Challenges and Solutions in Management of Distal Humerus Fractures

Abstract

Background: Management of distal humerus fractures remains a challenge for trauma surgeons and advancements in treatment options continue to be made to achieve the best results for patients presenting with these complex fractures. Our aim in this article is to provide the surgeons with a detailed review of current literature to help them make an evidence based decision when faced with managing such complex injuries in their surgical practice.

Methods: This is a comprehensive review of the current literature that details various aspects of distal distal humerus fractures such as classification, surgical anatomy, surgical approaches, treatment options, choices of devices, outcomes and complications.

Results: With the advancements in techniques and equipment, there has been improvement in patients' outcomes following surgical management of these fractures and a large proportion of these patients are able to achieve pre-injury level of function. The contoured locking plates have enabled successful fixation of many of these fractures that were previously considered unfixable. For those not amenable to surgical fixation, total elbow arthroplasty and elbow hemiarthroplasty are considered as good alternatives.

Conclusion: Since the days where the 'bag of bones' technique was the preferred method of treating these complex injuries, techniques and outcomes have advanced greatly. However, they still present a significant technical challenge and need meticulous technique and experience to achieve optimal results.

Keywords: Distal humerus plates; Elbow; Elbow approaches; Humerus; Humerus fractures; Total elbow replacement.

Fig. (1)

AO OTA classification of distal humerus fractures (From Journal of orthopaedics trauma. Marsh et al. 2007).

Fig. (2)

The Jupiter and Mehne classification of distal humerus fractures (From Jupiter and Mehne. Orthopaedics, 1992).

Fig. (3)

Sketches of medial (a) lateral and (b) blood supply to the distal humerus. SUC, superior ulnar collateral artery; IUC, inferior ulnar collateral artery; PUR, posterior ulnar recurrent artery; IR, interosseous recurrent artery; MC, middle collateral artery; RC, radial collateral artery; RR, radial recurrent artery. From Yamaguchi et al. [7].

Fig. (4)

Olecranon osteotomy approach. A: Olecranon osteotomy is marked in shape of shallow V or chevron. B: Thin-blade oscillating saw is used to start osteotomy. C: Osteotomized proximal olecranon fragment is elevated proximally; ulnar nerve is isolated, mobilized, and protected (From Canale & Beaty: Campbell's Operative Orthopaedics, 11^th edition, Mosby 2007).

Fig. (5)

Triceps-splitting approach to distal humerus. A: Triceps split. B: Split extended to transcutaneous border of ulna. (From Frankle MA: Triceps split technique for total elbow arthroplasty, Tech Shoulder Elbow Surg 3:23, 2002).

Fig. (6)

Paratricipital approach (From Advanced Surgical Approaches to the Humerus. Depuy Synthes Institute).

Fig. (7)

Plate application though Triceps reflecting approach to distal humerus (From Canale & Beaty: Campbell's Operative Orthopaedics, 11^th edition, Mosby (2007)).

Fig. (8)

Triceps-reflecting anconeus pedicle approach. A: Modified Kocher lateral approach is combined with medial triceps-reflecting approach. B: Access to distal humerus is similar to that provided by olecranon osteotomy. (From Sanchez-Sotelo J, Torchia ME, O'Driscoll SW: Principle-based internal fixation of distal humerus fractures, Tech Hand Upper Extremity Surg 5:179, 2001).