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Background Supracondylar humeral fractures are common injuries in children and can be associated with high morbidity and lead to lifelong disability. The method of treatment affects the risk of complications and potentially the functional outcome. Closed reduction and percutaneous pinning CRPP has become the most widely used treatment method in high-income countries. In the current literature, both CRPP and lateral straight arm traction have been shown to give good results and reasonable levels of complications. The two methods have never been tested against each other in a randomised trial. Furthermore, these methods have not been analysed prospectively in the low and middle income context. Methods The study will be a prospective randomised trial comparing lateral straight arm traction LSAT against CRPP. Recruitment will be at 8 large referral hospitals in Ethiopia. Based on non-inferiority power calculation, we plan to recruit 220 patients. The principal outcome measure will be the PROMIS parent proxy upper extremity short form 8a score version 3.0 at 12 months. The secondary outcome measures will be the Flynn’s criteria; complications; PROMIS parent proxy upper extremity short form 8a score version 3.0 at 6 months; PROMIS parent proxy global health 7 + 2 score version 3.0 administered at 6 and 12 months; and economic analysis of hospital costs for the two treatment modalities. Discussion Supracondylar humeral fractures are common and serious injuries which occur frequently in LMICs where often half the population are under 18 years of age. Such countries have limited capacity for fracture care. Finding solutions which may avoid referral and operative intervention is paramount in developing access to timely and affordable care for all people. If LSAT is non-inferior to CRPP, then children can be treated locally in a cost-effective manner with avoidance of disability. Trial registration ISRCTN Ref 62164933. Registered on 25 July 2024.

Purpose There has been little direct comparison between non-operative and operative management of humeral shaft fractures. The present study aimed to compare union rates and complication rates between these two modalities of treatment. Methods A retrospective cohort study was performed at a regional level 1 trauma centre. A total of 296 patients with humeral shaft fractures met inclusion criteria; 69 patients were treated with a functional brace and 227 with surgical intervention. The primary end point was radiographic union. Nonunion was defined as failure of radiological union at six months, requiring surgical intervention. Time to union, nerve palsy rate, and rate of infection were also examined. Results The nonunion rate was significantly higher in the non-operative group (23.2 % vs 10.2 %) despite higher rates of open fractures and high energy mechanisms of injury in the operative group. No significant difference in time to union was found. Nerve palsy was more common in the operative group (20 % vs 39 %); however, only two cases (1 %) of radial nerve palsy in the operative group were iatrogenic and both were transient. Infection rates were higher for the operative group (3.5 % vs 0 %). Conclusions Conservative treatment of humeral shaft fractures has a higher rate of nonunion, while operative treatment is associated with a low incidence of iatrogenic nerve palsy but higher rates of infection.

Purpose Lateral humeral condyle fracture (HLCF) is a common pediatric elbow injury. For minimally displaced fractures (≤ 2 mm), the optimal management strategy remains controversial. This systematic review and meta-analysis aimed to evaluate the feasibility and safety of conservative treatment for this specific subtype. Methods A systematic search of multiple databases was conducted to compare conservative and surgical management of minimally displaced (≤ 2 mm) pediatric HLCF. The primary outcome was fracture healing, defined by the absence of secondary displacement during follow-up. Secondary outcomes included elbow joint function, periarticular hyperplasia, and malunion. Results Twelve studies involving 1,022 children met inclusion criteria. Secondary displacement occurred in 18.4% of conservatively treated patients compared with 5.4% of surgically treated patients, indicating a higher risk of treatment failure with non‑operative management. Among fractures that ultimately healed, no significant differences were observed between conservative and surgical groups in elbow function, periarticular hyperplasia, or malunion. Conclusions Even minimally displaced (≤ 2 mm) pediatric HLCFs may demonstrate mechanical instability during follow‑up. Conservative treatment should therefore be undertaken with caution, and close radiographic monitoring is essential to detect early displacement. Treatment decisions should integrate displacement magnitude, fracture stability, imaging findings, follow‑up reliability, and family preference.

Background Humeral shaft fractures constitute around 1% of adult fractures in the UK, with an annual incidence of approximately 13 per 100,000 population. Historically, these injuries have been primarily managed non-operatively, with operative fixation reserved for specific indications. Although some recent retrospective studies have suggested there are potential benefits of operative fixation over humeral bracing, there is a deficiency in level 1 evidence to support operative management as the primary treatment for humeral shaft fractures. Methods/design This single-centre prospective randomised controlled trial aims to recruit 70 adult patients with an isolated closed fracture of the humeral diaphysis into one of two treatment arms: operative ( n  = 35) or non-operative ( n  = 35). The operative arm will undergo open reduction and internal fixation (ORIF) of the fracture using a standard fixation technique (plate and screws). The non-operative arm will be fitted with a prefabricated humeral brace until fracture union. All patients will be followed up for 1 year post-intervention. The primary outcome measure will be the Disabilities of the Arm, Shoulder and Hand (DASH) score at 3 months post-intervention. Secondary outcome measures will include pain, treatment complications, return to work or sporting activities, shoulder and elbow range of motion, radiographic assessment, EuroQol (EQ-5D) Health Outcome score and 12-item Short Form (SF-12) Health Survey score. A health economic analysis will be performed to compare the cost implications of each treatment strategy. Discussion This randomised controlled trial will provide level 1 evidence comparing a standard ORIF technique against functional bracing for isolated closed humeral shaft fractures. The investigators hope that the study results will assist surgeons in their decision-making when managing patients with these injuries. Trial registration ClinicalTrials.gov, NCT03689335 . Registered on 28 September 2018 (retrospectively).

IntroductionHumeral shaft fractures represent 1%–3% of all fractures and 20% of humeral fractures in adults. The treatment of these fractures is mainly conservative and operative treatment is usually reserved for specific circumstances. To date, no randomised controlled trial (RCT) has compared operative treatment of humeral shaft fractures with conservative treatment.Methods and analysisWe will conduct an RCT to compare the effectiveness and cost-effectiveness of surgical and conservative treatment of humeral shaft fractures. After providing informed consent, 80 patients from 18 years of age with humeral shaft fracture will be randomly assigned to open reduction and internal fixation with locking plate or conservative treatment with functional bracing. We will follow the patients for 10 years and compare the results at different time points. The primary outcome will be Disabilities of Arm, Shoulder and Hand (DASH) at 12 months. The secondary outcomes will include Numerical Rating Scale for pain at rest and in activities, Constant Score and quality of life instrument 15D. Patients not willing to participate in the RCT will be asked to participate in a prospective cohort follow-up study, ‘the declined cohort’. This cohort will be followed up at the same time points as the randomised patients to assess the potential effect of participation bias on RCT results and to enhance the external validity of the RCT. In one of the recruiting centres, all cooperative patients with humeral shaft fractures not eligible for randomisation will be asked to participate in a ‘non-eligible cohort’ study. We will use blinded data interpretation of the randomised cohort to avoid biased interpretation of outcomes. Our null hypothesis is that there is no clinically relevant difference in the primary outcome measure between the two treatment groups. We will consider a difference of a minimum of 10 points in DASH clinically relevant.Ethics and disseminationThe institutional review board of the Helsinki and Uusimaa Hospital District has approved the protocol. We will disseminate the findings of this study through peer-reviewed publications and conference presentations.Trial registration numberNCT01719887; pre-results.

Patients with humeral fracture often suffer from post-traumatic neuropsychiatric sequelae, which can cause immense anxiety or fear and worsen recovery. In this report, we examined the effect of low-dose esketamine versus dexmedetomidine on postsurgical recovery among patients who underwent humerus surgery with interscalene brachial plexus block. In this prospective, randomized, controlled study, 141 patients aged 18 to 65 years who underwent humerus reduction and internal fixation were recruited. Patients were randomly assigned to two groups: esketamine (Group E: received 0.2 mg/kg (i.v.) esketamine administration, with subsequent continuous 0.15mg/kg/h infusion); dexmedetomidine (Group D: received 10-min 0.8µg/kg dexmedetomidine infusion, with 0.4ug/kg/h maintenance infusion). All infusions were terminated at closure of surgical incisions. Our major endpoint was the Quality of Recovery-40 (QoR-40) score on postoperative day 1 (POD-1). The secondary outcomes were QoR-40 POD-3, the intraoperative modified observer's assessment of alert/Sedation (MOAA/S) scores at 5 min (T1) and 10 min (T2) post i.v. administration, at operation initiation (T3), at 10 min interval (T4), 30 min interval (T5) post operation, and at the end of operation (T6), Numeric Rating Scale (NRS) at POD-1, additional postoperative analgesic usage and hospital stays. In addition, we analyzed safety indices, such as hemodynamic profile, postoperative nausea and vomiting, adverse events (AEs) involving the central nervous system. The QoR-40 scores on POD-1 for Group E were substantially elevated relative to Group D. The T4 and T5 MOAA/S scores of Group D were lower relative to Group E. In comparison to Group E, Group D exhibited reduced T1 and T2 Mean arterial pressure (MAP) and T1-T6 Heart rate (HR). Lastly, we observed no marked alteration in other postsurgical AEs between the two patient cohorts. Continuous low-dose esketamine infusion seems safely and tolerably, it significantly improves the postoperative recovery quality among patients with ASA I or II receiving elective humeral trauma surgery.

Unless acute osteomyelitis in children is diagnosed promptly and treated appropriately, it can be a devastating or even fatal disease. This review summarizes the current approach to the treatment of acute osteomyelitis in children. Bacteria may reach bone through direct inoculation from traumatic wounds, by spreading from adjacent tissue affected by cellulitis or septic arthritis, or through hematogenous seeding. In children, an acute bone infection is most often hematogenous in origin. 1 In high-income countries, acute osteomyelitis occurs in about 8 of 100,000 children per year, 2 but it is considerably more common in low-income countries. Boys are affected twice as often as girls. 2 , 3 Unless acute osteomyelitis is diagnosed promptly and treated appropriately, 4 it can be a devastating or even fatal disease with a high rate of sequelae, especially in resource-poor countries where patients present . . .

Purpose of ReviewFracture fixation aims to provide stability and promote healing, but remains challenging in unstable and osteoporotic fractures with increased risk of construct failure and nonunion. The first part of this article reviews the clinical motivation behind finite element analysis of fracture fixation, its strengths and weaknesses, how models are developed and validated, and how outputs are typically interpreted. The second part reviews recent modeling studies of the femur and proximal humerus, areas with particular relevance to fragility fractures.Recent FindingsThere is some consensus in the literature around how certain modeling aspects are pragmatically formulated, including bone and implant geometries, meshing, material properties, interactions, and loads and boundary conditions. Studies most often focus on predicted implant stress, bone strain surrounding screws, or interfragmentary displacements. However, most models are not rigorously validated.SummaryWith refined modeling methods, improved validation efforts, and large-scale systematic analyses, finite element analysis is poised to advance the understanding of fracture fixation failure, enable optimization of implant designs, and improve surgical guidance.

Displaced medial epicondyle fractures are among the most controversial injuries in children, with increasing trends towards surgical fixation despite little supporting evidence. Approximately half of affected children undergo surgical fixation, while others receive non-surgical care. The SCIENCE trial aimed to determine whether surgical fixation to restore the position of the bone provides superior functional outcomes and is cost-effective compared with non-surgical care. We conducted a pragmatic multicentre, randomised, superiority trial across 59 hospitals in the UK, Australia, and New Zealand. Recruiting sites were secondary or tertiary care hospitals providing acute paediatric trauma care. Eligible participants were aged 7–15 years with a displaced medial epicondyle fracture and patients were excluded if the injury occurred more than 2 weeks prior, they had a medial epicondyle fragment that was incarcerated (trapped) within the joint, the injury was part of a complex elbow fracture (ie, extending into the joint), or there were additional fractured bones outside of the elbow. Participants were randomly assigned (1:1) to either surgical fixation or non-surgical care using a web-based randomisation software from Oxford Clinical Trials Research Unit, with minimisation (including a random element) stratified by centre and elbow dislocation status at presentation. Participants and their parents and carers could not be masked to treatment. Surgical fixation was performed under general anaesthesia and involved a surgical incision, restoration of the anatomical alignment, and fixing the fragment, typically with a screw or wires. Non-surgical care involved immobilisation of the elbow at approximately 90° of flexion using a cast, splint, or sling. Both groups were allowed mobilisation as pain allowed, although cast immobilisation beyond 4 weeks was discouraged. The primary outcome was upper limb function at 12 months, measured using the Patient Report Outcomes Measurement System (PROMIS) Upper Extremity Score for Children in the intention-to-treat population, which included all participants in the groups to which they were randomly assigned, irrespective of treatment received. Complications and serious adverse events were summarised in a safety (as-treated) population defined by treatment received. A within-trial economic evaluation was undertaken from the perspective of the UK National Health Service and Personal Social Services over a 12-month time period. The trial was registered with ISRCTN, ISRCTN16619778; recruitment is complete and extended follow-up to age 16 years is ongoing. Between June 10, 2019, and Sept 22, 2023, 647 patients from 59 sites met the inclusion criteria. 146 patients were excluded (64 due to the injury being more than 2 weeks old and 24 because the epicondyle fragment was incarcerated within the joint), 161 families of children meeting the eligibility criteria declined to participate, and for five patients there was no clinician equipoise. 335 participants were randomly assigned to an intervention (166 to the non-surgical care group and 168 to the surgical fixation group) and one was immediately excluded due to a randomisation error. Primary outcome data were collected from 285 (85%) participants. 170 (51%) participants were female and 164 (49%) were male. Mean participant age at baseline was 11·7 years (SD 2·3). At 12 months post-randomisation, the PROMIS Upper Extremity score was 53·1 (SD 7·8) in the non-surgical care group and 54·3 (5·7) in the surgical fixation group (mean treatment difference, 1·57 [95% CI –0·01 to 3·14; p=0·052]). This estimate of treatment effect was below the clinically important difference specified (4 points), supporting the conclusion that a clinically important effect is unlikely. Additional episodes of surgery, either planned or related to complications, occurred in 24 participants in the surgical group and three in the non-surgical group. Among the 150 participants who underwent surgical fixation, there were 14 intraoperative complications from 13 (9%) participants, and seven participants had a postoperative complication (5% participants) each requiring surgery. Routine screw or wire removal was undertaken in a further 17 (11%) participants. From the 184 participants in the non-surgical group, there were five complications among four (2%) participants, three (2%) of which required additional surgery. The mean per patient cost from the NHS and Personal Social Services perspective was £2435 (95% CI 1812 to 3057) more for participants in the surgical fixation group with a mean per patient quality-adjusted life year difference of –0·008 (95% CI –0·039 to 0·024). The probability that surgical fixation is cost-effective at the £20 000 or £30 000 per quality-adjusted life year willingness-to-pay threshold was 0%. The SCIENCE trial demonstrates that surgical fixation offers no clinical benefit and is not cost-effective compared with non-surgical care, while exposing children to avoidable surgical risks. These findings suggest that non-surgical care should be adopted as the default management strategy for these injuries, regardless of initial elbow dislocation status. National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (17/18/02), with additional support from the NIHR Academy, Oxford NIHR Biomedical Research Centre, and the Starship Foundation (New Zealand).