Notwendige Veränderungen des berufsgenossenschaftlichen Heilverfahrens

Total elbow replacement is well established for elbow destruction in rheumatoid arthritis. But its use for primary treatment of elbow fractures is less frequent than such treatment for fractures of the shoulder and hip joint. Posttraumatic conditions such as pseudarthrosis of the distal humerus and posttraumatic arthritis are rare indications for total elbow arthroplasty. This article gives an overview of the present literature regarding the indications and results for primary total elbow arthroplasty for fractures of the distal humerus. We also look at studies dealing with the role and limitations of total elbow replacement in posttraumatic arthritis, pseudarthrosis of the distal humerus, and stiff elbow.     

Prosthetic replacement for distal humerus fractures

Primary total elbow arthroplasty is a treatment option for elderly patients with osteopenic bone, increased comminution, and articular fragmentation. Recently, there has been a renewed interest in distal humerus hemiarthroplasty for the treatment of distal humerus fractures, including coronal shear fractures of the capitellum and trochlea. This article focuses on the evaluation and management of distal humerus fractures with prosthetic replacement.     

肱骨髁间粉碎性骨折的治疗

[目的]探讨肱骨髁间粉碎性骨折的术式选择及疗效。[方法]2001年2月-2005年12月治疗肱骨髁间粉碎性骨折患者21例，按AO分型：C1型5例，C2型9例，C3型7例。17例患者行切开复位钢板内固定术，4例行全肘关节置换术。内固定组采用尺骨鹰嘴截骨入路，肱骨小头和肱骨滑车复位后用松质骨螺钉或空心螺钉固定，肱骨干和肱骨远端之间采用AO双钢板或“Y”钢板固定，术后早期功能锻炼；肘关节置换组采用半限制型肘关节假体、骨水泥固定，术后4-7d开始功能锻炼。[结果]内固定组17例患者中14例获12-44个月随访，关节置换组4例全部获14，36个月随访，按Cassebaum肘关节功能评分，内固定组优g4例，良：6例，优良率71．4％，关节置换组优：2例，良：2例，优良率100％。[结论]肱骨髁间粉碎性骨折采用AO技术，经尺骨鹰嘴截骨入路切开复位，双重建钢板或“Y”钢板内固定，配合早期功能锻炼，大多数患者都能获得良好的疗效。对肱骨远端严重毁损，骨质疏松明显，年龄在50岁以上的患者，可选择全肘关节置换手术，近期疗效满意。     

Results of total elbow arthroplasty in the treatment of distal humerus fractures in elderly Asian patients

BACKGROUND: Distal humerus fractures in elderly patients are difficult to treat as these fractures are often complicated by varying degrees of comminution intra-articular involvement and osteoporosis. We retrospectively reviewed the results of primary total elbow arthroplasty in the treatment of distal humerus fractures in seven patients followed for a minimum of 1 year. METHODS: Between July 2000 and June 2002, seven patients with distal humerus fractures were treated electively with total elbow arthroplasty using the semiconstrained Coonrad-Moorey elbow replacement prostheses. The Mayo Elbow Performance Score was used to assess the outcomes. RESULTS: The mean age of our patients was 72.9 years. The mean duration of postoperative hospitalization stay was 7.6 days. The average length of follow up was 24.9 months. Six of these patients had no pain, and one patient had mild pain. The mean arc of flexion was 88.6 degrees. Six elbows had excellent results, while 1 elbow had good result. The mean Mayo score was 94.3 points. One elbow developed blisters postoperatively but resolved with dressings and antibiotics. CONCLUSIONS: Our review suggests that total elbow arthroplasty can give good to excellent short term results when used in the treatment of distal humerus fractures in elderly Asian patients.     

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。     

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.     

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.     

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.     

Total Elbow Replacement as Primary Treatment for Complex Fractures of the Distal Osteopenic Humerus

Background: The use of hip and shoulder arthroplasty in elderly patients for grossly displaced intraarticular fractures is becoming more and more accepted. Total elbow replacement (TER) has not been considered an option for the treatment of extensively comminuted fractures of the distal humerus because surgeons feel the outcome is generally not predictable after TER. Evaluation of TER: On the basis of a MEDLINE literature search of this issue and the documented results based on the improvement of implant designs, operative technique and patient selection, TER has a definite role in the treatment of some fractures of the 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.     

Fractures of the distal humerus in elderly patients treated with a ring fixator

The aim of distal humerus fracture treatment is articular surface reduction and stable fixation for early mobilisation and rehabilitation. This is usually performed by open reduction and internal fixation with plates. In the elderly osteoporotic patient this treatment is difficult to achieve due to fixation failure in fragile bone. We present our experience with treatment by closed reduction and external fixation with a non-bridging ring fixator in distal humerus fractures in elderly patients. There were ten females, aged 70–89 (average 78.4). Fracture types (AO/ASIF) included three supracondylar fractures (type A) and seven intercondylar fractures (type C). All patients were treated by closed reduction and external fixation with a non-bridging ring fixator of the distal humerus and immediate postoperative mobilisation of the elbow. External fixation was removed on an average of 72 days (range 62–90). All fractures united. Average time to union was 56 days. Average range of movement at six months was 22° extension lag (range 15°–30°) and 115° flexion (range 110°–120°). Complications included one patient with transient radial palsy and one patient with a superficial decubitus ulcer on the chest wall from the hardware. Minimally invasive treatment by closed reduction and external fixation with a ring fixator is effective for treatment of fractures of the distal humerus in elderly patients with osteoporotic bone. This treatment enables immediate mobilisation of the elbow, and allows return to function. It should be considered an alternative to open reduction and internal fixation or total elbow replacement.     

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.     

Linked total elbow arthroplasty as treatment of distal humerus nonunions in patients older than 70 years

Treatment of distal humerus nonunions may be challenging, especially in the elderly patient. Total elbow replacement has been proposed as an option in selected patients, but a high index of complications has been reported. We present the results of a linked elbow replacement in six patients older than 70 years with a symptomatic nonunion of the distal humerus. At a mean follow-up of 40 months, average range of motion was from 15 degrees to 125 degrees of flexion-extension. Only one patient had moderate pain in the elbow, but all six were satisfied with the results of the operation. The arthroplasty allowed all patients to do basic tasks of daily living activities. Our results are encouraging, and show that linked elbow replacement is a good option in elderly patients with symptomatic nonunions of the distal humerus. Appropriate selection of ideal candidates for this procedure is a key factor in reducing the risk of complications.     

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.     

Posterolateral subluxation exposure of the elbow for injuries involving the lateral column

The posterolateral subluxation exposure of the elbow is a useful surgical technique for addressing complex radial head or capitellar fractures. It can be modified to allow for exposure of the distal humerus or elbow in more complex cases including those resulting in the terrible triad injury. In this approach, dissection to the radiocapitellar joint via a posterior incision provides great exposure and allows for reduction and internal fixation or placement of a radial head prosthesis. The authors in this video presentation demonstrate the posterolateral approach for radial head fractures and radial head replacement along with some technical caveats.     

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。     

铰链式外固定支架辅助内固定治疗陈旧性肱骨远端B型骨折

目的 探讨采用铰链式肘关节外固定支架辅助内固定治疗陈旧性肱骨远端B型骨折的疗效.方法 2004年1月至2007年4月收治11例陈旧性肱骨远端B犁骨折患者,受伤至手术时间1.5～6.0个月(平均3.1个月),采用铰链式肘关节外固定支架辅助切开复位内固定进行治疗.根据Mavo肘关节功能评分标准对其疗效进行评定.结果 11例患者术后获10～18个月(平均12.5个月)随访.骨折临床愈合时间3.5～6.0个月,平均4.6个月.患者肘关节经功能锻炼后平均活动范围:伸直19.4°±6.5°,屈曲124.2°±11.3°;前臂旋前72.8°±5.4°,旋后67.6°±7.3°.按照Mayo肘关节功能评分标准:由术前(52.4±7.6)分上升至(85.7±9.3)分,差异有统计学意义(t=9.161,P=0.000);其中优5例,良4例,可2例.结论 采用切开复位内同定治疗陈旧性肱骨远端B型骨折,术后在铰链式外固定支架辅助下活动肘关节,早期进行功能锻炼,有利于肘关节功能的恢复,疗效满意.     

The use of pre-contoured plates in the treatment of C2–C3 fractures of the distal humerus: clinical experience

Open reduction and internal fixation is the treatment of choice in distal humerus fractures. The aims of the treatment are to obtain anatomic reconstruction and restoration of the elbow’s geometry followed by stable internal fixation that allows immediate rehabilitation. The plates are pre-contoured to fit the natural anatomy of the elbow and in the case of complex fractures they provide a guide for the anatomic restoration of the distal humerus. The two plates are placed parallel with the screws locked together by interdigitation creating a fixed angle in the distal fragments that provides stability to the entire distal humerus. Using this method we obtained good results according to the Mayo Elbow Performance Score (MEPS) and we are able to reduce the incidence of complications. Our experience shows also that it can be useful to obtain an anatomical reduction of distal humeral fractures using the pre-contoured plates in a parallel position recovering the anatomical antiversion of the articular surface.     

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.     

The pediatric vs. the adolescent elbow. Some insight into age-specific treatment

Almost 20 % of all long bone fractures in childhood and adolescents involve the elbow region. Physicians dealing with pediatric trauma cases on a regular basis must be familiar with the specific radiologic features of the elbow at every developmental stage. This includes the shape and the appearance of elbow ossification centers, and knowledge of age-specific injury patterns. In young children, lateral condyle and supracondylar fractures of the distal humerus are most common. Radial neck fractures, Monteggia’s lesion and olecranon fractures appear in every age during growth. Bicondylar fractures of the distal humerus, capitellar fractures and radial head fractures almost solely occur after the tenth year. Treatment options depend on fracture type, age and demands and vary from immobilization to closed reduction and open reduction including internal fixation with different types of materials. Special circumstances to influence the treatment regimen in every single injury entity are discussed. Additionally, the most common malformations and nontraumatic diseases of the elbow region are mentioned.