Comparison of outcomes after triceps split versus sparing surgery for extra-articular distal humerus fractures

Clinical Outcomes of Single Versus Double Plating in Distal-Third Humeral Fractures Caused by Arm Wrestling: A Retrospective Analysis

Background and Objectives: Arm wrestling is a simple and popular activity among young people that causes distal-third humeral fractures. However, injury to the young population may cause economic loss; therefore, they need to return to work as soon as possible. Accordingly, we aimed to compare radiological and functional outcomes of distal-third humeral fractures caused by arm wrestling treated with double and single plating. Materials and Methods: Thirty-four patients with distal-third humeral fractures caused by arm wrestling were treated between January 2015 and January 2021. They were separated into double- and single-plating groups and treated using a triceps-sparing approach. Regular follow-up was performed to evaluate elbow functionality, range of motion, bone union, and complications; the American Shoulder and Elbow Surgeons score was used for functional assessment. Results: Patients treated with single plating exhibited union rate, union time, and elbow range of motion similar to those of patients treated with double plating; however, they exhibited better pain and functional outcomes (American Shoulder and Elbow Surgeons score) at 2 weeks, 1 month, and 3 months postoperatively (84.50 ± 5.01 vs. 61.70 ± 12.53 at 2 weeks, 96.20 ± 2.63 vs. 84.25 ± 14.56 at 1 month, and 100.00 vs. 94.76 ± 9.71 at 3 months, p < 0.05). The two groups exhibited no significant differences after 1 year (100.00 vs. 98.54 ± 3.99, p < 0.13). The overall complication rate was significantly higher in patients treated with double plating than in those treated with single plating (18.75% vs. 5.56%). Radial nerve palsy was observed in patients in both groups. Conclusions: In patients with distal-third humeral fractures caused by arm wrestling, single plating provides a union rate and elbow range of motion similar to those of double plating, with significantly fewer complications and lower surgical time and blood loss with improved early functional outcomes.

Histologic Evaluation of the Triceps Brachii Tendon Insertion: Implications for Triceps-Sparing Surgery

PURPOSE

Triceps detachment and olecranon osteotomy are 2 techniques used to enhance exposure in elbow surgery. Both the techniques can potentially add considerable morbidity and lengthen the recovery after surgery. Triceps-sparing surgery can potentially mitigate those issues. The purpose of this study was to evaluate the triceps tendon insertion at a histologic level to help improve triceps-sparing surgical techniques used in elbow trauma and arthroplasty.

METHODS

Seventeen fresh-frozen cadaveric elbow specimens were collected. The olecranon and its soft tissue attachments were isolated. We performed gross measurements and sectioned the specimens for histologic evaluation in the saggital or coronal planes. The proximal-to-distal and medial-to-lateral dimensions of the tendon and the distance from the proximal tip of the olecranon to the proximal tendon insertion were measured microscopically on stained embedded sections.

RESULTS

The proximal-to-distal dimension of the triceps tendon insertion was less than previously reported, whereas the medial-to-lateral dimension was similar. The true distance from the tip of the olecranon to the proximal tendon insertion was greater than the previously reported distance obtained via gross measurement.

CONCLUSIONS

Gross measurement of the triceps tendon insertion overestimates and inaccurately represents the true insertional footprint. Gross measurement has been shown to demonstrate consistent disparity compared with histologic measurement. Histologic investigation provides a more accurate description.

CLINICAL RELEVANCE

The finding that the distance from the articular tip of the olecranon to the proximal tendon insertion is greater than previously reported may have clinical implications. A triceps split approach may allow more visualization and exposure of the posterior joint and, therefore, lessen the need for triceps detachment or olecranon osteotomy.

Humeral Shaft Fractures: A Literature Review on Current Treatment Methods

In this review, we aim to provide a concise yet comprehensive summation of the assessment and management of humeral shaft fractures. These are uncommon but prevalent enough that they are part of any trauma surgeon's scope of practice. They have historically been treated using non-operative methods, including braces and casts, supported by published excellent results in the rate of the bone union. However, recently published studies challenge these results and suggest the outcomes might be better with surgery, but the complications of an operation such as infection and nerve injury can not be overlooked. In summary, non-surgical treatment is still the gold standard in the treatment of these fractures, but the indications for surgical management are now clearer and include early signs of delayed union and patients who are unable to have a brace fitted or are uncompliant. It is likely that these new developments will start to change practice, and therefore the treatment of humeral shaft fractures should be a topic of interest of any clinician who deals with them.

Are Outcomes Comparable for Repair of AO/OTA Type 13C1 and Type 13C2 Distal Humeral Fractures Using the Paratricipital Approach?

Background

Studies have reported favorable outcomes using the paratricipital approach for fixation of distal humeral intra-articular fractures. However, literature evaluating the clinical results of the approach remains limited. The objective of this study was to compare clinical outcomes between type 13C2 and type 13C1 distal humeral fractures after open reduction and internal fixation performed using the same approach and same type of plate.

Methods

A total of 52 adults with type 13C1 or 13C2 distal humeral fractures were treated surgically at our institution during 2006 to 2018. We retrospectively analyzed data from 29 of these patients (19 with type 13C1 fractures and 10 with 13C2 fractures) who met the inclusion criteria. All subjects were followed for a minimum of 2 years postoperatively. Clinical and radiologic results were analyzed to determine differences in outcomes between the two types of fractures. Clinical results were evaluated using elbow range of motion (ROM), Mayo Elbow Performance Score (MEPS), and Quick Disabilities of the Arm, Shoulder and Hand (Q-DASH) score. Alignment, fracture union, and presence of posttraumatic arthritis were evaluated radiologically.

Results

The patients’ mean age was 51 years, and the mean duration of follow-up was 29 months. Mean ROM was 129.5° ± 21.5° in the type 13C1 group and 123.0° ± 20.6° in the 13C2 group (p = 0.20). Mean Q-DASH score was 12.6 ± 11.7 in the 13C1 group and 16.2 ± 19.8 in the 13C2 group (p = 0.60). Mean MEPS was 92.9 ± 8.5 in the 13C1 group and 85.0 ± 14.1 in the 13C2 group (p = 0.09). Carrying angle did not differ significantly between the 13C1 and 13C2 groups. No patient in either group exhibited nonunion or posttraumatic arthritis.

Conclusions

Although the paratricipital approach has the disadvantage of limited visualization of articular surfaces, there were no differences in surgical outcomes between type 13C1 and type 13C2 distal humeral fractures after fixation using this approach. Thus, surgeons may need to consider using the paratricipital approach for open reduction and internal fixation of 13C2 distal humeral fractures.

Triceps-Sparing Approach for Distal Humerus Fixation

The triceps-sparing approach to the posterior humerus affords broad exposure for fracture fixation with a minor risk of radial nerve palsy. By using a muscle-sparing interval, the approach facilitates reduction and fixation of humeral shaft and extra-articular distal humerus fractures without injury to the triceps. This video demonstrates the triceps-sparing approach used in the surgical treatment of a 23-year-old man with an extra-articular distal humerus fracture.

Surgical management for primary osteoarthritis of the elbow

The objective of this review is to summarize the surgical options for primary osteoarthritis of the elbow, reported clinical outcomes, and suggested indications in previous literatures. The surgical management of primary elbow arthritis has evolved because of an improved understanding of pathologic mechanisms and manifestations as well as the development of novel surgical techniques and devices. Osteocapsular arthroplasty (OCA), elbow debridement, distraction arthroplasty, and total elbow arthroplasty (TEA) have been employed for managing elbow osteoarthritis. Elbow debridement and OCA can be helpful in most cases of symptomatic elbow arthritis. TEA is usually recommended for end-stage arthritis in elderly patients after prosthetic implants have been in place for long periods or after complications. Distraction arthroplasty might find a place in the treatment of younger, active patients with end-stage arthritis.

Anatomic fit of precontoured extra-articular distal humeral locking plates: a cadaveric study

Background

Extra-articular distal humerus locking plates (EADHPs) are precontoured anatomical plates widely used to repair distal humeral extra-articular diaphyseal fractures. However, EADHPs frequently cause distal protrusion and resulting skin discomfort. The purpose of this study was to predict the occurrence of anatomic fit mismatch. We hypothesized that the smaller the humerus size, the greater the anatomic fit mismatch with EADHP.

Methods

Twenty humeri were analyzed in this study. Humeral length and distal humeral width were used as parameters of humeral size. Plate protrusion was measured between the EADHP distal tip and the distal humerus. We set the level of unacceptable EADHP anatomic fit mismatch as ≥10 mm plate protrusion.

Results

A significant negative linear correlation was also confirmed between humeral size and plate protrusion, with a coefficient of determination of 0.477 for humeral length and 0.814 for distal humeral width. The cutoff value of humeral length to avoid ≥10 mm plate protrusion was 293.6 mm (sensitivity, 88.9%; specificity, 81.8%) and for distal humeral width was 60.5 mm (sensitivity, 100%; specificity, 81.8%).

Conclusions

Anatomic fit mismatch in distal humeral fractures after EADHP fixation has a negative linear correlation with humeral length and distal humeral width. For patients with a distal humeral width <60.5 mm, ≥10 mm plate protrusion will occur when an EADHP is used, and an alternative implant or approach should be considered.

Anterolateral approach with two incisions versus posterior median approach in the treatment of middle- and distal-third humeral shaft fractures

Background

The surgical approaches remain controversial for the treatment of middle and distal-third humeral shaft (MDTHS) fractures. This study compared clinical effects of the anterolateral approach with two incisions (AATI) and the posterior median approach (PMA) in the treatment of MDTHS fractures.

Methods

A retrospective analysis was carried out. One hundred sixty-six patients with MDTHS fractures were selected from January 2015 to January 2017 in Xi’an Hong Hui Hospital. According to surgical approaches, patients were divided into AATI (86 cases) and PMA group (80 cases). All patients were treated with open reduction and plate fixation. Operation indexes were compared, including incision length, operation time, and bleeding. Bryan-Morrey score was used to evaluate elbow joint function. Complication incidence was compared, such as incision infection, iatrogenic radial nerve injury, and nonunion.

Results

The AATI group showed smaller incision length, less bleeding, lower iatrogenic radial nerve injury rate, and better elbow function than that of PMA group (P<0.05).

Conclusions

The middle and distal-third humeral shaft fractures can be successfully cured by both approaches. Compared with the posterior median approach, it has better clinical effects of the anterolateral approach with two incisions, which is worthy of clinical application and promotion.

Long dorsal "Y-shaped" plate for distal diaphyseal humeral fractures

BACKGROUND

Osteosynthesis of distal diaphyseal humeral fractures is challenging, especially if there is a metaphyseal extension of the fracture line with a butterfly third fragment or if the fracture is bifocal. These fractures put the radial nerve at risk at the time of the fracture and during surgery. We hypothesize that ORIF with a long dorsal Y-plate matching the dorsal aspects of the humeral diaphysis and of the two metaphyseal columns would provide a reliable method of fixation for distal diaphyseal humeral fractures even when there is a metaphyseal extension or bifocal component.

METHODS

Between 2015 and 2019, 17 distal diaphyseal humeral fractures in 17 consecutive patients (14 men, 3 women, mean age 38 years) were operated on with a long "Y-shaped" dorsal plate. There were two bifocal fractures and 11 diaphyso-metaphyseal fractures with butterfly fragments. All 17 patients could be retrospectively followed up clinically and radiographically at a mean follow-up of 25 months (min 4, max 40). Clinical charts included VAS pain, elbow range of motion, QuickDASH, MEPS and subjective elbow value.

RESULTS

Bone healing was observed in all cases. Five patients (29%) had a pre-operative radial nerve palsy. All pre-operative radial nerve palsies but one recovered spontaneously. One complete radial nerve palsy that was not present before the operation was observed after surgery. It recovered spontaneously in four months. One case of post-operative elbow stiffness required a revision. Only one case (5%) showing a complication directly related to the plate (secondary displacement) required revision. Mean post-operative elbow flexion was 134°. Extension deficit averaged 13°. Subjective elbow value, QuickDASH and MEPS averaged respectively 81%, 19 points and 92 points.

DISCUSSION

Currently available plates (long dorsal straight, short dorsal "Y-shaped", long lateral) may have limitations in terms of screw purchase or biomechanical efficiency when ORIF of distal diaphyseal humeral fractures is considered. A long dorsal "Y-shaped" plate is a new alternative which may be successfully used even in the most difficult cases.

CONCLUSION

Our study suggests that a long dorsal "Y-shaped" plate is suitable for distal diaphyseal humeral fractures especially when there is a metaphyseal bifocal or third fragment component.

Clinical outcome of AO/OTA type C fracture of the distal humerus using the expanded paratricipital approach and cadaveric comparison of the exposure of the paratricipital and expanded paratricipital approaches to the distal humerus

BACKGROUND

We investigated the overall clinical outcome of the expanded paratricipital approach in complex articular fractures of the distal humerus and the effect of lack of visualization in the surgical field. In addition, we performed a cadaveric study to investigate the expansion or limitation of articular access in the expanded paratricipital approach.

METHODS

Forty-one AO/OTA type 13C fracture cases treated using the expanded paratricipital approach at a single trauma center from 2013 to 2017 were enrolled in this study. We evaluated the overall clinical outcome and analyzed the effect of lack of visualization in the surgical field with the expanded paratricipital approach by comparing outcomes between 2 groups classified by the location of the main articular fracture (group 1, limited visualization; group 2, without limited visualization). The length of inaccessible and accessible articular segments were analyzed using 40 matched-pair elbows.

RESULTS

The average duration of follow-up was 15.1 months. All fractures (type C1 in 11 cases, type C2 in 21, and type C3 in 9) were radiologically healed at 3.2 months after surgery. No cases required additional surgery because of implant irritation. The average Mayo Elbow Performance Score was 90.5. The mean Disabilities of the Arm, Shoulder and Hand score was 18.5. Among the 41 cases, the limited visualization group (group 1, n = 21) had a longer surgical time and higher percentage of nonanatomic reduction than group 2. Although the expanded paratricipital approach allowed more articular exposure than the conventional approach, there was still a 20mm inaccessible articular segment (30% of transepicondylar width) in cadaveric dissection.

CONCLUSIONS

The expanded paratricipital approach can be used in type C1, type C2, and selective type C3 articular fractures of the distal humerus with favorable results. Relative to surgical times and achieving anatomic reduction, it is more successful in a fracture with a main articular fragment and with good visualization.

Iatrogenic Nerve Palsy Occurs With Anterior and Posterior Approaches for Humeral Shaft Fixation

OBJECTIVE

To determine if surgical approach impacts the rate of nerve palsy after plate fixation of humerus shaft fractures and whether or not iatrogenic nerve palsy recovers in similar ways to preoperative palsy.

DESIGN

Retrospective.

SETTING

Two trauma centers.

PATIENTS

Patients 18+ years of age with nonpathologic, extra-articular humerus shaft fractures (OTA/AO 12A/B/C and 13A2-3) treated with plate fixation.

INTERVENTION

Plate fixation of humerus shaft fractures, from 2008 to 2016.

MAIN OUTCOME MEASUREMENT

Rate of iatrogenic nerve palsy by a surgical approach and injury characteristics.

RESULTS

Two hundred sixty-one humeral shaft fractures were included. The rate of preoperative palsy was 19%. Radial nerve palsy (RNP) was present in 18%. Iatrogenic RNP occurred in 12.2% and iatrogenic ulnar palsy in 1.2%. Iatrogenic palsy occurred in 15.6% of middle and 15% of distal fractures, with fracture location significantly different in those developing RNP (P = 0.009). Iatrogenic RNP occurred in 7.1% of anterolateral, 11.7% of posterior triceps-splitting, and 17.9% of posterior triceps-sparing approaches (P = 0.11). Follow-up data were available for 139 patients at an average of 12 months. Preoperative RNP resolved less often than iatrogenic RNP, in 74% versus 95% (P = 0.06). Time to resolution was longer for preoperative RNP, at 5.5 versus 4.1 months (P = 0.91). Twenty-two percent with preoperative RNP underwent tendon transfer or wrist fusion, versus 0% after iatrogenic RNP (P = 0.006).

CONCLUSION

Iatrogenic RNP is not uncommon with humeral fracture fixation and occurs at similar rates in anterior and posterior approaches and with midshaft and distal fractures. Iatrogenic RNP had a high rate of recovery. Preoperative RNP more often requires surgery for unresolved palsy.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Radial Nerve Sensory Branch Anatomical Variant: A Case Report and Literature Review

CASE

Two patients sustained comminuted extra-articular distal humerus fractures. One patient was neurovascularly intact preoperatively. The other patient had a complete radial motor palsy with preserved sensation. Intraoperatively, both exhibited anatomic variants of the radial sensory nerve of the arm that pierced the triceps rather than branching from the distal third of the radial nerve proper, as is traditionally reported.

CONCLUSIONS

Although rare, variations in the radial nerve may exist about the distal humerus. Surgeons should be aware of these variations to avoid iatrogenic injury.

Paratricipital two window approach for complex intraarticular distal humerus fractures: A prospective analysis of 27 patients

BACKGROUND

To investigate the utility and complications of paratricipital 2 window approach for complex intra articular distal humerus fractures (AO/OTA type C).

METHODS

Between December 2012 and September 2016 , 27 patients (male-14, female-13) having mean age of 39 years (range, 22-62 years) with closed intra articular fracture (AO/OTA 13 type C) were surgically managed using paratricipital 2 window approach. Fractures were fixed as per AO principles. All patients were followed up for 21 months (range, 12-28 months) prospectively. Functional outcome was measured using Mayo Elbow Performance Score (MEPS) and complications were observed. Student t-test, Pearson co-relation coefficient and Kruskal Wallis test used for statistical evaluation.

RESULT

All cases unite by the end of 3 months. Mean flexion achieved was 120° and extension lag was 10°. Mean arc of motion was 111°. Mean pronation and supination was 70° and 77° respectively. MEPS and motion arc were weak negatively co- related with surgical delay and advancement in age. Post-operative transient ulnar nerve palsy and heterotrophic ossification (HO) was noted in 3.7% cases and infection occurred in 7.4% cases. Hardware prominence noted in 11.1% cases. Mean MEPS was 82. MEPS was excellent in 18.5%, good in 62.9%, fair in 11.1% and poor in 7.4% cases.

CONCLUSION

Paratricipital 2 window approach for these fractures had good functional outcome with fewer complications. We advocate paratricipital 2 window approach when dealing with these complex fractures particularly, in type C1 and type C2.

Outcome of Extra-Articular Distal Humerus Fractures Fixed by Single Column Extra-Articular Distal Humerus Locking Compression Plate Using Triceps Sparing Postero-Lateral Approach

Objective:

To determine the time to radiological union and final functional outcome of fixation of extra-articular distal humeral fractures with extra-artricular distal humerus locking plate.

Methods:

This prospective study was conducted from March 2014 to February 2018 and included extra-articular distal humeral fractures managed by operative fixation using extra-articular distal humerus locking plate. All the fractures were approached using lateral para-tricepetal approach of Gervin, and stabilized with extra-articular distal humerus locking plate with or without lag screws. Time to radiological union was assessed in the follow up and at the final follow up functional outcome was evaluated using Mayo Performance Elbow Score (MEPS). Complications and need for any additional procedures was also recorded.

Results:

A total of 20 patients with mean age of 36.5 years and an average follow up of 17 months were included. The mean time to radiological union was 17.4 weeks (12 to 36 weeks) which included one delayed union that required bone grafting. The mean flexion at elbow was 127o with only one patient having flexion extension arc movement of less than 100o at the final follow up. The average MEPS at final follow up was 94.7±8 with 19 patients having excellent and good results.

Conclusion:

Use of extra-articular distal humeral locking plate using lateral para-tricepetal approach in extra-articular distal humeral fractures allows stable fixation of the fracture to allow early return to function with minimal soft tissue dissection and excellent final functional results and minimum complications.

Plate fixation for management of humerus fractures

Proximal humerus, humeral shaft, and distal humerus fractures are all common adult fractures, and often occur in older patients. While the treatment of proximal humerus fractures remains controversial, certain fractures benefit from plate fixation such as fracture-dislocations and head-split fractures. When plate fixation is chosen, anatomic reduction and restoration of the medial calcar are important for successful results. Further research is required to minimize complications and determine the optimal surgical candidates for plate fixation. Humeral shaft fractures are generally treated non-operatively. However, certain shaft fractures warrant plate fixation, such as open fractures, those with associated forearm fractures, and those in poly-trauma patients. Choice of surgical approach and plate depends on the location and type of the fracture. The majority of intra-articular distal humerus fractures should be treated with plate fixation. Dual plating is generally accepted as the gold standard treatment, while the optimal surgical approach and plate configuration requires more research.

Best care paradigm to optimize functionality after extra-articular distal humeral fractures in the young patient

For younger patients with extra-articular distal humerus fractures closed management is plagued with high rates of malunion, suboptimal functional outcomes, extended immobilization with loss of early motion, a delay in return to work, and a general period of lost productivity. Surgical management offers an appealing alternative. Maintaining respect for the triceps musculature and minimizing iatrogenic injury to the radial nerve are primary concerns with operative treatment. Accordingly, use of a triceps-sparing approach and single column plating may be the optimal treatment paradigm in the young patient presenting with an extra-articular distal humerus fracture.

Modified anterolateral approach for internal fixation of Holstein-Lewis humeral shaft fractures

BACKGROUND

The authors modified the anterolateral approach for Holstein-Lewis humeral shaft fractures using a plating technique to achieve sufficient distal fixation by minimal splitting of the brachioradialis muscle to fix the most distal screws. The purpose of this retrospective study was to evaluate the efficacy of our modified anterolateral approach for Holstein-Lewis humeral fractures and document clinical and functional results.

MATERIALS AND METHODS

Between 2008 and 2014, 18 patients (mean age 35.4 years) with a Holstein-Lewis humeral shaft fracture who underwent open reduction and internal fixation with a plate and screws using the modified anterolateral approach and followed for a minimum of 12 months were included. Radiologic fracture configurations, number of distal cortical fixations, union rate, and time to union were analyzed. Clinical outcomes were evaluated using the Mayo elbow performance index system, range of elbow motion, and postoperative complications.

RESULTS

Mean fracture length was 60.2 ± 10.2 mm (range 49.2-77.2) and mean distal cortical length was 41.4 ± 7.04 mm (range 22.8-59.6). Distal fragments were fixed at a minimum of six cortical points (range 6-8) in all cases using the modified anterolateral approach. Average time to union was 10.5 weeks (range 8-12 weeks). All cases of radial nerve palsy completely recovered within 3 months. Mean elbow range of motion at final follow-up was 3.2 degrees of flexion contracture (range 0-10) and 135.4 degrees of further flexion (range 120-140), and the average Mayo elbow performance score was 96.3 points (range 90-100). There were no non-union or metal failures.

CONCLUSIONS

The results obtained indicate that the modified anterolateral approach is a safe and easy accessible method that provides sufficient distal osseous fixation for Holstein-Lewis humeral shaft fractures without serious complications. The modified anterolateral approach for plate osteosynthesis appears to be one of the most available options for the treatment of Holstein-Lewis humeral fractures.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Challenges and Solutions in Management of Distal Humerus Fractures

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.

Surgical treatment of extra-articular distal-third diaphyseal fractures of the humerus using a modified posterior approach and an extra-articular plate

PURPOSE

To evaluate the clinical and radiological outcomes of these fractures treated through a modified posterior approach with a distal humerus plate.

MATERIAL AND METHODS

Between 2013 and 2015 we performed a retrospective study of these fractures surgically treated in our centre.

INCLUSION CRITERIA

older than 18 years old, no pathological fractures, follow up 1 year at least. 23 patients underwent surgery, mean age 45 years old, with an average follow-up of 18 months. Patient characteristics, aetiology and type of fractures were recorded. The surgery was performed using Gerwin modified posterior approach with a posterolateral distal humerus plate. Clinical results were evaluated using Quick DASH, MEPS, VAS. Radiological results were also evaluated. Complications associated with treatment and radial nerve palsy incidence were recorded as well.

RESULTS

Type of fracture according AO/OTA: six 12-A, seven 12-B, ten 12-C. 23 patients progressed to union. After one year: QD 6.43, VAS 0.66, MEPS 88.88. No failure of internal fixation. Two superficial infections. 15 excellent results, 5 good, and 3 fair, with no poor results.

CONCLUSION

Surgical fixation of these fractures through a modified posterior approach with a posterolateral plate minimises iatrogenic nerve injury, provides better visualisation of the proximal humerus, provides stable fixation of these injuries and results in high union rates and overall excellent functional results.

Antero-lateral minimally invasive plate osteosynthesis (MIPO) with the radial nerve exploration for extra-articular distal-third diaphyseal fractures of the humerus

INTRODUCTION

Traditional open reduction and internal fixation (ORIF) of extra-articular distal humerus fractures has a risk of iatrogenic radial nerve injury, extensive soft tissue stripping, and long incision scar. We performed an antero-lateral minimally invasive plate osteosynthesis (MIPO) technique with the radial nerve exploration for distal-third diaphyseal fractures of the humerus and evaluated clinical and radiographic outcomes through this respective study.

METHODS

From April 2010 to June 2016, 28 cases of extra-articular distal-third diaphyseal fractures were treated with an antero-lateral MIPO procedure. Patient demographics, Disabilities of the Arm, Shoulder and Hand (DASH) Score, Mayo Elbow Performance (MEP) Score, elbow range of motion, scars and post-operative complications were recorded and analyzed.

RESULTS

All fractures were united with a mean time of 3.5 months. One patient exhibited delayed union (3.6%). The mean DASH Score was 6.6, and all patients had excellent or good MEP Score values. The average scar length was 6.8 cm, and the shortest was 4.5 cm.

CONCLUSIONS

The MIPO technique via an antero-lateral approach for extra-articular distal-third diaphyseal fractures of the humerus results in satisfactory clinical outcomes.

LEVEL OF EVIDENCE

Level IV, case series, treatment study.

Functional outcome of intraarticular distal humerus fracture fixation using triceps-sparing paratricipital approach

BACKGROUND

Displaced intraarticular distal humerus fracture has been conventionally treated operatively with various triceps disrupting approaches. These approaches are associated with several complications, such as triceps weakness, nonunion or delayed union of osteotomy, implant prominence, and delayed mobilization of the elbow. We present the functional outcome of intraarticular distal humerus fracture fixation using a triceps-sparing paratricipital approach which allows early elbow mobilization and preserving triceps strength.

MATERIALS AND METHODS

Twenty five patients with intraarticular distal humerus fracture were operated using triceps-sparing paratricipital approach with orthogonal plate construct. There were 16 male and 9 female patients and average age was 42.16 years (range 23-65 years). The mechanism of injury was fall from height (n = 8), road traffic accident (n = 13) and ground level fall (n = 4). Clinical, radiological, and functional assessment with Mayo Elbow Performance Index (MEPI) were obtained at follow up period.

RESULTS

All fractures united primarily. At the mean follow up of 13.58 months (range 6-22 months), mean elbow flexion was 121.08° (range 94°-142°) and mean motion arc was 114.92°(range 65°-140°). The mean MEPI score was 94.40 points (range 70-100) with 17 excellent, five good, and three fair results. The mean flexion deformity or extension loss was 6.16° (range 5°-15°).

CONCLUSION

Open reduction and internal fixation of intraarticular distal humerus fractures with triceps-sparing paratricipital approach provide adequate exposure with no adverse effect on triceps muscle strength and allows early initiation of elbow motion. We analyzed, age and injury to surgical interval with relation to functional range of elbow using Z-test which is insignificant.

Simultaneous bilateral "floating arm" of the humeri: an uncommon presentation of a rare complex injury and review of the literature

The timing of definitive fixation for simultaneous fractures of the humerus in polytrauma patient is controversial. We report on the management of a patient that sustained bilateral "floating arm" fractures of the humeri. When dealing with such injury patterns, it is important to always carry out stabilization of the humeral diaphysis first and afterwards to treat the sub-injury or over-injury fractures. Our patient healed after twelve weeks in both humeri. After seven years MEPS showed excellent and good results in the right and left arms, while UCLA scores proved excellent in both sides. We encountered no intraoperative and postoperative complications.