was no joint space. Conversion to open surgery was chosen. According to the technique described by Hill Hastings, MD we performed osteoplasty of the elbow. Through a medial and lateral elbow approach osteoplasty of the humerus was performed, resection of osteophytes from the anterior compartment, anterior capsular release and release of the posterior and transverse band of the medial collateral ligament. Flexion improved to 110 degrees extension to 20 degrees.  The ulnar nerve was transposed.

After the osteoplasty range of motion improved significantly, especially in elbow flexion. The terminal extension was still compromised with a loss of 30 degrees of terminal extension.

Terrible triad injury. The importance of the LCL complex

Terrible triad injuries are high energy traumatic events to the elbow which are associated with significant soft tissue trauma. The following case illustrates an obese patient who suffered such an injury. The elbow was severely unstable while the weight of the arm was contributing to the instability as well. During surgery the following "inside to outside" algorithm for fixation is used. Fixation begins with the deep structures and we move superficially through a lateral approach. The sequence is the following;

1. Assessment of the coronoid fracture - if large fragment then fixation with sutures or with a screw is indicated

2. Radial head replacement

3. Primary repair of the lateral collateral ligament complex using bone tunnels at the humerus and no anchors. We avoid use of anchors that increase the risk of infection

If the elbow is stable after following the above 3 steps then repair of the medial collateral ligament complex is not indicated. In this case the MCL was ruptured as well however the elbow was stable after the completion of step 3 as illustrated above.

If the elbow is unstable after completion of the above 3 steps then the MCL is repaired. If still unstable then a static external fixator is applied for 6 weeks.

Key points for success of treatment are (a) avoidance of overstuffing of the joint by undersizing the prosthetic radial heads (b) stable fixation of the lateral collateral ligament in the acute setting with a Krackow suturing method. A common mistake is use of large radial prosthetic head "for better stability". Large heads increase the change of subluxation, pain and stiffness.  The illustration below indicates the importance of anatomic stable fixation of the LCL using the Krackow method.

trauma films

first reduction was unsuccessful due to inadequate flexion of the elbow and weight of the arm.

Second attempt was successful in close reduction

Undersized the radial head implant is important. One method of assessing potential overstuffing of the joint is the following:

"Incongruity of the medial ulnohumeral joint which becomes apparent radiographically only after overlengthening of the radius by ≥6 mm. Intraoperative visualization of a gap in the lateral ulnohumeral joint is a reliable indicator of overlengthening following the insertion of a radial head prosthesis". We also use the congruency of the proximal radioulnar joint surface line as an indicator of appropriate height of the prosthesis. No step off should be seen.

Sprengel Deformity in adulthood -

This is a complex congenital condition which most of the time is associated with other syndromes or congenital defects. An alternative term used to describe this condition is scapula elevata. Patients may have a cosmetic deformity with a "high riding" scapula which is "hypomobile" and there is some degree of scapula winging. In severe forms of the disease there is a omovertebra bone with joint like connection between the cervical spine and the medial border of the scapula. 

There are authors who have described good results after surgical intervention when the condition is diagnosed before the age of 6 . The main problem in this clinical condition is restricted range of shoulder motion. Most of the time forward elevation and abduction is limited, due to loss of the scapular motion or scapulohumeral rhythm as described by Codman in the 1930s. 

When the loss of motion is minimal then surgery is usually contra-indicated. Associated syndromes such as Klippel Feil syndrome or other syndromes may compromise surgical care of this condition. 

The following case illustrates a patient who present with the condition in adulthood and had no treatment before. The fused upper ribs and deformed thoracic cage indicate in this situation the failure of the scapula to decent during development. Associated hypoplasia of the affected scapula is not uncommon. 

The forward elevation of the shoulder in the following case was around 100 degrees and for that reason no surgery was offered. 

The stiff arthritic shoulder with flattened posteriorly decentered humeral head. Tips for a successful anatomic arthroplasty.

Posterior subluxation of the humeral head in primary osteoarthritis of the shoulder is common. It is usually associated with a B2 Walch glenoid deformity. When there is associated flattening of the humeral head, as seen in this case below, usually there is significant limitation is motion and stiffness. 

When planning the total shoulder anatomic replacement, it is important not to proceed with an aggressive humeral head cut. Significant decrease of the volume of the head due to an aggressive humeral head cut will help with glenoid exposure BUT it will make the posterior instability worse. While some surgeons use posterior augmented glenoid components, I prefer to address the instability with soft tissue balancing, conservative humeral head cut, eccentric humeral head - dialing eccentricity anteriorly - and possible closure of the rotator cuff interval at the end of the surgery. 

Below you will find xrays of a case that illustrates a clinical situation where such approach had to be used.

The ideal position of the glenosphere in primary reverse total shoulder arthroplasty

The reverse shoulder arthroplasty is a highly technical operation. It requires appropriate soft tissue balancing and correct component positioning. When done for primary rotator cuff arthropathy has a very high success rate in restoring mobility and providing pain relief. When Paul Grammont introduced with procedure in France in the 1980s, the rest of the world saw it with scepticism and some orthopaedic surgeons had concerns. Today, it provides solutions for problems that we did not have a solution before. Below are the radiographs of a patient that has primary rotator cuff arthropathy, the patient is an elderly individual 70 years or older.

Postoperative radiographs show a press fit stem, inferior placement of the glenosphere and overhanging inferiorly by 2mm to avoid notching. Inferior tilting of the glenoid component is seen as well.

The superior screw at the 12 o'clock position is aiming towards the base of the coracoid, the inferior 6 o'clock screw is aiming to the spine of the scapula. The posterior screw is aimed inferiorly and anteriorly and the anterior screw superiorly and posteriorly. These are important details that achieve appropriate implantation and seating of the glenosphere which is the most critical aspect of this surgery.

The overhanging of the glenosphere by 2 mm avoids impingement of the polyethylene to the scapula

Correct position of the glenosphere

The axillary view shows  the appropriate orientation of the glenosphere.

Eccentric prosthetic humeral head for Walch B2 arthritic glenoids.

The following case illustrates the benefit of using anteriorly directed eccentric head in anatomic arthroplasty to address the posterior subluxation of the humeral head seen often with a B2 arthritic glenoid. The details of the technique can be found by clicking here.

The deforming forces in proximal humerus fractures

Proximal humerus fracture fixation is challenging when there is insufficient bone density, more than 2 parts, an associated dislocation, and more importantly bone loss or impaction of the head in the setting of an obese patient or large deltoid which makes the exposure difficult. 

The deforming forces can be eliminated to a certain extend when the patient is placed in the supine position with the arm on a hand table and abducted to 90 degrees which relaxes the deltoid to allow for space retraction and application of the plate. The most significant deforming forces are:

1. Pectoralis major pulls the shaft anterior and medial

2. The greater tuberosity is pulled superiorly and posteriorly by the supraspinatus, infraspinatus and teres minor

Those forces can be significant and suture passing around the fragments can help with manipulation of the bone fragments. In the majority of cases the difficulty is in raising the articular surface, filling the defects of the bone without overstuffing and repairing the tuberosities. The head shaft angle is better tolerated in the valgus than in the varus position.

It is important to achieve the following after ORIF if possible:

a. Avoid long head screws as the most common complication is head screw penetration

b. Choose isolated screw fixation only in the young patient with good bone stock

c. Restore medial disrupted bone hinge

d. avoid step off in head splits

e. try to proceed with ORIF of head splits in young patients and avoid arthroplasty.

f. avoid superior migration of the greater tuberosity - or posterior superior migration - of more than 5 mm.

g. Pass sutures around the rotator cuff and tight them to the plate.

h. Avoid superior placement of the plate as it may impinge to the acromion with elevation of the shoulder or arm

Below is a fracture treated with ORIF taking into consideration those principles.