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.     

Intraarticular distal humerus fracture complicated by osteogenesis imperfecta treated with primary total elbow arthroplasty: a case report

Intraarticular fractures of the distal humerus are challenging problems for the treating surgeon. When these fractures are complicated by severe comminution and poor bone quality, open reduction and internal fixation may lead to poor clinical outcomes when compared with those treated with primary total elbow arthroplasty. The population in which this clinical scenario most often arises is the elderly. An unusual case is presented in which a 38-year-old individual was successfully treated with primary total elbow arthroplasty for a highly comminuted, intraarticular distal humerus fracture with severe osteopenia due to osteogenesis imperfecta in which standard plate osteosynthesis was unlikely to provide sufficient stable fixation.     

Das präformierte LCP®-Plattenfixateursystem bei distalen Humerusfrakturen AO-Typ 13C3

In distal intraarticular humerus fractures primary stable osteosynthesis is essential for early mobilization of the elbow joint. Double-plate osteosynthesis techniques using different configurations are the gold standard. In the literature plate position is sometimes discussed controversially. In cases of distal humerus fractures (type AO 13C3) with metaphyseal comminution, as well as in elderly patients with poor bone quality, utilizing locking plates with angular stability was found to have increased structural properties with regard to primary fixation stability. The dorsal approach with osteotomy of the olecranon seems to be very effective in open reduction and internal fixation of this type of fracture.One new development is the anatomically preformed plate-fixation systems such as the LCP-System for distal humerus (Synthes). This study presents our first experience with this system in 11 cases of open reduction and internal fixation of type AO 13C3 distal humerus fractures. The system-specific features and intraoperative options were analyzed.     

Problematik osteoporotischer Frakturen am Ellenbogen

According to demographic data, treatment of osteoporotic fractures will increase in importance. In geriatric patients, injuries to the elbow mainly involve fractures of the olecranon and the distal humerus. Luxations of the elbow with isolated ligamentous tears are rather rare as the weakened bone fractures before the joint displaces. Osteoporotic fractures of the elbow frequently feature destruction of the articular surface combined with severe comminution of the metaphyseal bone. Due to the complex anatomy of the elbow joint and fracture patterns of the osteopenic bone, treatment of these fractures remains a challenge. As conservative fracture treatment leads to poor functional outcome, these fractures are mainly treated by open reduction and internal fixation. In osteoporotic olecranon fractures, reconstruction of the joint surface and osteosynthesis by plate fixation is the treatment of choice. New anatomically preshaped implants with several options for angular stable screw fixation have proved reliable for stable osteosynthesis. In massive comminution and non-reconstructable situations of the olecranon in elderly patients, the resection of the defect with adquate refixation of the triceps muscle can be considered. With respect to the distal humerus, supra-diacondylar fractures are observed in the majority of osteoporotic cases. In recent years, the therapy of choice has become double plating osteosynthesis in combination with olecranon osteotomy. The anatomically preshaped implants with different possibilities of angular stable fixation have also shown promising results. As in younger patients, the aim of the operative procedure is the reconstruction of a congruent articular surface as well as preservation of the extensor system for early functional movement. For complex and non-reconstructable fractures, total elbow arthroplasty is the preferred option.     

老年肱骨远端骨折的治疗选择

老年患者肱骨远端骨折常因骨质疏松而致关节面严重粉碎,治疗十分困难。由于全肘关节置换有一定的使用年限,对于活动量较大的成年人,内固定仍是主要的选择,但是对于老年患者,究竟应该选择内固定还是进行全肘关节置换,始终是一个充满争议的话题。在过去几十年,肱骨远端骨折的处理有了很大的进步,其主要进展包括双钢板固定的提出、三维CT重建的广泛应用、对更复杂的关节面剪切骨折的认识、平行钢板技术的理解、关节周围解剖钢板的应用以及全肘关节置换术的选择性应用。本文对国内外的相关文献进行回顾,对老年肱骨远端骨折患者的治疗选择做一综述。     

Frakturendoprothetik der distalen Humerusfraktur

The treatment of choice for fractures of the distal humerus is double plate osteosynthesis. Due to anatomical preshaped angle stable plates the primary stability and management of soft tissues has been improved. However, osteoporotic comminuted fractures in the elderly are often not amenable to stable osteosynthesis and total elbow arthroplasty has been established as an alternative therapy. Although complication rates have been reduced, complications of total elbow arthroplasty are still much more frequent than in total hip replacement. Furthermore, patients are advised not to exceed a weight bearing of 5 kg. Therefore, the indications for elbow arthroplasty must be evaluated very strictly and should be reserved for comminuted distal humeral fractures in the elderly with poor bone quality that are not amenable to stable osteosynthesis or for simple fractures in cases of preexisting symptomatic osteoarthritis. This article introduces and discusses modern concepts of elbow arthroplasty, such as modular convertible prosthesis systems, hemiarthroplasty and radial head replacement in total elbow arthroplasty.     

Distale Humerusfrakturen

Because of the complex anatomy of the elbow joint, distal fractures of the humerus present a great challenge to the attending trauma surgeon. A requirement for adequate treatment is the intimate knowledge of the joint-related structure and biomechanics. The aim of treatment is the restoration of a pain-free entire range of motion. An essential condition for that is the anatomical reposition of the joint complex, restoration of the ligamentous stability and an exercise-stable osteosynthesis. A further problem is the increasing number of osteoporosis-related fractures of the distal humerus in the elderly. These fractures often cause complex osseous lesions that require endoprosthetic treatment primary or secondary.     

Primäre Ellenbogengelenkendoprothetik

Primary joint replacement of the elbow is rare and as a rule even complex fractures of the distal humerus or proximal ulna can be stabilized with modern anatomical implants. In multifragmented articular AO (Working group for osteosynthesis questions) type C fractures and very far distal AO type A fractures (low flexion type), in osteoporosis of older patients and/or failure of internal fixation without a promising possibility of revision, semiconstrained joint replacement of the elbow can be a reliable form of treatment and frequently is the only viable option for difficult fracture situations especially in elderly patients. Between 2005 and 2010 a total of 14 patients with supracondylar humeral fractures were treated with primary total elbow arthroplasty and13 were followed up 1 year after surgery (range 11–14 months). Wound complications had not occurred in any case and all patients were satisfied with the functional result. Pain was present only in low grade and the mean arc of flexion-extension was 15–107°. The mean arc of pronation-supination was 84–70° and all elbows were stable. No patient needed a reoperation or an exchange replacement.     

The LCP-concept in the operative treatment of distal humerus fractures--biological, biomechanical and surgical aspects

Distal humerus fractures in adults are treated by open reduction and internal fixation, which produces good results in the majority of patients. However, in elderly patients or in cases with metaphyseal comminution, stable fracture fixation still remains problematic. Anatomical joint reconstruction and primary stable osteosynthesis are often particularly difficult to achieve in this group of patients since poor bone mineral quality is frequently encountered. Consequently, longer immobilization is necessary, which is known to negatively influence functional outcome. Over the past few years, double-plate osteosynthesis techniques using different configurations have become the treatment of choice. Nevertheless, complications due to inappropriate primary stability and/or implant failure have been described. Investigations on whether the recently introduced Locking Compression Plates (LCPs) could enhance primary stability are rare. On the basis of clinical and biomechanical experiences, the authors consider LCPs a helpful tool for increasing primary stability in osteosynthesis of distal humerus fractures. LCPs might be of substantial advantage in patients with diminished bone mineral quality or in the presence of metaphyseal comminution.     

Distal humeral fractures treated with noncustom total elbow replacement

BACKGROUND: The purpose of this study was to review the cases of patients with a distal humeral fracture that was treated with a noncustom total elbow arthroplasty. We hypothesized that, on the basis of the functional and clinical outcome, total elbow replacement is a reliable option for the treatment of elderly patients with a severe, comminuted fracture of the distal part of the humerus. METHODS: We retrospectively reviewed forty-nine acute distal humeral fractures in forty-eight patients who were treated with total elbow arthroplasty as the primary option. The average age of the patients was sixty-seven years. Forty-three fractures were followed for at least two years. According to the AO classification, five fractures were type A, five were type B, and thirty-three were type C. The average age of the forty-three patients was sixty-nine years and the average duration of follow-up was seven years. Fourteen patients died during the review period. Postoperative clinical function was assessed with use of the Mayo elbow performance score, and anteroposterior and lateral radiographs made at follow-up examinations were reviewed. RESULTS: At the latest follow-up examination, the average flexion arc was 24 degrees (range, 0 degrees to 75 degrees ) to 131 degrees (range, 100 degrees to 150 degrees ) and the Mayo elbow performance score averaged 93 of a possible 100 points. Heterotopic ossification was present to some extent in seven elbows, with radiographic abutment noted in two. Thirty-two (65%) of the forty-nine elbows had neither a complication nor any further surgery from the time of the index arthroplasty to the most recent follow-up evaluation. Fourteen elbows (29%) had a single complication, and most of them did not require further surgery. Ten additional procedures, including five revision arthroplasties, were required in nine elbows; five were related to soft tissue and five were related to the implant or bone. CONCLUSIONS: Complex distal humeral fractures should be assessed primarily for the reliability with which they can be reconstructed with osteosynthesis. When osteosynthesis is not considered to be feasible, especially in patients who are physiologically older and place lower demands on the joint, total elbow arthroplasty can be considered. This retrospective review supports a recommendation for total elbow arthroplasty for the treatment of an acute distal humeral fracture when strict inclusion criteria are observed.     

Ellenbogentotalendoprothetik bei traumatischen und posttraumatischen Knochendefekten

Total elbow arthroplasty is currently most commonly carried out due to acute trauma or post-traumatic conditions. Bone defects are often present and must be considered in the (pre-)operative workup. The use of semi-constrained prostheses with a systematic cementing technique through a triceps-on approach leads to satisfying clinical results, however, the outcome is worse when compared with rheumatic patients.Primary total elbow arthroplasty for complex distal humerus fractures in the elderly patient or secondary implantation following failed conservative treatment or osteosynthesis represent possible indications for (post?)traumatic joint replacement. The condyles do not have to be reconstructed and the humerus can be shortened by 2–3?cm without sacrificing the functionality of the extensor apparatus. In the case of post-traumatic joint destruction and pronounced chronic instability following complex fractures of the proximal forearm – especially following terrible triad or Monteggia-like injuries – total elbow arthroplasty can be considered as a treatment option. The extensor apparatus must be reconstructed, and the implantation of the prosthesis must thus be combined with plate osteosynthesis of the ulna – if necessary. Chronic deformity should only be corrected as much as needed in order to avoid early aseptic loosening due to increased shearing forces and polyethylene wear.Massive bone loss is problematic and can be compensated with allografts or tumor prostheses. The results of these salvage procedures are less predictable, and complication rates increase significantly.     

A special technique of compound osteosynthesis of the distal humerus. A case report about extramedullary blast crisis in chronic myelogenous leukemia

In a rare case of chronic myelogenous leukemia, extramedullary myeloblast crisis occurred in the distal humerus after 27 years. The pathological fracture was stabilized with double-plate compound osteosynthesis. The small distal fragment was stabilized without restriction of the range of movement of the elbow joint. The osteosynthesis remained stable until the patient died.     

Fractures of the distal humerus: role of elbow replacement

Rigid osteosynthesis and early motion is the well-accepted norm to treat distal humerus fractures. This article addresses the role of elbow replacement related to fractures of the distal humerus, including indications, technique, and results. For severe posttraumatic osteoarthrosis, total elbow replacement using the semiconstrained Coonrad-Morrey prosthesis has proven to be a suitable and reliable option for older patients.     

Extensor mechanism-sparing paratricipital posterior approach to the distal humerus

Adequate exposure of the articular surface of the distal humerus and elbow joint is required for operative stabilization of bicolumnar distal humerus fractures. The transolecranon approach, which provides complete posterior visualization and access to the distal humerus, is commonly used. Nevertheless, an olecranon osteotomy and other extensor mechanism-disrupting approaches have risks and possible complications. Alternative exposures have been described primarily for total elbow arthroplasty, but these involve extensive and potentially devascularizing dissections. In extra-articular (OTA type A) and simple articular distal humeral fractures with simple or multifragmentary metaphyseal involvement (OTA type C1 and C2), extensile approaches may not be necessary. For these fracture patterns, an alternative exposure is the extensor mechanism-sparing paratricipital posterior approach to the distal humerus through a midline posterior incision. This approach avoids an osteotomy and mobilizes the triceps and anconeus muscle off the posterior humerus and the intermuscular septae and provides adequate exposure for open reduction and internal fixation.     

肘关节后侧肱三头肌-肘肌瓣入路治疗肱骨远端骨折

目的探讨自行设计的肱三头肌-肘肌瓣入路治疗肱骨远端骨折效果。方法采用自行设计的肱三头肌-肘肌瓣入路对57例C型(AO分类)肱骨远端骨折患者进行切开复位内固定治疗。结果患者均获得随访,时间5～26个月,57例骨折均获骨性愈合。按Jupiter肘关节功能评分:优41例,良12例,中3例,差1例(伤前存在肘关节畸形),优良率为92.3%。无切口皮肤坏死、深部感染、肱三头肌萎缩、骨化性肌炎、及骨不愈合发生。结论肱三头肌-肘肌瓣入路是治疗肱骨远端骨折的理想入路,可取得良好的肘关节和肱骨远端显露,内固定安放方便,术后可早期功能锻炼,临床效果好。     

全肘关节置换手术入路的选择与现状

全肘关节置换术最早主要用于治疗风湿性关节炎,但是随着近十几年来技术的进步,其适应证已扩大到创伤后不稳定、创伤性关节炎以及老年人新鲜肱骨远端骨折。但是其术后伤口感染、不愈合、尺神经损伤以及肱三头肌肌力下降等并发症一直是困扰临床骨科医师的问题。全肘关节置换术接受程度最为广泛的入路为Bryan-Morrey入路,近年保留肱三头肌鹰嘴附丽点的入路逐渐增多。本文回顾国内外全肘关节置换术相关的入路报道以及生物力学研究,对全肘关节置换手术入路的选择与现状做一综述。     

经尺骨鹰嘴截骨入路双钢板内固定治疗肱骨远端C型骨折

目的探讨经尺骨鹰嘴截骨入路双钢板内固定治疗肱骨远端C型骨折的疗效。方法采用经尺骨鹰嘴截骨入路双钢板内固定治疗19例肱骨远端C型骨折患者。分析术后并发症、骨折愈合时间及肘关节功能等指标。结果19例均获得随访,时间13~24个月。骨折均愈合,时间12~23周。未发生手术并发症。末次随访时,按照Mayo肘关节功能评分标准评定疗效:优11例,良6例,可1例,差1例,优良率17/19;肘关节屈伸活动度为80°~140°(109.8°±12.2°),前臂旋转活动度为110°~180°(140.6°±22.6°)。结论经尺骨鹰嘴截骨入路双钢板内固定治疗肱骨远端C型骨折显露充分,复位及内固定操作方便,双钢板固定牢固,术后并发症少,肘关节功能恢复好。     

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.     

切开复位内固定治疗成人陈旧性肱骨小头-滑车冠状面骨折

目的 探讨切开复位内固定治疗成人陈旧性肱骨小头-滑车冠状面骨折的临床疗效.方法 回顾分析自2011-02-2018-12采用切开复位内固定治疗的9例成人陈旧性肱骨小头-滑车冠状面骨折,观察骨折愈合时间、术后并发症情况以及末次随访时肘关节屈伸活动度.结果 9例均顺利完成手术并获得随访,随访时间12～48个月,平均14.5...     

Management of distal humeral fractures in the elderly

Although relatively uncommon, fractures of the distal humerus in the elderly patient population are significant injuries of which optimal management is a subject of debate in orthopaedic literature. The combination of complex anatomy, poor bone quality and extensive comminution often seen with these fractures makes successful treatment difficult. Currently, most surgeons support surgical fixation of distal humeral fractures with the belief that restoration of the patient's native elbow joint provides the best opportunity for a good functional outcome. Others have proposed the use of total elbow arthroplasty as a primary treatment method for geriatric distal humeral fractures based on the difficulties associated with ORIF and the relatively low demands of this patient population. To date, there have been no prospective randomised trials comparing these two treatment alternatives, and a comparison of available outcome data shows good functional outcome for both forms of fracture management. With the aging of the population and an associated increase in the incidence of distal humeral fractures, the debate over the optimal treatment regime will undoubtedly continue.