Fracture-dislocation proximal humerus is regarded as the most severe form of proximal humeral fracture compendium. This injury is unique where there is a substantial chance of subsequent avascular necrosis of humeral head. We retrospectively reviewed the fracture-dislocation of the proximal humerus in young patients treated from the year 2012 to 2019. Among 28 cases of proximal humerus fracture-dislocation, 26 were men, with 22 were right-sided injuries. Most are right dominant, 23 of 28 fracture-dislocation. Ages range from 19 to 56 years (average 38 years). Six patients (21.4%) were two-part fracture-dislocation, 13 cases (46.4%) were three-part fracture dislocation, and 9 cases (32.1%) were four-part fracture-dislocation. Mean constant Murley score at 6 weeks 31 .45 and at 12 weeks 48.46 and 70.78 at one year. Major complication observed as avascular necrosis in 3 patients, secondary tuberosity displacement in 2 patients and axillary nerve injury in one patient. There is no nonunion or wound infection.

Introduction: Internal fixation of displaced middle third clavicle fractures can reduce the rate of non-union and offer a faster return of function compared to non-operative management. Complications associated with surgery include infection, non-union, altered sensation and metalwork prominence. The aim of this study is to compare an oblique skin incision following Langer’s lines with a transverse incision and study the impact of each on the rate of complications. Methods: we retrospectively collected data on 108 patients who underwent open reduction, internal fixation for displaced mid-shaft clavicle fractures. The surgical approach used was either an oblique or a transverse incision according to surgeon’s preference. A pre-contoured diaphyseal locking plate was used in all cases. Data on fracture classification, minor complications (irritation from prominent plate, chest wall numbness, superficial wound infection) and major complications (irritation from plate necessitating removal of metalwork, periprosthetic fracture, deep infection, neurovascular injury and non-union) was collected. Results: 57 patients underwent clavicle fixation via the oblique approach and 51 via the transverse approach. Age, gender and fracture pattern in the two groups were comparable. Common complications included skin numbness (25.93%) and metalwork irritation (8.33%). 5 patients elected to have removal of metalwork. Deep infection and non-union were not common (each 2%). No statistically significant difference in the rate of complications was identified between the two skin incisions. Conclusions: we reasoned that an incision following Langer’s lines might reduce tension at the incision and therefore reduce complications. This theory has not been supported in this group of patients.

INTRODUCTION: Clavicle fractures are common injuries in adults, especially due to sporting activities or road traffic accidents. Most lesions occur at the level of the middle-third presenting some degree of displacement often. Traditionally, non-surgical management was considered the first treatment option for the most clavicle fractures. Nowadays, various authors suggest early surgical fixation of displaced midshaft fractures. We present to you the surgical outcome and the incidence of complications following ORIF and plating of midshaft clavicle fractures. PATIENTS AND METHODS: 176 patients with displaced middle third clavicle fractures were included in the prospective study, evaluating the clinical and functional outcomes and the complication rate with a follow-up average of 48 months. RESULTS: There was significant improvement in the constant scores and DASH score and VAS score. 3 patients developed wound dehiscence and 7 patients had deep infection which resolved after plate removal. CONCLUSION: Surgical treatment with ORIF of displaced middle-third clavicular fractures achieved good and excellent functional results, shorter time to complete return to work and earlier bone union with minimal complications.

Abstract
Background
Unstable distal clavicles experience higher non-union rates, prompting surgeons to recommend surgery for more predictable outcomes. There is a lack of consensus on the optimal method of surgical fixation with an array of techniques described in the literature. We describe an alternative method of fixation involving the use of a distal clavicular anatomical locking plate with Fibertape cerclage augmentation in our series of patients.

Methods
10 patients who sustained an unstable fracture of the distal clavicle in our institution were treated with the use of our described technique. Post-operative range of motion, functional and pain scores along with time to radiographical union were measured. Incidences of post-operative complications were also recorded.

Results
The mean VAS score was 0.89 ± 0.60, with a mean Disability of the Arm, Shoulder and Hand (DASH) score of 1.67 ± 1.04 and American Shoulder and Elbow Surgeons (ASES) score of 93.0 ± 4.03. The mean range of motion achieved were forward flexion 167 ± 23.4, abduction 168 ± 20.4 and external rotation 71.1 ± 7.62. All patients were able to achieve internal rotation at a vertebral height of at least L2. All patients achieved radiographical union at a mean of 10 weeks. No removal of implant for hardware or knot prominence was required.

Conclusions
Our described technique is effective, produces good clinical outcomes, has minimal complications, and does not require a secondary surgery for removal of implants.

Introduction: Displaced multifragmentary intraarticular distal humeral fractures still pose a surgical challenge. The purpose of the study was to report the functional outcomes and complications after open reduction and internal fixation (ORIF) for acute distal humeral fractures C2-C3 with minimum 2 years follow-up. Our hypothesis was that ORIF provides functional outcomes that are comparable to total elbow arthroplasty (TEA) and elbow hemiarthroplasty (EHA) reported in the literatures. Materials and Methods: We used our institutional database to identify all patients sustaining these fractures during a 6-years period (2011-2016). Twenty-three patients older than 45 years were treated with double-plating for C2 or C3 fracture included. The Oxford Elbow Score (OES) was used as primary outcome; and Mayo Elbow Performance Score (MEPS), pain severity score (VAS), range of motion, reoperations and complications were used as secondary outcomes. Results: Median OES was 42. Twenty patients achieved "good" to "excellent" outcomes. Median MEPS was 85. Eighteen patients achieved "good" to "excellent outcomes". VAS was 2 (range 0-5). The median flexion/extension and supination/pronation arcs were 120 and 160 degree respectively. Eight complications were recorded in seven patients, four of them required reoperation. Ten patients were occupationally-active and nine of them returned to the same occupation. Our results are comparable to the results of previously published studies regarding the outcome of ORIF, EHA, or TEA for AO/OTA type 13-C fractures. Conclusion: ORIF is a reliable treatment option for acute distal humeral fractures AO/OTA C2 and C3 in middle-aged and elderly patients, despite the considerable rate of complications.

Introduction: Intercondylar and supracondylar humeral fractures account for 2% of the total adult fractures, usually caused by direct trauma to the elbow. In the elderly they result from low-energy trauma but in young patients always result from violent impact. Since the introduction of methods of internal fixation and joint reconstruction that these results have been most encouraging. Methods: Retrospective study of 16 patients submitted to ORIF of supracondylar and intercondylar humeral fractures, between January 2019 and December 2019. Fracture type, age, gender, waiting time to surgery and complications were assessed. The MEPS Score was used for functional assessment. Results: 14 males and 2 females with a mean age of 46 years. High energy trauma was observed in 62.5% of injuries and 2 patients had open fractures (type I of G.A. classification). The mean time between injury and surgery was 1,2 days. All patients underwent internal fixation with plates and screws and olecranon osteotomy was performed in 7 of them. The average of the MEPS Score was 82 points; 37.5% had excellent results, 25% good, 25% reasonable and 12.5% poor. Conclusion: Our series is according to the literature regarding the age and trauma mechanism; instead, men were clearly more affected (87.5%). Surgery in less than 24h is associated with better functional outcomes and lower complication rates. Poor MEPS Score results may be correlated to the severity of the injury and the advanced age in some patients, which is pointed by many authors as a limitation on functional recovery.

Background: Tears of the biceps tendon at the elbow are most oftenly caused by a sudden injury and surgery is usually recommended in selected patients. Objectives: A retrospective study was performed in order to analyse the post-operative outcomes of surgical treatment for distal biceps brachii avulsion using suspensory cortical button. Methods: A total of eight people were included in this study. All of them were submitted to surgical repair of tendon to tuberosity with a suspensory cortical button (ToggleLoc™Device-ZimmerBiomet). The average waiting time for surgery was sixteen days. An anterior single-incision technique was used in six of the patients, while in the remaining two a dual incision technique was performed. All patients were afterwards discharged with cast immobilization during an average time of twenty-two days (two to four weeks), immediately followed by a careful rehabilitation program. Results: All patients achieved an elbow flexion with no limitation of motion or strength at three-month follow-up. A 10-15º limitation of extension was noted in all patients. In the early post-operative time, one patient developed a local haematoma with associated suture dehiscence. Dysesthesias of the radial forearm were reported in two patients, with different severity levels, and were no longer present at six-month follow-up. Conclusions: The suspensory cortical button is, individually and amongst the most common surgical options (suture anchor, bone tunnel, interference screw), the fixation that is most resistant to force. Residual mobility anomalies were not restraining to any of the patients and all of them returned to their daily activities without restrictions.

Introduction: “Terrible triad injury of elbow” associated with olecranon fracture has not been described in the literature. This case report brings to light this hereto undescribed variant of terrible triad which may be labelled as “Terrible quadruple”. Material and methods: We are describing this injury in a 42 years male who presented after 3 weeks of injury. X-ray and CT scan were done to see the exact configuration of fracture and other injuries. Operation was done under tourniquet in lateral position. Firstly, radial head arthroplasty was done via Kocher’s approach. Thereafter, a modified posteromedial incision was given between the conventional posterior and medial approaches to the elbow. The skin and subcutaneous tissues were taken as a single flap to preserve the vascularity. Deep dissection was done in the conventional manner for approaching olecranon first and coronoid later. Olecranon was fixed with 3.5 mm precontoured-plate and coronoid by 2 lag screws and also buttressed by a 2.7 mm L-plate. Postoperatively, cast was applied for 3 weeks following which movements were started. Results: At 18 months follow-up, flexion-extension arc was 10-110 and supination & pronation of 70 degrees each. Carrying angle was 10 degrees of valgus. There was no instability and the patient able to perform normal routine activities. Conclusion: “Terrible quadruple” seems to be challenging to manage. Ideally, one should get both CT scan and MRI. Management has to be surgical in the form of radial head fixation/replacement, anatomic restoration of olecranon & coronoid and addressal of ligamentous injury, if any.