Combined olecranon osteotomy and posterior triceps splitting approach for complex fractures of the distal humerus

Complex fractures involving the intercondylar/supracondylar distal humerus with extension into the mid to proximal humeral shaft are difficult to manage through a single standard surgical approach. We present and review a technique that combines an olecranon osteotomy with a posterior triceps splitting approach to the humerus. This technique was used in two patients who presented with severe intercondylar fractures of the distal humerus and extension proximally to the midshaft of the humerus. The technique allowed extensive distal humerus exposure, including the supracondylar/intercondylar region, and excellent exposure of the humeral shaft proximally to the surgical neck.     

Surgical treatment of fractures of the distal end of the humerus in children

The author presents his epyerience in the treatment of 473 children with fractures of the distal end of the humerus. An effort is made to systemize the fractures according to the degree of their dislocation for working out the optimal method of surgical treatment. Preference is given to actively surgical methods. The problems of stable fixation of the fragments are considered and it is suggested to use a lateral dosed compression apparatus as a fixator. The period of immobilization is considered from the point of siev of the restoration of the circulation in the distal fragment and it is proposed to extend the period of immobilization in the fractures of the distal epiphysis to 5 or 6 weeks. The immediate and the long-term results of the treatment of the fractures of the distal end of the humerus in children are analysed.     

Fractures of the distal humerus

The quality of elbow function after fracture of the distal humerus is related to the degree to which normal anatomic relationships are restored. This article addresses the issues related to fractures of the distal humerus, including challenges, controversies, surgical exposure, postoperative management, and complications.     

Treatment of the displaced distal humeral fractures- the original AO procedure by means of two reconstructive plates

The aim of this paper is to assess the actual method of surgical treatment of the displaced fractures of the distal humerus, that is the AO technique, by means of 2 reconstructive plates. Until recently, we were very keen on using the Lecestre-type plate placed on the lateral pillar of the distal humerus. Since September 2001 we have managed to treat these types of fractures in the manner they are treated all over the world. Thus, the arch of motion of the elbow is improved both in terms of flexion and extension. Moreover, the 2 reconstructive plates can be properly molded on the surface of the bone entailing a firmly stabilized distal humerus.     

Incidence and risk factors of heterotopic ossification following major elbow trauma

Heterotopic ossification is a common complication of Orthopaedic Trauma Association (OTA) type C distal humerus fractures and ulnohumeral fracture dislocations. The purpose of this study was to precisely define the incidence of heterotopic ossification following major elbow trauma and to identify risk factors for the development of clinically significant heterotopic ossification and for surgical excision of elbow heterotopic ossification.Current Procedural Terminology codes identified 156 patients who underwent operative intervention for a distal humerus fracture or an ulnohumeral fracture dislocation at 2 Level I trauma centers over 6 years. The incidence of elbow heterotopic ossification was recorded at >90 days following the definitive procedure. Risk factors for the development of class 3 or 4 heterotopic ossification and for surgical excision of heterotopic ossification were evaluated using separate multivariable logistic regression analyses. Brooker class 3 or 4 heterotopic ossification occurred following 18 (14%) of 125 distal humerus fractures, 15 (22%) of 69 OTA type C distal humerus fractures, and 11 (35%) of 31 ulnohumeral fracture dislocations. Surgical excision of heterotopic ossification was performed after 12 (10%) of 125 distal humerus fractures, 10 (14%) of 69 OTA type C distal humerus fractures, and 8 (26%) of 31 ulnohumeral fracture dislocations. Sustaining a severe elbow injury (P<.05) or a delay of fixation (P=.05) was found to be independent risk factors for Brooker class 3 or 4 heterotopic ossification. Severe elbow injury (P<.05) and male sex (P<.05) were associated with operative excision of heterotopic ossification.     

经尺骨鹰嘴截骨入路双钢板内固定治疗肱骨髁间粉碎骨折

目的探讨肱骨髁间粉碎骨折经尺骨鹰嘴截骨入路双钢板内固定的疗效。方法采用尺骨鹰嘴截骨、骨折复位解剖型双钢板内固定治疗肱骨髁间粉碎骨折15例。结果15例随访6—24个月，骨折均愈合。按改良Cassebaum评分系统评分：优6例，良6例，可2例，差1例。结论采用尺骨鹰嘴截骨、关节面解剖复位、双钢板固定治疗肱骨髁间粉碎骨折临床疗效良好。     

Distale Humerusfraktur beim ?lteren Menschen

The intraarticular fracture of the distal humerus in an elderly patient remains a challenge for trauma surgeons. In case of severe co-morbidities and/or osteoporosis stable fixation with screws and plates is difficult and in some cases can be impossible. Even if osteosynthesis is feasible the clinical outcome is still incalculable due to delayed or non-union of the fracture fragments. Endoprosthetic replacement of the elbow joint for comminuted distal humerus fractures has been used for almost 20?years. The clinical results are predominantly excellent or good and better predictable than those of osteosynthesis. There still is no guideline when a prosthesis for the elbow joint should be used. We reviewed the literature and outline the current recommendations for diagnostics and surgical therapy for distal humerus fractures in the elderly.     

Distale Humerusfrakturen

Only 2–6% of all fractures are in the distal humerus. The initial aim is anatomical reduction to allow the achievement of a long-term good functional result with no pain or posttraumatic arthrosis. In most cases, this means that stable osteosynthesis is necessary. The rare fractures without or with only minor dislocation can be treated without surgery in some cases. The surgical and conservative treatment options for fractures of the humerus in adults is presented with reference to the authors’ own methods.     

Fractures of the distal humerus in the elderly. Pros and cons of endoprosthetic replacement

The intraarticular fracture of the distal humerus in an elderly patient remains a challenge for trauma surgeons. In case of severe co-morbidities and/or osteoporosis stable fixation with screws and plates is difficult and in some cases can be impossible. Even if osteosynthesis is feasible the clinical outcome is still incalculable due to delayed or non-union of the fracture fragments. Endoprosthetic replacement of the elbow joint for comminuted distal humerus fractures has been used for almost 20 years. The clinical results are predominantly excellent or good and better predictable than those of osteosynthesis. There still is no guideline when a prosthesis for the elbow joint should be used. We reviewed the literature and outline the current recommendations for diagnostics and surgical therapy for distal humerus fractures in the elderly.     

Proximal and distal humerus fractures in advanced age

In contrast to distal humeral fractures, humeral head fractures represent a common injury to the old patient. For both fracture localizations osteoporosis and multi-morbidity are of significant importance. The classification for humeral head fractures in one-, two-, three- and four-part fractures is generally accepted. Valgus impacted head fractures as well as head-splitting fractures are considered a separate entity. In none or minimally displaced fractures good functional results are achieved by conservative means. Although numerous therapeutical procedure are offered in the treatment of displaced fractures of the proximal humerus the result are often disappointing. Generally, minimal invasive surgical procedures should be preferred. However, in dislocated multi-part fractures a primary humeral head replacement is often the treatment of choice. In patients with multifarious morbidity a conservative treatment is always to be included into the therapeutical considerations. Distal fractures of the humerus are classified into extraarticular, intraarticular uni-condylar and intraarticular bi-condylar fractures. The therapeutical recommendations, also in the elderly, is relatively homogeneous: primary open reduction and internal fixation (ORIF) should be carried out aiming for an early postoperative functional treatment. Depending from soft tissue conditions and accompanying injuries the functional results are often good or moderate and are generally comparable to those of younger patients. Following a correct indication for surgical intervention the main priority for both distal and proximal humeral fractures is an early definitive surgical treatment.     

Metaphyseo-diaphyseal junction fracture of distal humerus in children

Six metaphyseo-diaphyseal junction fractures of distal humerus and 182 supracondylar fractures of humerus treated in our institute over a period of 5 years were retrospectively analyzed. Clinical data regarding child's age, neurovascular status, mechanism of injury, mode of treatment, and ultimate clinical outcome were collected for both these fractures and a comparison was made. Oblique (n=2), comminuted (n=3), and transverse types (n=1) of fracture patterns were identified at distal humeral metaphyseo-diaphyseal junction. The oblique and comminuted fractures were managed by closed reduction and plaster of Paris cast, whereas the only transverse fracture was treated by closed reduction and Kirschner wire fixation. In contrast, 125 patients of supracondylar fractures were treated by closed reduction and plaster of Paris cast and the remaining 57 fractures needed Kirschner wire fixation after closed reduction. Assessment by Flynn criteria after 1 year after of injury revealed better functional outcome in metaphyseo-diaphyseal junction fractures. Although transverse fractures are unstable and may require surgical fixation; oblique and comminuted fractures at the metaphyseo-diaphyseal junction of distal humerus can be managed conservatively.     

Essential concepts in the treatment of common joint fractures: A narrative review

Proximal fractures of the humerus are at high risk of osteonecrosis if the medial calcar is disrupted and the metaphyseal extension of the head fragment is <8mm. Risk factors for failure of osteosynthesis include: poor bone stock, varus dislocation, head dislocation and medial comminution.During surgical treatment of distal humerus fractures, one should aim to restore the arc and stabilize the columns. Several technical rules have been outlined by O´Driscoll and are mentioned in this article in detail.In fractures of the distal radius, the length, the joint surface, and joint angles (palmar inclination ca. 11°, radial inclination ca. 22°) should be reconstructed. Several surgical factors are associated with the development of radiocarpal osteoarthritis including the sagittal depth of the articular cavity and the anterior-posterior diameter of the fossa lunata of the distal radius.When managing fractures of the proximal tibia, a four- or more column classification system should be used to plan the surgical steps and choose the appropriate approach(es).In ankle fractures, intraoperative 3-D-Scan should be considered especially in the case of syndesmotic involvement or involvement of the posterior malleolus.     

Intra-articular distal humeral fractures in adults

This article describes a technique of open reduction and internal fixation of intra-articular fractures of the distal humerus in adults. The historical treatment of these fractures is surveyed, including current classification systems. Anatomy is reviewed, specifically as it pertains to surgical intervention. The results in 23 consecutive patients stabilized through an intra-articular olecranon osteotomy exposure are reported.     

Fractures of the upper extremity in the elderly

PROBLEM: The primary goal in treating fractures in elderly persons is safe and rapid restoration of their functional capabilities to secure independence in everyday activities. The intention of this paper is to present an overview of treatment principles useful in this age group. METHODS: We analysed a series of 404 patients above the age of 70 years who underwent surgery for fractures of the arm between 1981 and 1997. RESULTS: Diaphyseal fractures are less frequent in this age group and their treatment does not differ significantly from principles established for younger patients. The majority of fractures of the proximal humerus and the distal radius can be treated by conservative means. Unstable fractures are frequent in the distal humerus and the olecranon requiring operative reduction and osteosynthesis. CONCLUSIONS: Preferred operative techniques in aged persons inflict minimal surgical trauma and have a low rate of complications and secondary interventions. In contrast, anatomical reconstruction has the highest priority in younger individuals.     

Frakturen des Oberarms im Wachstumsalter

Because of the quite different growth-potential at the proximal and the distal end on the one hand and the different anatomy as well as function of the shoulder joint proximal and the ellbow joint distal on the other hand, fractures of the humerus in children represent a very inhomogeneous group. The proximal humerus has a very high potential for spontaneous correction of deformities, because 70–80% of the growth of the humerus results from the proximal epiphysis. In addition the wide range of motion of the shoulder joint in all three planes allows for further compensation of residual deformities. Therefore fractures of the proximal humerus are easy to treat and operative intervention is rarely indicated. On the distal humerus the potential for spontaneous correction is low. Furthermore deformities of the distal humerus tend to have an significant negative impact on elbow function. Because of the anatomic structure of the distal humeral epiphysis, fractures involving the epiphysis have an higher incidence. Therfore fractures of the distal humerus are difficult to treat and operative intervention to restore the anatomy and joint function are often indicated.     

Treatment trends in distal humerus fractures between ABOS part II candidates

PurposeThe purpose of this study was to determine how fellowship training influences the treatment of distal humerus fractures with either total elbow arthroplasty (TEA) or open reduction internal fixation (ORIF).MethodsThe American Board of Orthopaedic Surgery (ABOS) Part II Examination Database was queried for all orthopaedic surgeons who sat for the Part II examination between the years 2003-2019. Inclusion criteria were ORIF or TEA cases, selected by individual CPT codes for each procedure, and patients of at least age 65 years who sustained acute distal humerus fractures. Analysis was performed for each type of fellowship training completed, total number of procedures performed, the type of procedure performed, patient demographics, and any complications.ResultsThere were 149 TEAs and 1306 ORIFs performed for distal humerus fractures between the exam years of 2003-2019. The proportion of TEA to ORIF increased from 7.6% to 11.0%. Partitioned by fellowship training, Hand and Upper Extremity surgeons performed 69 (17.4%) TEAs and 328 (82.6%) ORIFs, Shoulder and Elbow surgeons performed 34 (29.6%) TEAs and 81 (70.4%) ORIFs, Sports Medicine surgeons performed 14 (5.1%) TEAs and 263 (94.6%) ORIFs, and Trauma surgeons performed 16 (4.2%) TEAs and 366 (95.8%) ORIFs. Hand and Upper Extremity surgeons treated the most distal humerus fractures (397, 27.3%), followed by Trauma surgeons (382, 26.3%).ConclusionOur data suggests that fellowship training does influence the surgical decision-making process for treating distal humerus fractures in elderly populations. Hand and Upper Extremity surgeons performed the greatest number of TEA for acute distal humerus fractures, followed by Shoulder and Elbow surgeons. Conversely, trauma surgeons performed the lowest proportion of TEA to ORIF.Level of EvidenceIII.     

Pediatric supracondylar fractures and pediatric physeal elbow fractures

Elbow fractures in children are extremely common, making up approximately 15% of all fractures in pediatric patients. The unique radiographic anatomy of the pediatric elbow, along with the potential for neurovascular compromise, often provokes anxiety in orthopedic surgeons. A thorough understanding of the anatomy and treatment principles makes the care for these children more straightforward, however. The distal humerus makes up approximately 85% of all elbow fractures in children. The most common fractures of the distal humerus in children are supracondylar humerus fractures, lateral condyle fractures, medial epicondyle fractures, and transphyseal humerus fractures. Each of these fractures is discussed in detail, outlining their radiographic features, principles of treatment, and potential complications.     

Distal humerus fractures in the elderly: osteosynthesis or endoprosthesis? Review of the literature

Fractures of the distal humerus in adults are rare but challenging for the orthopaedic trauma surgeon. The bimodal distribution reflects the trauma mechanism. While distal humerus fractures are caused by high-energy traumata in young male adults, a fall from a standing height is the most common reason for humerus fractures among elderly females. As a rule, fractures of the distal humerus are treated surgically. In young patients, open reduction and internal fixation (ORIF) with anatomic locking plates are the gold standard. In elderly patients, reconstruction is not always possible, and total elbow arthroplasty (TEA) becomes necessary. The present article provides an overview of the current diagnostic and treatment recommendations. The current literature is reviewed and the results discussed.     

Variation in risk factors for fractures at different sites

Fractures in older people are important medical problems. Knowledge of risk factors is essential for successful preventive measures, but when fracture sites of diverse etiology are combined, risk factors for any one site are difficult to identify and may be missed entirely. Among older people, incidence rates of hip, proximal humerus, and vertebral fractures increase with age, but not rates of distal forearm and foot fractures. Low bone mineral density is strongly associated with hip, distal forearm, vertebral, and proximal humerus fractures, but not foot fracture. Most fractures of the hip, distal forearm, and proximal humerus result from a fall, whereas smaller proportions of fractures of the foot and vertebrae follow a fall. Frail people are likely to fracture their hip or proximal humerus, while healthy, active people tend to fracture their distal forearm. We strongly recommend that studies identify risk factors on a site-specific basis.     

AO extra-articular distal humerus locking plate: extended spectrum of usage in intra-articular distal fractures with metaphyseal extension—our experience with 20 cases

Background

LCP extra-articular plate designed by AO has been used in extra-articular fractures of the distal humerus, mal-unions, and nonunions of the distal humerus. They provide anatomically shaped and angular stable fixation system for extra-articular fractures of the distal humerus. We extended the usage spectrum of this plate to the extra-articular with intra-articular distal humerus fractures and compared it with the standard orthogonal locking plate fixation.

Methods

We included 22 consecutive distal humerus intra-articular fractures with metaphyseal and diaphyseal extension into the study. Each case underwent osteosynthesis with LCP extra-articular plate fixation and augmented the intra-articular fragments with 4.0 mm partially threaded cancellous screws. The cost, surgical time, VAS, Modified Mayo Clinic Performance Index for elbow, and postoperative complications were recorded. The radiological union and postoperative elbow range of motion were assessed at 6 weeks, 6, and 12 months of follow-up. Twenty cases completed the scheduled follow-up. The results were compared with retrospective data of 20 cases from our institute where similar fractures were treated with standard orthogonal LCP distal humerus plate (LCPDHP).

Results

The radiological union rates and the range of motion at 6 weeks, 6, and 12 months in both the groups were comparable and did not vary significantly (p > 0.05). The cost and operative time with the LCP extra-articular plates were significantly less (p < 0.05) when compared to the group LCPDHP.

Conclusion

The usage spectrum of extra-articular distal humerus locking plate can be extended to intra-articular fractures. It provides good results and significantly reduces the cost and operative time.