Lateral epicondyle osteotomy approach for coronal shear fractures of the distal humerus:Report of three cases and review of the literature

BACKGROUND Coronal shear fractures of the distal humerus are rare injuries and are technically challenging to manage.Open reduction and internal fixation(ORIF)has become the preferred treatment because it provides anatomical reduction,stable internal fixation,and early motion,but the optimal surgical approach remains controversial.CASE SUMMARY We report three cases of coronal shear fractures of the distal humerus treated successfully by ORIF via a novel surgical approach,in which lateral epicondyle osteotomy was performed based on the extended lateral approach.We named the novel surgical approach the lateral epicondyle osteotomy approach.All patients underwent surgical treatment and were discharged successfully.All patients had excellent functional results according to the Mayo elbow performance score.The average range of motion was 118°in flexion/extension and 172°in pronation/supination.Only case 2 had a complication,which was implant prolapse.CONCLUSION We demonstrated that the lateral epicondyle osteotomy approach in ORIF is effective and safe for coronal shear fractures of the distal humerus.

Olecranon osteotomy vs.triceps-sparing for open reduction and internal fixation in treatment of distal humerus intercondylar fracture:a systematic review and meta-analysis

Background:The open reduction and internal fixation(ORIF)was a standard treatment approach for fracture at distal humerus intercondylar,whereas the optimal way before ORIF remains inconclusive.We,therefore,performed a systematic review and meta-analysis to assess the efficacy and safety of olecranon osteotomy vs.triceps-sparing approach for patients with distal humerus intercondylar fracture.Methods:The electronic searches were systematically performed in PubMed,EmBase,Cochrane library,and Chinese National Knowledge Infrastructure from initial inception till December 2019.The primary endpoint was the incidence of excellent/good elbow function,and the secondary endpoints included Mayo elbow performance score,duration of operation,blood loss,and complications.Results:Nine studies involving a total of 637 patients were selected for meta-analysis.There were no significant differences between olecranon osteotomy and triceps-sparing approach for the incidence of excellent/good elbow function(odds ratio[OR]:1.37;95%confidence interval[CI]:0.69-2.75;P=0.371),Mayo elbow performance score(weight mean difference[WMD]:0.17;95%CI:-2.56 to 2.89;P=0.904),duration of operation(WMD:4.04;95%CI:-28.60 to 36.69;P=0.808),blood loss(WMD:33.61;95%CI:-18.35 to 85.58;P=0.205),and complications(OR:1.93;95%CI:0.49-7.60;P=0.349).Sensitivity analyses found olecranon osteotomy might be associated with higher incidence of excellent/good elbow function,longer duration of operation,greater blood loss,and higher incidence of complications as compared with triceps-sparing approach.Conclusions:This study found olecranon osteotomy did not yield additional benefit on the incidence of excellent/good elbow function,while the duration of operation,blood loss,and complications in patients treated with olecranon osteotomy might be inferior than triceps-sparing approach.

Bilateral triceps tendon approach is flexible and efficient in the treatment of type C distal humerus fractures

Purpose:The purpose of this study was to assess and compare elbow range of motion,triceps extension strength and functional results of type C(AO/OTA)distal humerus fractures treated with bilateral triceps tendon(BTT)approach and olecranon osteotomy(00).At the same time,we are also trying to know whether BTT approach can provide sufficient vision for comminuted intra-articular fractures of the distal humerus,and whether it is convenient to convert to the treatment to total elbow arthroplasty(TEA)or 00.Methods:Patients treated with 00 and BTT approaches for type C distal humerus fractures between July 2014 and December 2017 were retrospectively reviewed.Inclusion criteria include:(1)patients'age were more than 18 years old,(2)follow-up was no less than 6 months,and(3)patients were diagnosed with type C fractures(based on the AO/OTA classification).Exclusion criteria include:(1)open fractures(Gustillo type 2 or type 3),(2)treated by other approaches,and(3)presented with combined injuries of ipsilateral upper extremities,such as ulnar nerve.Elbow range of motion and triceps extension strength testing were completely valuated,when the fractures had healed.Assessment of functional results using the Mayo elbow performance score and complications were conducted in final follow-up.The data were compared using the two tailed Student's t-test.All data were presented as mean±standard deviation.Results:Eighty-six patients of type C distal humerus fractures,treated by 00 and BTT approach were retrospectively reviewed between July 2014 and December 2017.Fifty-five distal humerus fractures(23 males and 32 females,mean age 52.7 years)treated by BTT approach or 00 were included in this study.There were 10 fractures of type Cl,16 type C2 and 29 type C3 according to the AO/OTA classification.Patients were divided into two surgical approach groups chosen by the operators:BTT group(28 patients)and 00 group(27 patients).And the mean follow-up time of all patients was 15.6 months(range,6-36 months).Three cases in BTT group were converted to TEA,and one converted to 00.Only one case in BTT group presented poor articular reduction with a step more than 2 mm.There were not significantly different in functional outcomes according to the Mayo elbow performance score,operation time and extension flexion motion are values between BTT group and 00 group(p>0.05).Complications and reoperation rate were also similar in the two groups.Triceps manual muscle testing were no significant difference in the two groups,even subdivided in elder patients(aged>60 years old).Conclusion:BTT is a safe approach to achieve similar functional result comparing with 00.BTT were not suitable for every case with severe comminuted pattern,but it avoids the potential complications related to 00,and has no complications concerning with triceps tendon.It is convenient for open reduction internal fixation and flexible to be converted to 00,as well as available to be converted to TEA in elder patients.

Elbow dislocation and articular fracture of the distal humerus

Objective To describe dislocation of the elbow with articular fracture of the distal humerus,a type of elbow fracture-dislocation about which little has been written.Methods Four patients with a dislocation of the elbow and fracture of the distal humerus were identified.Three had dislocation and complex intraarticular fracture of the capitellum,trochlea,and lateral epicondyle.Results Two patients(one treated with a second operation to address avascular necrosis of the capitellum)achieved a functional arc of elbow motion and one patient was lost after removal of the implants 3 months after fracture with documented healing.The fourth patient had a complex open fracture dislocation involving the entire articular surface.An attempt to salvage the articular surface resulted in deep infection.Extensive heterotopic bone led to arthrodesis of the elbow.Conclusions Dislocations of the elbow with articular fracture of the humerus are uncommon.Most injuries involve the capitellum,lateral trochlea,and lateral epicondyle.Open reduction and internal fixation of the distal humerus fracture can restore stability without repairing the medial collateral ligament.

Evaluation of Surgical Treatment of Distal Humeral Fractures in Adults

Introduction: Fractures of the distal end of the humerus are becoming increasingly frequent in young subjects because of the increase in road traffic accidents, and in elderly subjects because of osteoporosis related to aging populations. Materials and Methods: It was a prospective, monocentric study from January 2018 to December 2020 involving 14 patients who received and were treated surgically for distal humeral fractures and followed up. Results: We collected 14 patients, including 11 men (78.57%) and 3 women (21.43%), with a sex ratio of 3.7. The mean age was 36.41 years. The circumstances of onset were dominated by road traffic accidents, with 12 cases (85.71%). The dominant side was right-handed, with 11 cases (78.57%). Standard elbow radiography revealed 8 cases of type A fractures (57.14%), 4 cases of type B and 2 cases of type C fractures of the AO. We performed Lecestre plate osteosynthesis in 12 patients and external fixator in 2 others, using the trans-olecranial and transtricipital approaches. Elbow stiffness was the most frequent complication, with 6 cases (42.86%). After six months’ follow-up, our results were excellent and good in 78.57% of cases (MEPS). Conclusion: Surgical treatment with posterior approaches enabled us to achieve restitution of the articular surfaces, solid restraint and early mobilization of the elbow with satisfactory functional results.

Percutaneous fixation of neonatal humeral physeal fracture: A case report and review of the literature

BACKGROUND Neonatal distal humeral physeal fractures are rare and difficult to diagnose.Thus,missed diagnoses and delayed healing are possible.Few studies have reported surgical treatment,because a callus may develop at the fracture site 5 d after the fracture,resulting in difficult reduction,and reduction of the limb may cause further physeal injury.Other surgical challenges include the provision of adequate anesthesia and complexity of the operation.However,without appropriate reduction and fixation,a varus elbow deformity may develop.Manual reduction and percutaneous pin fixation are ideal treatment options.CASE SUMMARY A 4-day-old neonate with left elbow pain accompanied by limited movement for 4 d was admitted,and diagnosed with delayed physeal fracture of the distal humerus based on physical examination,ultrasonography,and magnetic resonance imaging.The patient was treated by manual reduction combined with percutaneous pin fixation under arthrography.Postoperatively,the reduction was successful.The upper limbs could have been lifted and the fingers could have been moved freely on the second day after the operation.CONCLUSION The techniques of manual reduction and percutaneous pin fixation,to treat neonatal distal humeral physeal fractures,are safe and reliable.

Comparative study of perpendicular versus parallel double plating methods for type C distal humeral fractures

Background Double plate osteosynthesis is the standard treatment for intra-articular fractures of the distal humerus.However,there is still controversy concerning dual plate positions in terms of providing optimal stability.The purpose of this retrospective study was to compare the clinical outcomes in patients with type C intra-articular distal humeral fractures using perpendicular and parallel plating methods.Methods Between March 2008 and June 2011,a total of 45 patients with type C distal humerus fractures were treated using two different dual plating methods.Of them,24 patients were treated by perpendicular plating （group Ⅰ） and 21 patients were treated by parallel plating （group Ⅱ）.The surgical time,blood loss,and union time were compared between the two groups.The fiexion-extension arc,the total range of flexion and extension at the end of follow-up were compared between the two groups.The Mayo Elbow Performance Score （MEPS） was used to determine the elbow functional results.Results All patients were followed up.The mean duration of follow-up was 16 months （range 12-25 months） in group Ⅰ and 15.5 months in group Ⅱ （range 12-25 months）.There were no significant differences in the surgical time,blood loss,and the bone union time between the two groups.In group Ⅰ,the mean elbow flexion-extension arc was 101° and the mean MEPS was 85 points.The rate of excellent and good results was 87.5%.In group Ⅱ,the mean flexion-extension arc was 100° and the mean MEPS was 86.1 points.The rate of excellent and good results was 90.5%.There were no significant differences in the MEPS,flexion-extension arc,and the total range of flexion and extension between the two groups.Conclusions Perpendicular and parallel plate configurations with the appropriate surgical techniques can provide anatomical reconstruction and stable fixation of type C intra-articular distal humeral fractures and allow early mobilization of the elbow after an operation.The occurrence of post-operative elbow stiffness can be reduced and good outcomes can be obtained.