Abstract Objective To evaluate the postoperative functional and radiographic outcomes of the shoulder of patients submitted to transosseous suturing of a greater tuberosity fracture (GTF) through an anterolateral route and the influence of the glenohumeral dislocation on these outcomes. Methods We conducted a retrospective study and functional assessment using the Constant-Murley score. The distance between the greater tuberosity and the joint surface of the proximal humerus (in true anteroposterior radiographs) after the union was calculated. We used the Fisher exact test for the categorical independent variables, and the Student t or Mann-Whitney test for the non-categorical variables. Results In total, 26 patients met the inclusion criteria, and 38% of the sample presented an association between glenohumeral dislocation and GTF. The mean Constant-Murley score was of 82.5 + 8.02 points. The presence of an associated dislocation did not alter the functional outcome. The mean distance between the greater tuberosity of the humerus and the joint surface of the humeral head after the union was of 9 + 4.3 mm below the articular line of the humeral head. The dislocation led to a lower level of reduction, but this did not influence the Constant-Murley score. Conclusion The cases of GTF submitted to surgical treatment with transosseous sutures had good functional outcomes. The presence of dislocation made the anatomical reduction of the greater tuberosity difficult. However, it did not influence the Constant-Murley score.

Resumo Objetivo Avaliar os resultados funcional e radiográfico pós-operatórios do ombro, em pacientes submetidos a sutura transóssea de fratura da tuberosidade maior (FTM) por acesso anterolateral, e a influência da luxação glenoumeral nesses resultados. Métodos Realizou-se estudo retrospectivo e avaliação funcional (pela escala de Constant-Murley). Calculou-se a distância entre a tuberosidade maior e a superfície articular do úmero proximal (por meio de radiografia em incidência anteroposterior verdadeira) após a consolidação. Usou-se o teste Exato de Fisher para as variáveis independentes categóricas, e os testes tde Student ou de Mann-Whitney para as não categóricas. Resultados Ao todo, 26 pacientes preencheram os critérios de inclusão. A associação de luxação glenoumeral com FTM foi observada em 38% da amostra. A média da pontuação na escala de Constant-Murley foi de 82,5 + 8,02. A presença de luxação associada não alterou o resultado funcional. A distância média da consolidação da tuberosidade maior do úmero em relação à superfície articular da cabeça umeral foi de 9 + 4,3 mm abaixo da linha articular da cabeça umeral. Pacientes com luxação associada evoluíram com redução menor, mas isso não influenciou na pontuação na escala de Constant-Murley. Conclusão As FTMs submetidas ao tratamento cirúrgico com sutura transóssea evoluíram com bom resultado funcional. A presença de luxação dificultou a redução anatômica da tuberosidade maior. Entretanto, isso não influenciou na pontuação na escala de Constant-Murley.

ABSTRACT Background: Proximal humeral fractures can progress to osteonecrosis of the humeral head. Hertel developed a binary classification system (12 subtypes) and demonstrated that some patterns have more risk to develop osteonecrosis. Hertel described the prevalence and the risk factors for Humeral head osteonecrosis after osteosynthesis using a Deltopectoral approach. Few studies have evaluated the prevalence and the capacity of Hertel’s classification to predict Humeral Head osteonecrosis following osteosynthesis of proximal Humeral fractures through the anterolateral approach. The objectives of this study were to correlate osteonecrosis predictors established by the Hertel classification with the risk of developing osteonecrosis and its prevalence after osteosynthesis using the anterolateral approach. Methods: This was a retrospective study of patients who underwent osteosynthesis of proximal humerus fractures using an anterolateral approach. Patients were divided into two groups: high risk for necrosis (group 1) and low risk for necrosis (group 2) according to Hertel’s criteria. The overall prevalence of osteonecrosis and the prevalence in each group were calculated. A radiological examination was performed in the true anteroposterior (Grashey), scapular, and axillary views, before and after the operation (minimum 1 year after surgery). A KaplanMeier curve was used to assess the pattern of the temporal evolution of osteonecrosis. The groups were compared using the Chi-square test or Fisher’s exact test. The unpaired t-test (parametric variables - age) and the MannWhitney test (non-parametric time between trauma and surgery) were used. Results: In total, 39 patients were evaluated. The postoperative follow-up time was 14.5 ± 3.3 months. The time to onset of necrosis was 14.1 ± 3.9 months. Sex, age, and time between trauma and surgery did not influence the risk of necrosis. Type 2, 9, 10, 11, and 12, or fractures with posteromedial head extension less than or equal to 8 mm, or diaphysis deviation greater than 2 mm, as well as grouping did not influence the risk for osteonecrosis. Conclusions: Hertel’s criteria were not able to predict the development of osteonecrosis after osteosynthesis of proximal humerus fractures performed through the anterolateral approach. The total prevalence of osteonecrosis was 17.9% with a tendency toward an increased incidence after 1 year of surgical treatment.

RESUMO A mortalidade de pacientes após osteossíntese de fratura de úmero proximal (FUP) é pouco estudada em comparação com as fraturas do fêmur proximal. Objetivo: Avaliar a mortalidade de pacientes idosos com FUP submetidos a tratamento cirúrgico. Métodos: Estudo retrospectivo de pacientes submetidos ao tratamento cirúrgico FUP entre 2009 e 2019. Foram avaliados dados demográficos, classificação de Neer e a mortalidade dessa coorte de pacientes. As variáveis não categóricas foram testadas pelo teste de Kolmogorov-Smirnov. Utilizou-se o teste t não pareado para variáveis paramétricas. As variáveis categóricas foram testadas pelo teste exato de Fisher. Construiu-se a curva de mortalidade pelo método de Kaplan-Meier. Resultados: Foram avaliados 59 pacientes, havendo predomínio do sexo feminino na faixa dos 60 anos. As fraturas mais prevalentes foram as do tipo III de Neer. A maior mortalidade ocorreu nos quatro primeiros anos pós-operatórios (4,1 + 3,2 anos). A única comorbidade capaz de mudar a curva de sobrevida foi o diabetes mellitus (p = 0,03). Conclusão: A mortalidade geral foi de 11,3%. A maior mortalidade ocorreu nos primeiros quatro anos de seguimento. Pacientes diabéticos evoluem com mortalidade mais precoce e possuem sete vezes mais chance de óbito. Nível de Evidência III, Estudo Retrospectivo.

ABSTRACT Mortality of patients after osteosynthesis of proximal humeral fractures (PHF) has been poorly studied in contrast to fractures of the proximal femur. Objective: To evaluate the mortality of older patients with PHF undergoing surgical treatment. Methods: Retrospective study of patients undergoing surgical treatment PHF between 2009-2019. Demographic data, Neer classification, and mortality of this cohort of patients were evaluated. Non-categorical variables were tested using the Kolmogorov-Smirnov test. The unpaired t-test (parametric variables) was used. Categorical variables were tested by Fisher’s exact test. A Kaplan-Meier mortality curve was constructed. Results: 59 patients were evaluated. There was a predominance of females in the sixth decade of life. The most prevalent fractures were Neer’s type III. The highest mortality occurred in the first 4 years after surgery (4.1 + 3.2 years). The only comorbidity capable of changing the survival curve was DM (p = 0.03) Conclusion: Overall mortality was 11.3%. The highest mortality occurred in the first 4 years of follow-up. Diabetic patients evolve with earlier mortality and have 7 times more chance of death. Level of Evidence III, Retrospective Study.

RESUMO A maior parcela dos estudos epidemiológicos não aborda exclusivamente as fraturas tratadas cirurgicamente, mas engloba as de tratamento conservador. No Brasil existem poucos estudos epidemiológicos que versam sobre a prevalência das fraturas submetidas ao tratamento cirúrgico. Objetivo: Avaliar a prevalência, os dados demográficos e as lesões associadas das fraturas da diáfise do úmero tratadas cirurgicamente. Métodos: Estudo retrospectivo conduzido entre 2009 e 2019, com pacientes submetidos a osteossíntese de fratura diafisária do úmero. As variáveis categóricas foram testadas pelo teste qui-quadrado ou teste exato de Fisher, enquanto as não categóricas foram medidas pelo teste t não pareado. Adotou-se nível de significância de 5%. Resultados: Foram avaliados 115 pacientes. A média de idade foi de 37,9 ± 15,6 anos, com uma predominância de pacientes do sexo masculino (66,9%) devido a acidentes automobilísticos. A fratura tipo 12 A3 foi a mais prevalente. A prevalência de fratura exposta foi de 11,3%. A lesão nervo radial ocorreu em 33%, principalmente em traumas de baixa energia. Conclusão: As fraturas diafisárias do úmero tratadas cirurgicamente foram mais prevalentes em homens jovens e relacionadas a traumas de alta energia, com padrão de traço transverso. Fraturas secundárias e traumas de baixa energia tiveram maior associação com lesão do nervo radial. Nível de Evidência III, Estudo Epidemiológico, Retrospectivo.

ABSTRACT Most epidemiological studies do not exclusively address fractures treated surgically but include those with conservative treatment. In Brazil, few epidemiological studies address fractures prevalence undergoing surgical treatment. Objective: To assess the prevalence, demographics, and associated injuries of surgically treated humeral shaft fractures. Methods: A retrospective study between 2009 and 2019 with patients undergoing osteosynthesis of humeral shaft fracture. Categorical variables were assessed using Fisher’s chi-square or exact test, and non-categorical variables were assessed using the unpaired t-test. A significance level of 5% was adopted. Results: A total of 115 patients were evaluated. Mean age was 37.9 ± 15.6 years, with a male predominance (66.9%) due to car accidents. The most prevalent fracture type was 12 A3. Open fracture prevalence was 11.3%. Radial nerve damage prevalence was 33% and low-energy trauma was twice as likely. Conclusion: Surgically treated humeral shaft fractures were more prevalent in men, young, and related to high-energy trauma, with a transverse line pattern. Fractures secondary to low-energy trauma had a greater association with radial nerve injury. Level of Evidence III, Epidemiological, Retrospective Study.

RESUMO Objetivo: As vias de acesso anterolaterais para a osteossíntese do úmero proximal permitem a exposição direta do aspecto lateral do úmero sem necessitar das retrações musculares da via deltopeitoral. Contudo, há grande preocupação com a possibilidade de lesão iatrogênica do nervo axilar e consequente piora no resultado funcional pós-operatório. Identificar a incidência de lesões iatrogênicas do nervo axilar e avaliar os resultados funcionais da osteossíntese do úmero proximal com placas bloqueadas, utilizando as vias anterolaterais. Métodos: Revisão da literatura seguindo o protocolo PRISMA. Resultados: Foram selecionados 23 artigos do total de 786 indivíduos submetidos às vias de acesso anterolaterais. Foram confirmados 3 casos (0,38%) de lesões iatrogênicas do nervo axilar. Os resultados dos testes funcionais foram semelhantes aos da via deltopeitoral. Conclusão: As vias de acesso anterolaterais são uma alternativa viável e segura para a osteossíntese do úmero proximal com placas bloqueadas. Nível de Evidência II, Revisão Sistemática.

ABSTRACT Objective: Anterolateral approaches for proximal humerus osteosynthesis have great advantages because they allow direct exposure of the lateral aspect of the humerus without the muscular retraction seen in the deltopectoral approach. However, much resistance is found among surgeons due to the potential risk of iatrogenic injury to the axillary nerve. To identify the incidence of axillary nerve iatrogenic lesions and evaluate the functional results of proximal humerus osteosynthesis with locking plates using anterolateral approaches. Methods: The literature review followed the PRISMA protocol. Results: A total of 23 articles were selected from 786 patients submitted to anterolateral approaches. Three cases (0.38%) of iatrogenic axillary nerve lesions were confirmed. The results of the functional tests were similar to those of the deltopectoral approach. Conclusion: Anterolateral approaches are a viable and safe alternative for proximal humerus osteosynthesis with locking plate. Subacromial impingement was the most frequent complication. Level of Evidence II, Systematic Review.

Objective : To evaluate the results of displaced radial neck fractures in children trated surgically with flexible titanium intramedullary nails. Method : This is a retrospective study of five cases of radial neck fractures with displacement greater than 30° fixed with flexible intramedullary nails. Patients were evaluated regarding functional outcome through range of motion and the Mayo Elbow Performance Score (MEPS), as well as radiographic exams. Results : Five patients, with a mean age of 8.4 years were assessed, during a mean post-operative follow up of 12.2 months. Open reduction was necessary in three cases with major displacement. At the end of the follow up, 80% of the patients had excellent results, 20% good results, and all fractures healed. As complications we observed: heterotopic ossification, superficial infection and radial head necrosis. Conclusions : In spite of the small sample, our results with flexible titanium intramedullary nails were similar to the current literature, with good functional outcomes. Level of Evidence III, Retrospective Study.

OBJECTIVES: To evaluate the functional outcome of patients with surgically treated terrible triad of the elbow. METHODS: A retrospective evaluation was performed using the MEPS score (Mayo Elbow Performance Score) of patients diagnosed with terrible triad of the elbow who underwent surgical treatment. RESULTS: 14 patients (nine men and five women) and 15 elbows (one bilateral case) were evaluated. A MEPS average score of 78 points and 86% good and excellent results was obtained. As complications, we had one case of infection and three of neuropraxia of the ulnar nerve. CONCLUSION: The patients had stable elbow with good function, however with reduced range of motion. Level of Evidence IV, Case Series.