Management of distal humerus fractures

European Journal of Orthopaedic Surgery & Traumatology - Distal humeral fractures represent approximately 2% of fractures in adults and are often treated operatively to restore stable humeral...     

Management of distal humerus fractures in adults

From January 1992 to May 1997, 46 distal humeral fractures were treated by open reduction and internal fixation. Among these, 30 were intra-articular, which were managed by the transolecranal approach, routine ulnar nerve transposition, 3.5-mm dual-plate fixation and early active mobilisation. We encountered 2% non-union, 2.2% fixation failure, 11.1% nerve complications, 28.2% overall heterotopic ossification and 11.1% poor range-of-motion rates.     

Management of distal humerus fractures with minifragment fixation

Minifragment implants provide several advantages for the stabilization of distal humerus fractures. Compared with small fragment implants, minifragment implants may provide enhanced fracture fixation because a greater number of screws can be placed into the distal fragments. In addition, minifragment plates are easier to contour and less prominent. We describe the surgical technique of minifragment fixation.     

Treatment of distal humerus fractures

The elbow is a complex joint and is vital in positioning the hand in space. We believe that open reduction internal fixation offers the best chance for return to function following intra-articular fractures of the distal humerus. We advocate the following principles for the effective treatment of these injuries: identification and protection of the ulnar nerve followed by transposition, broad exposure of the fracture utilizing an olecranon osteotomy, anatomic restoration of the articular surface with preservation of all osteochondral fragments, rigid fixation of both columns using pre-contoured plates and screws, and the institution of early range of motion post-operatively.     

Transcondylar fractures of the distal humerus

We classify transcondylar fractures of the distal humerus into four groups: undisplaced; simple displaced; T-type; and fracture dislocations (Posada's fracture). Our treatment of these fractures is based upon this classification. Undisplaced fractures are treated with immobilization. Displaced fractures are reduced and stabilized with internal fixation. Stabilization of these fractures is difficult because the distal fragments are small and a large portion of their surface is covered with articular cartilage. Transposition of the ulnar nerve allows us to use the cubital tunnel as a point for fixation. We found in our series of 11 patients that undisplaced fractures have the best prognosis. However, all of our patients lost elbow motion, particularly extension. Radiographic signs of post-traumatic arthritis were more pronounced in displaced fractures.     

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.     

临床病例讨论——肱骨远端骨折的手术治疗

病历摘要 患者,女,42岁,交通伤致右肘、腕关节肿胀伴畸形3 h就诊.查体:一般情况好,右肘、腕关节轻度肿胀、畸形,无开放性伤口.右手感觉、运动正常,患肢桡动脉搏动正常,末梢皮温、充盈正常.     

临床病例讨论——肱骨远端骨折的手术治疗

病历摘要 患者,女,42岁,交通伤致右肘、腕关节肿胀伴畸形3 h就诊.查体:一般情况好,右肘、腕关节轻度肿胀、畸形,无开放性伤口.右手感觉、运动正常,患肢桡动脉搏动正常,末梢皮温、充盈正常.     

临床病例讨论——肱骨远端骨折的手术治疗

病历摘要 患者,女,42岁,交通伤致右肘、腕关节肿胀伴畸形3 h就诊.查体:一般情况好,右肘、腕关节轻度肿胀、畸形,无开放性伤口.右手感觉、运动正常,患肢桡动脉搏动正常,末梢皮温、充盈正常.     

Comminuted intra-articular fractures of the distal humerus

Summary Seventy-five intra-articular fractures of the distal humerus were treated from 1980 to 1991 in our hospital by open reduction and internal fixation with AO small and mini-fragment instrumentation. Müller's classification into C1, C2 and C3 types was used and the results graded by Burri and Lob's criteria after a minimum follow up of 1.6 years to a maximum of 12 years. Results were satisfactory in 77%, fair in 16% and poor in 7%. The correct indications are important together with anatomical reduction and postoperative physiotherapy. These results are encouraging compared with others previously reported.

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Résumé La réduction anatomique suivie de fixation stable et rigide des fractures de l'extrémité inférieure de l'humérus réalisée de façon atraumatique pour préserver la vascularisation des parties molles réclame une grande habileté technique et permet d'obtenir un coude fonctionnel, stable, indolore et mobile. Cette étude présente les résultats obtenus dans 75 cas, traités de 1988 à 1991 par réduction à ciel ouvert et fixation par le mini-matériel AO. Ces cas ont été classés d'après Muller en types C1, C2 et C3 et les résultats ont été évalués selon les critères de Burri et Lob avec un recul de 1,6 an au moins et de 12 ans au plus (jusqu'en Janvier 1993). Les résultats sont bons chez 58 patients (77%), passables chez 12 (16%) et mauvais chez 5 (7%). Nos résultats sont favorables si on les compare aux séries précédemment publiées. Ils sont excellents lorsque les indications, la reconstruction chirurgicale et la rééducation ont été parfaitement exécutées.

     

Treatment for type C fractures of the distal humerus with the LCP distal humerus system

Background

Although the locking compression plate-distal humerus system (LCP-DHS) is a biomechanically proven implant for fractures of the distal humerus, few have reported its clinical results.

Methods

Thirteen cases of type C intercondylar fractures of the distal humerus according to AO classification that were treated with the LCP-DHS followed for a minimum of 1?year were enrolled for this study. The mean age at the time of operation was 46.8?years (range, 26–80?years), and the mean follow-up period was 25.1?months (range, 13–39?months). The timing of bone union, implant failure, and loosening around screws were assessed on simple radiographs. For clinical evaluations, we analyzed range of motion, Mayo Elbow Performance Score (MEPS), Disabilities of the Arm, Shoulder and Hand (DASH) score, Visual Analogue Scale (VAS), and patient satisfaction.

Results

Bone union was achieved radiologically in all cases. The mean timing of bone union was 8.5?weeks (range, 5–18?weeks) after operation. At the last follow-up, the mean range of motion was 16 degrees (range, 0–40 degrees) in flexion and 131 degrees (range, 130–150 degrees) in extension deficit. The MEPS was 87.3 points (range, 45–100 points); the DASH score, 17.6 points (range, 0–86.7 points); and the VAS, 1.5 (range, 0–4). Complications included screw loosening and delayed union in 1 case, limited range of motion that led to adhesiolysis in 1 case, and transient ulnar nerve palsy in 1 case.

Conclusions

The internal fixation using the LCP-DHS for type C fractures of the distal humerus was stable, enabling early postoperative mobilization and good clinical results.     

Treatment of distal humerus fractures in the elderly

Geriatric patients with osteopenic bone present unique challenges in the treatment of fractures of the distal humerus, and require different strategies from the traditional treatment philosophies. Fracture union, rather than motion, is the first priority, because motion can be restored reliably by subsequent contracture release, if necessary, as long as the fracture heals. Modifications in the surgical technique, combined with newer implants incorporating distal, transcondylar screws into the plate to improve distal fixation, may improve outcomes. The use of massive, tricortical autogenous bone grafts to replace very comminuted segments of the medial and lateral columns also is helpful. Finally, modification of olecranon osteotomy fixation will minimize healing and hardware problems at this site. For fractures that are judged intraoperatively not to be stable enough to commence early motion, the implementation of a short period of immobilization followed by early soft tissue release will avoid exposing the patient to the risk of nonunion, and result in a more predictable functional outcome.     

Complex coronal shear fractures of the distal humerus

This is a retrospective review of nine coronal shear fractures of the distal humerus. Two were isolated fractures and seven were associated with other peri-articular elbow injuries, termed "complex" coronal shear fractures. All cases underwent immediate open reduction and internal fixation (ORIF) and were then followed for an average of 14 months (range: 6.5 to 23 months) with outcomes evaluated using the Mayo Elbow Performance Scoring system. There was a significant difference found between injuries limited to the radiocapitellar (RC) joint (isolated coronal shear fractures, or those associated only with radial head fractures) and the complex injuries extending beyond the RC joint. Scores for the RC injuries were 100 and other complex injuries had an average score of 69 (range: 35 to 95; p = .025). All complications were limited to the group with the complex injuries, including stiffness, nonunion, pain, and gross instability. Much of the current thinking in treatment of this fracture was upheld in this study; computed tomography aids in diagnosis, ORIF is a necessity, and there is a need for anatomic reduction. When a coronal shear fracture is complicated by a concomitant injury outside the RC joint, both the surgeon's and patient's expectation need to be adjusted accordingly.     

Management of the smashed distal humerus

The purpose of this article is to present a principle-based approach to treating the smashed distal humerus. These injuries are challenging to even the most experienced surgeons. The four goals, in order of priority, are soft tissue healing without infection, restoration of diaphyseal bone stock, union between the distal fragments and the shaft, and a stable and mobile articulation.     

肱骨远端C型骨折手术治疗的研究进展

肱骨远端C型骨折是一少见而又复杂的关节内损伤,非手术治疗难以准确复位骨折和重建关节面,切开复位内固定则是目前最理想的治疗选择。尺骨鹰嘴截骨入路可以提供充足的术野显露,是最常用的手术入路,但存在截骨处不愈合、内固定失败等并发症。为避免牺牲鹰嘴的完整性,肱三头肌内外侧入路、肱三头肌翻转入路、肱三头肌-肘肌瓣翻转入路、肱三头肌劈开入路及肱三头肌腱膜舌形瓣入路等则应用到骨折的显露中,但不同入路的局限性,使得入路选择在术野暴露与伸肘功能受影响之间存在一定矛盾性。随着"双柱"理论的推广,双钢板固定C型骨折比单钢板具有显著力学优势。在体外生物力学试验中,即便平行双钢板较垂直双钢板更有优势,但目前尚不清楚两者在临床运用中是否存在差异。对于关节面无法重建的C型骨折,肘关节置换术可能是最终的选择,由于技术水平限制,其长期疗效还有待观察。