CURRENT CONCEPTS IN ADULTS UPPER EXTREMITY FRACTURES

21452Ugur_TiftikciCurrent_Consept_in_adults.kapak

OPERATIVE MANAGEMENT STRATEGIES FOR DISTAL HUMERAL FRACTURES

Zafer Güneş

Ankara Training and Research Hospital, Department of Orthopedics and Traumatology, Ankara, Türkiye

Güneş Z. Operative Management Strategies for Distal Humeral Fractures. In: Tiftikçi U, Erdoğan E, Ergün C, Güneş Z, editors. Current Concepts in Adults Upper Extremity Fractures. 1st ed. Ankara: Türkiye Klinikleri; 2025. p.127-135.

ABSTRACT

The elbow joint exhibits a hinge joint structure. Between the lateral and medial columns, there exists a strong bony triangular structure formed by the olecranon and coronoid fossa. The capitellum can be found on the front surface of the lateral column, while the posterior surface is non-articular. The trochlea, shaped like a pulley, is situated centrally. The anatomy of the distal humerus is complex, and therefore, the treatment of its fractures involves significant challenges. In most cases, surgical treatment is required, and they often fall into the category of complicated fractures due to fragmentation of the joint surface or difficult exposure. It exhibits a bimodal distribution. It occurs as a result of high impact trauma in young adult males, while in older women, it is associated with low-energy trauma due to osteoporotic bone.

In the elderly, complex fractures can occur from simple falls, while in younger individuals, they are more often due to high impact trauma, and polytrauma is common. Additionally, in cases of open fractures, vascular injuries may accompany them; therefore, vascular pathologies that may be associated with open fractures must always be considered. In cases of intense pain surrounding the elbow and forearm, along with an inability to tolerate active or passive finger and wrist extension, compartment syndrome must be considered. The radiological assessment should incorporate anteroposterior, lateral, oblique, and traction X-rays. Additionally, X-rays of the shoulder and wrist on the same extremity should certainly be obtained. The most widely utilized classification is the Orthopaedic Trauma Association (AO/OTA) system. According to the AO classification, the distal humerus is made up of lateral and medial columns, with the trochlea functioning as the primary supporting structure.

In the presence of any non-displaced fractures or advanced organ failure that may prevent anesthesia, as well as additional medical issues such as paralysis in the affected extremity, non-surgical treatments may be considered. The treatment of distal humerus fractures predominantly involves surgical approaches, and there are numerous surgical approaches available. Every approach, except for that addressing coronal shear fractures, begins with an incision on the posterior skin. Olecranon osteotomy, triceps splitting, triceps sparing, triceps lifting, and triceps reflecting (elevating, Bryan-Morrey) approaches are the most commonly used posterior approaches. Olecranon osteotomy, also known as Chevron Osteotomy, is a traditional surgical approach to the elbow and it provides excellent visibility of the elbow joint, enabling effective reduction and fixation of the fractured pieces. Dual plating is superior in terms of stability compared to screw or wire fixation and is the most commonly used method in surgery. However, the question of whether parallel or orthogonal plating is better with dual plating remains unclear. Arthroplasty is typically considered a viable treatment option for elderly patients with low demands who present with poor bone quality and significant fragmentation of the distal humerus.

Keywords: Distal humerus; Elbow fracture; Posterior approach; AO/OTA classification; Dual plating

Referanslar

  1. Robinson CM, et al. Adult distal humeral metaphyseal fractures: epidemiology and results of treatment. J Orthop Trauma. 2003;17(1):38-47. [Crossref]  [PubMed]
  2. Galano GJ, Ahmad CS, Levine WN. Current treatment strategies for bicolumnar distal humerus fractures. J Am Acad Orthop Surg. 2010;18(1):20-30. [Crossref]  [PubMed]
  3. Nauth A, McKee MD, Ristevski B, Hall J, Schemitsch EH. Distal humeral fractures in adults. J Bone Joint Surg Am. 2011;93(7):686-700. [Crossref]  [PubMed]
  4. Amis AA, Miller JH. The mechanisms of elbow fractures: an investigation using impact tests in vitro. Injury. 1995;26(3):163-168. [Crossref]  [PubMed]
  5. John H, Rosso R, Neff U, Bodoky A, Regazzoni P, Harder F. Operative treatment of distal humeral fractures in the elderly. J Bone Joint Surg Br. 1994;76(5):793-796. [Crossref]  [PubMed]
  6. Gofton WT, Macdermid JC, Patterson SD, Faber KJ, King GJ. Functional outcome of AO type C distal humeral fractures. J Hand Surg Am. 2003;28(2):294-308. [Crossref]  [PubMed]
  7. Gupta R, Khanchandani P. Intercondylar fractures of the distal humerus in adults: a critical analysis of 55 cases. Injury. 2002;33(6):511-515. [Crossref]  [PubMed]
  8. Aitken SA, Jenkins PJ, Rymaszewski L. Revisiting the 'bag of bones': functional outcome after the conservative management of a fracture of the distal humerus. Bone Joint J. 2015;97-B(8):1132-1138. [Crossref]  [PubMed]
  9. Jupiter J, Morrey B. The elbow and its disorders. Fractures of the distal humerus in the adult. 2000:328-366.
  10. Ring D, Jupiter JB. Complex fractures of the distal humerus and their complications. J Shoulder Elbow Surg. 1999;8(1):85-97. [Crossref]  [PubMed]
  11. Jupiter JB, Neff U, Holzach P, Allgöwer M. Intercondylar fractures of the humerus. An operative approach. J Bone Joint Surg Am. 1985;67(2):226-239. [Crossref]  [PubMed]
  12. Hewins EA, Gofton WT, Dubberly J, MacDermid JC, Faber KJ, King GJ. Plate fixation of olecranon osteotomies. J Orthop Trauma. 2007;21(1):58-62. [Crossref]  [PubMed]
  13. Gofton WT, Macdermid JC, Patterson SD, Faber KJ, King GJ. Functional outcome of AO type C distal humeral frac Güneş Operative Management Strategies for Distal Humeral Fractures tures. J Hand Surg Am. 2003;28(2):294-308. [Crossref]  [PubMed]
  14. Coles CP, Barei DP, Nork SE, Taitsman LA, Hanel DP, Bradford Henley M. The olecranon osteotomy: a six-year experience in the treatment of intraarticular fractures of the distal humerus. J Orthop Trauma. 2006;20(3):164-171. [Crossref]  [PubMed]
  15. Ali AM, Hassanin EY, El-Ganainy AE, Abd-Elmola T. Management of intercondylar fractures of the humerus using the extensor mechanism-sparing paratricipital posterior approach. Acta Orthop Belg. 2008;74(6):747-752.
  16. Ziran BH, Smith WR, Balk ML, Manning CM, Agudelo JF. A true triceps-splitting approach for treatment of distal humerus fractures: a preliminary report. J Trauma. 2005;58(1):70-75. [Crossref]  [PubMed]
  17. Bryan RS, Morrey BF. Extensive posterior exposure of the elbow. A triceps-sparing approach. Clin Orthop Relat Res. 1982;(166):188-192. [Crossref]
  18. Wilkinson JM, Stanley D. Posterior surgical approaches to the elbow: a comparative anatomic study. J Shoulder Elbow Surg. 2001;10(4):380-382. [Crossref]  [PubMed]
  19. Shin SJ, Sohn HS, Do NH. A clinical comparison of two different double plating methods for intraarticular distal humerus fractures. J Shoulder Elbow Surg. 2010;19(1):2-9. [Crossref]  [PubMed]
  20. Lee SK, Kim KJ, Park KH, Choy WS. A comparison between orthogonal and parallel plating methods for distal humerus fractures: a prospective randomized trial. Eur J Orthop Surg Traumatol. 2014;24(7):1123-1131. [Crossref]  [PubMed]
  21. Schoch B, Wong J, Abboud J, Lazarus M, Getz C, Ramsey M. Results of Total Elbow Arthroplasty in Patients Less Than 50 Years Old. J Hand Surg Am. 2017;42(10):797-802. [Crossref]  [PubMed]
  22. McKee MD, Wilson TL, Winston L, Schemitsch EH, Richards RR. Functional outcome following surgical treatment of intra-articular distal humeral fractures through a posterior approach. J Bone Joint Surg Am. 2000;82(12):1701-1707. [Crossref]  [PubMed]
  23. Theivendran K, Duggan PJ, Deshmukh SC. Surgical treatment of complex distal humeral fractures: functional outcome after internal fixation using precontoured anatomic plates. J Shoulder Elbow Surg. 2010;19(4):524-532. [Crossref]  [PubMed]
  24. Foruria AM, Lawrence TM, Augustin S, Morrey BF, Sanchez-Sotelo J. Heterotopic ossification after surgery for distal humeral fractures. Bone Joint J. 2014;96-B(12):16811687. [Crossref]  [PubMed]
  25. Shearin JW, Chapman TR, Miller A, Ilyas AM. Ulnar Nerve Management with Distal Humerus Fracture Fixation: A Meta-Analysis. Hand Clin. 2018;34(1):97-103. [Crossref]  [PubMed]