Introduction: The pre-hospital trauma life-support (PHTLS) program aims to optimize the pre-hospital phase of trauma care. Promising results of the introduction of the PHTLS-program in non-European countries have been published in the past. The aim of the current study was to determine the impact of PHTLS®-course participation on self-confidence of emergency personnel from a metropolitan area in Europe, regarding the pre-hospital treatment of severe trauma patients.
Methods: Healthcare providers from local emergency services involved in pre-hospital care in the metropolitan area of a large European city who completed a PHTLS-course were contacted and asked to fill-out a structured questionnaire. The impact of course-participation on self-confidence, communication, and routines in the treatment of severe trauma after PHTLS-training was investigated. Furthermore, prior course participations, working experience and profession were reported.
Results: An overall response rate of 76% was calculated. 6 transport paramedics (TPs), 66 emergency paramedics (EPs) and 15 emergency doctors (EDs) were included. Increased self-confidence in treatment of trauma upon PHTLS®-training was reported by 86% of the participants. Moreover, according to 84% of respondents, pre-hospital trauma care changed upon course completion. PHTLS®-associated participants had improved communication in 93% of cases. This was significantly more frequent in EPs than TPs (P=0.03). Multivariable analysis revealed emergency paramedics benefit the most from PHTLS®-course participation.
Conclusion: The current study demonstrates that all medical professionals involved in the pre-hospital care of trauma patients, in a metropolitan area in Europe, do benefit from PHTLS®-training. This was independent of profession, previous working experience or prior alternative course participations.

Objective
To analyze differences in injury patterns and mortality rates in relation to the cause of trauma (suicidal attempts vs. accidental falls from greater height) in polytraumatized patients.
Methods
Retrospective data analysis of 233 consecutive polytraumatized patients treated at a level I trauma center between 1995 and 2019.
Results
Suicidal attempts were documented in 50.2%. Out of all polytraumatized patients, 31.3% (n=73) were female. Significantly more women presented with suicidal attempts (p<0.001). The overall mean injury severity score (ISS) was 35.7 points (18 to 75 points) and the median age was 43.0 years (17 to 96 years). 38.2% of all patients died, 29.2% in the acute phase within 24 hours after the trauma, and 9% in the late in-hospital phase. Patients with suicidal attempts were significantly younger (p<0.001) and presented with significantly higher ISS (p<0.001). No differences regarding the injury severity in the body regions head, thorax or extremities were documented. Significantly higher AIS scores regarding pelvic fractures were seen in suicidal patients (p=0.005). Suicidal attempt had significant influence on the overall survival (p=0.001) and the acute-phase survival (p<0.001).
Conclusion
In the presented population suicidal attempts account for about half of the polytraumatized patients. Suicidal patients are significantly more often female, younger and have a higher injury severity. Pelvic fractures with higher AIS scores are more frequent in suicidal patients. The presence of suicidal attempt has a significant influence on the acute-phase and overall survival.

Aims: Management of peri-implant fracture of the humerus is challenging and there are no standard treatment protocols described. This study aims to report the new technique of add-on plate fixation in peri-implant fracture. Patients and Methods: We have analyzed 20 patients who have undergone surgery for peri-implant humerus fracture between January 2015 and January 2019 with a minimum follow-up of 2 years. Of the 20 patients, add-on plating was done in 13 and revision plating was performed in 7 cases. Analysis: Patients were analyzed for the duration of surgery, blood loss in add-on plate fixation and revision plating, union, and complications associated with revision surgery. Results: The median time duration from index surgery to peri-implant fracture is 56 months. Statistically, a significant difference was noted concerning the duration of surgery, blood loss, and length of the implant in revision plating compared to add-on plating. Union rate is comparable in both the groups. 2 cases of wrist drop and a surgical site infection were noted in the study. Conclusions: Management of peri-implant fracture humerus is challenging and add-on plate fixation is a better solution to achieve stable fixation with minimal exposure and fewer complications.

Purpose: To present the characteristics, mechanism, and treating experience regarding arm wrestling fracture.
Methods: 27 patients of humeral shaft fractures sustained during arm wrestling were retrospectively analyzed. Clinical data during arm wrestling was systematically collected. Fracture configurations were analyzed under radiograph assessment. The Disability of the Arm, Shoulder, and Hand questionnaire (DASH) scores and complication were evaluated.
Results: All cases were spiral fractures, of which 11 were 12-A1 type and 16 cases were 12-B2 type with the wedge fragment. The two types differed in total fracture line length (0.180.04 in type A1 versus 0.230.04 in type B2, p<0.001). There were no significant differences in fracture line length when excluding the confounding interference of wedge fragment (0.180.04 in type A1 versus 0.190.04 in type B2, p=0.581). Radial nerve injury rate was 0/11 in A1 type and 7/13 in B2 type (p = 0.011). Both groups showed improved DASH scores at final follow-up (type A1: 77.825.14 to 10.255.38, type B2: 78.917.46 to 8.953.17, p<0.001). No significant differences were found despite lateral plating treatment showed most improved DASH scores (lateral plating: 80.805.36 to 7.722.51, posterior plating: 76.187.35 to 9.713.47, dual-plating: 79.456.67 to 10.386.05).
Conclusion: 12-B2 type has a similar fracture line morphology and rate of radial palsy than 12-A1. The abnormal muscle activity of m. brachioradialis and special geometrical structure of the bone might be the main mechanism of this kind of fracture. Both groups demonstrated desirable clinical outcomes with surgical treatment. The lateral plating fixation might be the preferred treatment choice.

Keywords: Distal humerus, orthogonal plating, parallel plating.

Background:These fractures are difficult to treat because of its complex anatomy, small area for fixation, articular comminution ,neurovascular architecture adjacent to joint. The majority of authors currently recommending at least two plates be utilized to provide adequate stability and allow for adequate restoration of anatomy. However, the position of plate remains controversial regarding optimal stability. The purpose of this study is to compare functional and radiogical outcomes and complications in patients with type C intra-articular distal humeral fractures using perpendicular and parallel plating methods.

Methods and materials: 34 subjects with type c distal humerus fracture were included in this RCT and randomly divided into 2 groups. Group 1-orthogonal plating Group 2 - parallel plating . Surgical time, blood loss, union time were compared. Arc of motion, complications were compared at the end of the follow up. MEPS score were used to determined elbow functional results.

Results: All patients were followed up for minimum 6 months. There were no significant difference between blood loss, operative time and union time. In this study, the average MEPS score at the end of 6 month was slightly superior for orthogonal plating technique patiens (89.12; Good to Excellent) compared to parallel plating technique patients (85.88; Good ). There was no significant difference. The complication rate was slightly higher in patients operated with parallel plating.

Conclusion: In conclusion, distal humerus type c fractures treated with a parallel configuration have no advantage over the orthogonal plating except hardware prominence.

Objective: The aim of this study is to evaluate the clinical outcome in patients of midshaft clavicle fracture treated with screw intramedullary elastic nail and titanium elastic nail. Materials and methods: 20 patients of midshaft clavicle fracture who met the inclusion criteria were included in this study and treated surgically either with a screw intramedullary nail or a titanium elastic nail. Blood loss, mean operating time, post-operative complications, hospital stay and time for bone union was recorded. Follow up examination was done at 1 month, 3 months and 6 months & the outcomes were evaluated with radiographic assessment, visual analog scale (VAS) score, the Constant-Murley, and the disabilities of the arm, shoulder, and hand (DASH) scores. Results: The mean blood loss was 55.27 +/- 20.25 ml, mean operating time was 50.05 +/- 10.45 mins , mean hospital stay was 8.56 +/- 2.64 days, and mean time for bone union was 10.45 +/- 2.63 weeks. Conclusion: Midshaft clavicle fractures treated with screw intramedullary elastic nail and titanium elastic nail has a better functional outcome with lower complication rate, faster return to routine activities of daily life, and a good cosmetic result and on top of that it’s a minimally invasive surgery.

In radial head fractures of Mason-type II or higher, surgical treatment is recommended which varies from plate to screw fixation. Common complications consist of nonunion, heterotopic ossifications or hardware loosening. A new and less invasive technique is percutaneous elevation for depressed articular surface fractures. This study aimed to investigate the radiographic outcome, complication and revision rate following percutaneous radial head reduction without fixation.
A retrospective study was performed between 2018 and 2021. Data on demographics, fracture morphology applying the Mason classification, dislocation in mm based on pre-, one week and 6 weeks postoperative x-rays as well as complications including revision surgery were noted.
In 23 patients a percutaneous elevation was planned however, in 3 patients no satisfactory radiographic results (2 Mason type II and 1 Mason type III fractures) were obtained why an open reduction was performed, leaving 20 patients for inclusion. The mean age was 38.6±12.9 years, males were affected in 60% (n=12/20) of cases. In all patients a Mason type II fracture was observed with a mean step of 2.2±1.1mm on anteroposterior and 1.6±1.0mm on lateral view. The mean surgical time was 15.5minutes (range 2-37minutes) and not intra- or postoperative complications were observed. At initial follow up 7±3 days postoperatively, the step was 0.1±0.2mm on anteroposterior (p<0.005) and 0.4±0.4mm on Coyle view (p<0.005). No secondary fracture dislocation was observed at final follow up 71±200days.
This study shows that percutaneous closed reduction without fixation in Mason type II fractures is a very effective technique with little to no complications.

INTRODUCTION: To determine the functional and radiological outcome following open reduction and internal fixation of AO type C distal humerus fractures using anatomically pre-contoured, angular-stable dual column plating system. This study was carried out, with a minimum follow-up of two years. MATERIALS AND METHODS: The study is a prospective analysis of 62 patients with type C fractures. There was 10 C1, 7 C2 and 45 C3 fractures. All were closed fractures following a history of fall or RTA. Follow-up was performed on 60 patients with fractures (96%) after 14 months (range, 12-22). The mean age was 49 years (range 14-70). Functional outcome was evaluated with the Mayo Elbow Performance Score (MEPS); the Disabilities of the Arm, Shoulder and Hand score (DASH); and range-of motion (ROM) measurements. Postoperative and follow-up X-rays were analyzed and complications were documented. RESULTS: fifty-eight fractures were considered stable and were allowed early physiotherapy. With a mean MEPS of 85 points, 56 patients (56/62 [90%]) were rated as excellent or good. The mean DASH score was 22.7 points, and the ROM (extension-flexion) was 105° (range, 50-140). 9 major complications (3 implant failure, 2 non-union, 4 stiffness) were noted. CONCLUSION: The anatomically pre-contoured and angular-stable dual column plating provides adequate immediate postoperative stability to allow early physiotherapy, in AO type C- fractures. Excellent results could be achieved in the majority of patients, independent of having had a complication or not. Complication rates usually are high, emphasizing the difficulties associated with this complex type of fracture.

Essex-Lopresti lesion (ELL) is a severe injury of the forearm involving dislocation of distal radio-ulnar joint (DRUJ), radial head fracture, and disruption of interosseous membrane (IOM). It’s usually recognized during chronic phase, after an initial misdiagnosis and represents a therapeutic challenge for orthopaedic surgeons. We report a case of a 51 year-old-man, who suffered a forearm and elbow trauma after a fall on an outstrectched hand with elbow in extension and developed a chronic ELL after a radial head comminuted fracture treated with radial head resection, in a misdiagnosed DRUJ and forearm longitudinal instability. Firstly, he underwent a cubital shortening osteotomy and fixation with a 3.5mm DCP-plate and screws. He still showed longitudinal forearm instability afterwards, being later submitted to an anconeus interposition radial head arthroplasty combined with a new cubital osteotomy, reduction and temporary fixation of DRUJ with 2 K-wires and an IOM reconstruction with a Zip-Tight system. The carpal tunnel was also released due to median nerve paresthesia. Followed a 6-week elbow and wrist immobilization cast, he started physiotherapy rehabilitation program to increase range of motion. Returned to work (as carpenter) after 4 months postoperatively. After a 2-years follow-up, his QUICK-DASH score decreased from 88,6% to 22,7%, with an elbow ROM 0-120º and functional wrist range of motion, complete pronation and lack of 20º of supination.

Purpose: This study aimed to demonstrate the stress distribution pattern, particularly in osteoporotic 3-part proximal humerus fractures involving greater tuberosity (GT) with different screw configurations.
Materials and methods: Using the CT images of two patients, who had osteoporosis and the other had normal bone density, 3-part fractures involving the GT, without medial support were reconstructed. To reflect the osteoporosis or real bone density, Hounsfield unit of CT scans were utilized. A force of 200 N was applied in 30° varus direction. The proximal screws were set in two ways: 6 screws without inferomedial supporting screws and 9 screws with inferomedial supporting screws. Qualitative and quantitative analysis of internal stress distribution were performed.
Results: The most proximal part area near humeral head vertex and near the 1st screw’s passage and tip had more stress concentrated in osteoporotic 3-part fractures. The stress distribution around the proximal screws was found near the GT fracture line and its lateral side, where the local max values located. Inferomedial supporting screws decreased these effects by changing the points to medial side from the GT. The ratio in osteoporotic bone model decreased to that in normal bone model when inferomedial supporting screws were applied.
Conclusions: In osteoporotic 3-part proximal humerus fracture, the stress distribution was concentrated on the area near the humeral vertex, 1st row screw tips, and lateral side region from the GT fracture line. Moreover, inferomedial supporting screws ensured that the stress distribution is similar to that in normal bone setting, particularly in osteoporotic condition.

The modified method of CRPP can be applied in the treatment of Type III & IV Supracondylar Fractures Humerus in Children for getting superior results by avoiding the usual complications. In the doubtful vascular injury cases, the return of the radial pulse with good capillary flow immediately after the completion of CRPP on the table avoids unnecessary vascular exploration. It is a study of 40 cases of age 1.5 to 16. Closed reduction is done in 3 steps. Elbow is positioned at 10degree flexion for distraction to avoid iatrogenic injuries to neurovascular bundle. Persistent pressure is applied over the medial-epicondyle with a finger for shifting the edema, for feeling the ulnar nerve to push backwards with the thumb for creating a safe entry point for the K-wire. Primary fixation was done with 2K-wires- 1.6mm in crossed manner from both epicondyles sparing the olecranon fossa without any skin incision. 2 more wires are added in crossed manner by incorporating the major fragments which increase the strength of the hardware and to avoid rotation. The K-wire is shortened and placed in the subcutaneous plane and external support by POPslab. Complicated fractures with inter condylar or Y condylar fragments were fixed first with one or two transverse k-wires. Then the major fragments were incorporated in the wires fixing with the shaft to complete a triangular hardware framework by encircling the comminuted metaphyseal fragments avoiding the metaphyseal collapse. 96% excellent and good results achieved on analysis with Flynn criteria and Mayo Elbow Performance Score.