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Distal humerus fractures: a review of current therapy concepts

  • Elbow Soft Tissue Surgery (L Oh, Section Editor)
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Abstract

Fractures of the distal humerus in the adult comprise approximately one third of all humeral fractures. Successful management of distal humerus fractures depends on correct reduction of the fracture, reconstruction of the articular surface if needed, stability and rigidity of the fixation, and appropriate rehabilitation. In this review, we evaluated the available literature and highlighted current therapy concepts. We assessed the evolution of internal fixation and elbow arthroplasty focusing on the established surgical approaches against the background of a growing incidence of distal humeral fractures in an aging patient population. Therefore evaluating the aspect and influence of age-dependent comorbidities like osteoporosis on successful treatment.

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References

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  1. Rose SH, Melton LJ, Morrey BF, Ilstrup DM, Riggs BL. Epidemiologic features of humeral fractures. Clin Orthop Relat Res. 1982;168:24–30.

    PubMed  Google Scholar 

  2. Anglen J. Distal humerus fractures. J Am Acad Orthop Surg. 2005;13(5):291–7.

    Article  PubMed  Google Scholar 

  3. Jupiter JB, Mehne DK. Fractures of the distal humerus. Orthopedics. 1992;15(7):825–33.

    CAS  PubMed  Google Scholar 

  4. Robinson CM, Hill RMF, Jacobs N, Dall G, Court-Brown CM. Adult distal humeral metaphyseal fractures: epidemiology and results of treatment. J Orthop Trauma. 2003;17(1):38–47.

    Article  PubMed  Google Scholar 

  5. Palvanen M, Niemi S, Parkkari J, Kannus P. Osteoporotic fractures of the distal humerus in elderly women. Ann Intern Med. 2003;139(3):W61.

    Article  Google Scholar 

  6. Palvanen M, Kannus P, Niemi S, Parkkari J. Secular trends in the osteoporotic fractures of the distal humerus in elderly women. Eur J Epidemiol. 1998;14(2):159–64.

    Article  CAS  PubMed  Google Scholar 

  7. Kannus P, Niemi S, Parkkari J, Palvanen M, Heinonen A, Sievänen H, et al. Why is the age-standardized incidence of low-trauma fractures rising in many elderly populations? J Bone Miner Res. 2002;17(8):1363–7.

    Article  PubMed  Google Scholar 

  8. Egol K, Koval K, Zuckerman J. Handbook of fractures. Philadelphia: Lippincott Williams & Wilkins; 2010.

    Google Scholar 

  9. Bucholz R. Rockwood and Green’s fractures in adults. Philadelphia: Lippincott Williams & Wilkins; 2006.

    Google Scholar 

  10. Bryan R. Fractures about the elbow in adults. Instr Course Lect. 1981;30:200–23.

    CAS  PubMed  Google Scholar 

  11. Lecestre P, Dupont J. “[Severe fractures of the lower end of the humerus in adults (author’s transl)]. Rev Chir Orthop Reparatrice Appar Mot. 1978;65(1):11–23.

    Google Scholar 

  12. Dubberley JH, Faber KJ, Macdermid JC, Patterson SD, King GJW. Outcome after open reduction and internal fixation of capitellar and trochlear fractures. J Bone Joint Surg Am. 2006;88(1):46–54.

    Article  PubMed  Google Scholar 

  13. Muller M, Nazarian J, Koch P. Fracture and dislocation compendium. Orthopaedic Trauma Association Committee for Coding and Classification. J Orthop Trauma. 1996;10.

  14. Wang Y, Zhuo Q, Tang P, Yang W. Cochrane database of systematic reviews, vol. 1. Chichester: Wiley; 1996.

    Google Scholar 

  15. Hausman M, Panozzo A. Treatment of distal humerus fractures in the elderly. Clin Orthop Relat Res. 2004;425:55–63.

    Article  PubMed  Google Scholar 

  16. Gupta R, Khanchandani P. Intercondylar fractures of the distal humerus in adults: a critical analysis of 55 cases. Injury. 2002;33(6):511–5.

    Article  PubMed  Google Scholar 

  17. Holdsworth BJ, Mossad MM. Fractures of the adult distal humerus. Elbow function after internal fixation. J Bone Joint Surg (Br). 1990;72(3):362–5.

    CAS  Google Scholar 

  18. Jupiter JB, Neff U, Holzach P, Allgöwer M. Intercondylar fractures of the humerus. An operative approach. J Bone Joint Surg Am. 1985;67(2):226–39.

    CAS  PubMed  Google Scholar 

  19. Jupiter J, Morre B. Fractures of the distal humerus in the adult, The Elbow and its disorder. 2nd ed. Philadelphia: WB; 1993.

    Google Scholar 

  20. Ring D, Jupiter JB. Complex fractures of the distal humerus and their complications. J Shoulder Elbow Surg. 1999;8(1):85–97.

    Article  CAS  PubMed  Google Scholar 

  21. Ring D, Gulotta L, Chin K, Jupiter JB. Olecranon osteotomy for exposure of fractures and nonunions of the distal humerus. J Orthop Trauma. 2004;18(7):446–9.

    Article  PubMed  Google Scholar 

  22. Elmadag M, Erdil M, Bilsel K. The olecranon osteotomy provides better outcome than the triceps-lifting approach for the treatment of distal humerus fractures. Eur J Orthop Surg Traumatol. 2014;24(1):43–50.

    Article  PubMed  Google Scholar 

  23. Zhang C, Zhong B. Comparing approaches to expose type C fractures of the distal humerus for ORIF in elderly patients : six years clinical experience with both the triceps-sparing approach and olecranon osteotomy. Arch Orthop Trauma Surg. 2014;134(6):803–11. The approach is a decisive part of the surgical treatment of distal humerus fractures. Olecranon osteotomy determines the gold standard but has substantial disadvantages. The triceps sparing approach is a frequently used and established alternative. Zhang et al. show a six year follow up and comparison of these two approaches demonstrating advantages of the sparing approach in AO type C1 and C2 fractures.

    Article  PubMed  Google Scholar 

  24. Bryan RS, Morrey BF. Extensive posterior exposure of the elbow. A triceps-sparing approach. Clin Orthop Relat Res. 1982;166:188–92.

    PubMed  Google Scholar 

  25. Schildhauer TA, Nork SE, Mills WJ, Henley MB. Extensor mechanism-sparing paratricipital posterior approach to the distal humerus. J Orthop Trauma. 2003;17(5):374–8.

    Article  PubMed  Google Scholar 

  26. Campbell WC. Arthroplasty of the elbow. Ann Surg. 1922;76(5):615–23.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. 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):70–5.

    Article  PubMed  Google Scholar 

  28. Deakin DE, Deshmukh SC. The triceps-flexor carpi ulnaris (TRIFCU) approach to the elbow. Ann R Coll Surg Engl. 2010;92(3):240–2.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  29. “Distal humerus - Indication - B1 - AO Surgery Reference.” [Online]. Available: https://www2.aofoundation.org

  30. “Distal humerus - Approach - Medial approach - B2.1 - AO Surgery Reference.” [Online]. Available: https://www2.aofoundation.org

  31. Archdeacon MT. Combined olecranon osteotomy and posterior triceps splitting approach for complex fractures of the distal humerus. J Orthop Trauma. 2003;17(5):368–73.

    Article  PubMed  Google Scholar 

  32. Cheung EV, Steinmann SP. Surgical approaches to the elbow. J Am Acad Orthop Surg. 2009;17(5):325–33.

    Article  PubMed  Google Scholar 

  33. Huang TL, Chiu FY, Chuang TY, Chen TH. The results of open reduction and internal fixation in elderly patients with severe fractures of the distal humerus: a critical analysis of the results. J Trauma. 2005;58(1):62–9.

    Article  PubMed  Google Scholar 

  34. Ek ETH, Goldwasser M, Bonomo AL. Functional outcome of complex intercondylar fractures of the distal humerus treated through a triceps-sparing approach. J Shoulder Elbow Surg. 2008;17(3):441–6.

    Article  PubMed  Google Scholar 

  35. Erpelding JM, Mailander A, High R, Mormino MA, Fehringer EV. Outcomes following distal humeral fracture fixation with an extensor mechanism-on approach. J Bone Joint Surg Am. 2012;94(6):548–53.

    Article  PubMed  Google Scholar 

  36. Aktekin CN, Toprak A, Ozturk AM, Altay M, Ozkurt B, Tabak AY. Open reduction via posterior triceps sparing approach in comparison with closed treatment of posteromedial displaced Gartland type III supracondylar humerus fractures. J Pediatr Orthop B. 2008;17(4):171–8.

    Article  PubMed  Google Scholar 

  37. Chen G, Liao Q, Luo W, Li K, Zhao Y, Zhong D. Triceps-sparing versus olecranon osteotomy for ORIF: analysis of 67 cases of intercondylar fractures of the distal humerus. Injury. 2011;42(4):366–70.

    Article  PubMed  Google Scholar 

  38. Iselin LD, Mett T, Babst R, Jakob M, Rikli D. The triceps reflecting approach (Bryan-Morrey) for distal humerus fracture osteosynthesis. BMC Musculoskelet Disord. 2014;15:406. doi:10.1186/1471-2474-15-406.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Fernández-Valencia JA, Muñoz-Mahamud E, Ballesteros JR, Prat S. Treatment of AO Type C fractures of the distal part of the humerus through the Bryan-Morrey triceps-sparing approach. ISRN Orthop. 2013;2013:525326.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Mejía Silva D, Morales de los Santos R, Ciénega Ramos MA, González Pérez C. [Functional results of two different surgical approaches in patients with distal humerus fractures type C (AO)]. Acta ortopédica Mex. 2008;22(1):26–30.

    Google Scholar 

  41. 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-A(12):1701–7.

    CAS  PubMed  Google Scholar 

  42. Korner J, Diederichs G, Arzdorf M, Lill H, Josten C, Schneider E, et al. A biomechanical evaluation of methods of distal humerus fracture fixation using locking compression plates versus conventional reconstruction plates. J Orthop Trauma. 2004;18(5):286–93.

    Article  PubMed  Google Scholar 

  43. Kinzl L, Fleischmann W. The treatment of distal upper arm fractures. Unfallchirurg. 1991;94(9):455–60.

    CAS  PubMed  Google Scholar 

  44. Pajarinen J, Björkenheim JM. Operative treatment of type C intercondylar fractures of the distal humerus: results after a mean follow-up of 2 years in a series of 18 patients. J Shoulder Elb Surg. 2002;11(1):48–52.

    Article  Google Scholar 

  45. 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. 2013;24(7):1123–31. Double palting being the gold standard for treatment of distal humerus fractures, this prospective study including 72 patients is focusing on the key controversy of this surgical technique, questioning whether parallel or perpendicular plating could be superior concerning clinical and radiological outcome. Lee et al. demonstrated in this study that no significant difference between the two groups could be found in short and long term follow up.

    Article  PubMed  Google Scholar 

  46. Jacobson SR, Glisson RR, Urbaniak JR. Comparison of distal humerus fracture fixation: a biomechanical study. J South Orthop Assoc. 1997;6(4):241–9.

    CAS  PubMed  Google Scholar 

  47. Self J, Viegas SF, Buford WL, Patterson RM. A comparison of double-plate fixation methods for complex distal humerus fractures. J Shoulder Elbow Surg. 2005;4(1 Pt 1):10–6.

    Google Scholar 

  48. Scolaro JA, Hsu JE, Svach DJ, Mehta S. Plate selection for fixation of extra-articular distal humerus fractures: A biomechanical comparison of three different implants. Injury. 2014;45(12):2040–4.

    Article  PubMed  Google Scholar 

  49. Helfet DL, Hotchkiss RN. Internal fixation of the distal humerus: a biomechanical comparison of methods. J Orthop Trauma. 1990;4(3):260–4.

    Article  CAS  PubMed  Google Scholar 

  50. Schemitsch EH, Tencer AF, Henley MB. Biomechanical evaluation of methods of internal fixation of the distal humerus. J Orthop Trauma. 1994;8(6):468–75.

    Article  CAS  PubMed  Google Scholar 

  51. Bogataj M, Kosel F, Norris R, Krkovic M, Brojan M. Biomechanical study of different plate configurations for distal humerus osteosynthesis. Med Biol Eng Comput. 2015;53(5):381–92.

    Article  CAS  PubMed  Google Scholar 

  52. Shin SJ, Sohn HS, Do NH. A clinical comparison of two different double plating methods for intraarticular distal humerus fractures. J Shoulder Elb Surg. 2010;19(1):2–9.

    Article  Google Scholar 

  53. Schuster I, Korner J, Arzdorf M, Schwieger K, Diederichs G, Linke B. Mechanical comparison in cadaver specimens of three different 90-degree double-plate osteosyntheses for simulated C2-type distal humerus fractures with varying bone densities. J Orthop Trauma. 2008;22(2):113–20.

    Article  PubMed  Google Scholar 

  54. Korner J, Lill H, Müller LP, Rommens PM, Schneider E, Linke B. The LCP-concept in the operative treatment of distal humerus fractures—biological, biomechanical and surgical aspects. Injury. 2003;34 Suppl 2:B20–30.

    Article  PubMed  Google Scholar 

  55. Ellwein A, Lill H, Voigt C, Wirtz P, Jensen G, Katthagen JC. Arthroplasty compared to internal fixation by locking plate osteosynthesis in comminuted fractures of the distal humerus. Int Orthop. 2015;39(4):747–54.

    Article  PubMed  Google Scholar 

  56. Mansat P, Bonnevialle N, Rongières M, Bonnevialle P. The role of total elbow arthroplasty in traumatology. Orthop Traumatol Surg Res. 2014;100(6):S293–8.

    Article  CAS  PubMed  Google Scholar 

  57. Frankle MA, Herscovici D, DiPasquale TG, Vasey MB, Sanders RW. A comparison of open reduction and internal fixation and primary total elbow arthroplasty in the treatment of intraarticular distal humerus fractures in women older than age 65. J Orthop Trauma. 2003;17(7):473–80.

    Article  PubMed  Google Scholar 

  58. Smith GCS, Hughes JS. Unreconstructable acute distal humeral fractures and their sequelae treated with distal humeral hemiarthroplasty: a two-year to eleven-year follow-up. J Shoulder Elb Surg. 2013;22(12):1710–23.

    Article  Google Scholar 

  59. Burkhart KJ, Nijs S, Mattyasovszky SG, Wouters R, Gruszka D, Nowak TE, et al. Distal humerus hemiarthroplasty of the elbow for comminuted distal humeral fractures in the elderly patient. J Trauma Inj Infect Crit Care. 2011;71(3):635–42.

    Article  Google Scholar 

  60. Jupiter JB, Goodman LJ. The management of complex distal humerus nonunion in the elderly by elbow capsulectomy, triple plating, and ulnar nerve neurolysis. J Shoulder Elbow Surg. 1992;1(1):37–46.

    Article  CAS  PubMed  Google Scholar 

  61. Obert L, Ferrier M, Jacquot A, Mansat P, Sirveaux F, Clavert P, et al. Distal humerus fractures in patients over 65: complications. Orthop Traumatol Surg Res. 2013;99(8):909–13.

    Article  CAS  PubMed  Google Scholar 

  62. Pereles TR, Koval KJ, Gallagher M, Rosen H. Open reduction and internal fixation of the distal humerus: functional outcome in the elderly. J Trauma. 1997;43(4):578–84.

    Article  CAS  PubMed  Google Scholar 

  63. Kaiser T, Brunner A, Hohendorff B, Ulmar B, Babst R. Treatment of supra- and intra-articular fractures of the distal humerus with the LCP Distal Humerus Plate: a 2-year follow-up. J Shoulder Elbow Surg. 2011;20(2):206–12.

    Article  PubMed  Google Scholar 

  64. Helfet DL, Hotchkiss RN. Internal fixation of the distal humerus: a biomechanical comparison of methods. J Orthop Trauma. 1990;4(3):260–4.

    Article  CAS  PubMed  Google Scholar 

  65. Hoppe S, Uhlmann M, Schwyn R, Suhm N, Benneker LM. Intraoperative mechanical measurement of bone quality with the DensiProbe. J Clin Densitom. 2015;18(1):109–16.

    Article  PubMed  Google Scholar 

  66. Egol KA, Tsai P, Vazques O, Tejwani NC. Comparison of functional outcomes of total elbow arthroplasty vs plate fixation for distal humerus fractures in osteoporotic elbows. Am J Orthop (Belle Mead NJ). 2011;40(2):67–71.

    Google Scholar 

  67. Prasad N, Dent C. Outcome of total elbow replacement for distal humeral fractures in the elderly: a comparison of primary surgery and surgery after failed internal fixation or conservative treatment. J Bone Joint Surg (Br). 2008;90(3):343–8.

    Article  CAS  Google Scholar 

  68. Cobb TK, Morrey BF. Total elbow arthroplasty as primary treatment for distal humeral fractures in elderly patients. J Bone Joint Surg Am. 1997;79(6):826–32.

    CAS  PubMed  Google Scholar 

  69. Chalidis B, Dimitriou C, Papadopoulos P, Petsatodis G, Giannoudis PV. Total elbow arthroplasty for the treatment of insufficient distal humeral fractures. A retrospective clinical study and review of the literature. Injury. 2009;40(6):582–90.

    Article  CAS  PubMed  Google Scholar 

  70. McKee MD, Veillette CJH, Hall JA, Schemitsch EH, Wild LM, McCormack R, et al. A multicenter, prospective, randomized, controlled trial of open reduction--internal fixation versus total elbow arthroplasty for displaced intra-articular distal humeral fractures in elderly patients. J Shoulder Elbow Surg. 2009;18(1):3–12.

    Article  PubMed  Google Scholar 

  71. 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):1132–8.

    Article  CAS  PubMed  Google Scholar 

  72. Maraka S, Kennel KA. Bisphosphonates for the prevention and treatment of osteoporosis. BMJ. 2015;351:h3783.

    Article  PubMed  Google Scholar 

  73. Ng AJH, Yue B, Joseph S, Richardson M. Delayed/non-union of upper limb fractures with bisphosphonates: systematic review and recommendations. ANZ J Surg. 2014;84(4):218–24.

    Article  PubMed  Google Scholar 

  74. Watson JT, Nicolaou DA. Orthobiologics in the Augmentation of Osteoporotic Fractures. Curr Osteoporos Rep. 2014;13(1):22–9. Due to demografic changes the treatment of fractures in osteopenic bone is one of the major tasks today and in the future. J.T. Watson et al. report about current osteoporosis therapy and effects on bone density and fracture treatment. Further it reports about orthobiologic augmentation, its advanteges and disadvanteges and outlines the need of development of combined therapy strategies and the aims of onward research.

    Article  Google Scholar 

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    1. Department of Traumatology and Orthopedic Surgery, University Hospital Basel, Spitalstr. 21, 4031, Basel, Switzerland

      Steinitz Amir, Sailer Jannis & Rikli Daniel

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    1. Steinitz Amir
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    Correspondence to Steinitz Amir.

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    Amir Steinitz and Jannis Sailer declare that they have no conflict of interest. Daniel Rikli reports grants from the AO Foundation and personal fees from DePuySynthes. He is also a consultant for DePuySynthes.

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    Steinitz Amir and Sailer Jannis contributed equally to this work.

    This article is part of the Topical Collection on Elbow Soft Tissue Surgery

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    Amir, S., Jannis, S. & Daniel, R. Distal humerus fractures: a review of current therapy concepts. Curr Rev Musculoskelet Med 9, 199–206 (2016). https://doi.org/10.1007/s12178-016-9341-z

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