ORIGINAL ARTICLE


https://doi.org/10.5005/jp-journals-10080-1546
Strategies in Trauma and Limb Reconstruction
Volume 17 | Issue 1 | Year 2022

Double Plating in Type C Distal Humerus Fractures: Current Treatment Options and Factors that Affect the Outcome


Efstratios D Athanaselis1https://orcid.org/0000-0002-5924-5868, Georgios Komnos2https://orcid.org/0000-0002-6832-0014, Dimitrios Deligeorgis3https://orcid.org/0000-0002-0724-0846, Michael Hantes4https://orcid.org/0000-0001-9494-6048, Theofilos Karachalios5https://orcid.org/0000-0002-9043-0535, Konstantinos N Malizos6https://orcid.org/0000-0001-6594-3649, Sokratis Varitimidis7https://orcid.org/0000-0003-3193-9566

1–7Department of Orthopaedic Surgery and Musculoskeletal Trauma, University Hospital of Larissa, Larissa, Greece

Corresponding Author: Sokratis Varitimidis, Department of Orthopaedic Surgery and Musculoskeletal Trauma, University Hospital of Larissa, Larissa, Greece, e-mail: svaritimidis@hotmail.com

How to cite this article: Athanaselis ED, Komnos G, Deligeorgis D, et al. Double Plating in Type C Distal Humerus Fractures: Current Treatment Options and Factors that Affect the Outcome. Strategies Trauma Limb Reconstr 2022;17(1):7–13.

Source of support: Nil

Conflict of interest: None

ABSTRACT

Purpose: This is a retrospective cohort study of type C distal humeral fractures (AO classification system) aimed at evaluating the effectiveness of current operative treatment options.

Materials and methods: Thirty-seven patients with type C distal humeral fractures, treated operatively from January 2002 to September 2016, were retrospectively studied. Thirty-two were eligible for inclusion. Patients were treated by open reduction using the posterior approach, olecranon osteotomy and parallel-plate two-column internal fixation. Patients were evaluated for fracture healing, functional outcomes and complications (infection, ulnar neuropathy, heterotopic ossification and need for implant removal). Restoration of the normal anatomy was defined by measuring carrying angle, posterior angulation and intercondylar distance of distal humerus.

Results: The mean follow-up time was 8.7 years [range 2–15.5 years, standard deviation (SD) = 3.96]. Mean time to fracture union was 8 weeks for 29 patients (90.6%) (range, 6–10 weeks). In nine cases, there was malunion of varied importance (28.1%). There was one case with postoperative ulnar neuropathy and one case with deep infection. The mean Disabilities of the Arm, Shoulder and Hand (DASH) score and mean Mayo Elbow Performance Score (MEPS) were 20 (range 0–49) and 83.3 (range 25–100), respectively.

Conclusion: In complex distal humerus fractures, the posterior approach with olecranon osteotomy and parallel plating of two columns, after anatomic reconstruction of the articular segment, is a prerequisite for successful elbow function.

Keywords: Distal humeral fractures, Double plating technique, Heterotopic ossification, Olecranon osteotomy, Tension band osteosynthesis, Two-column theory, Ulnar nerve management.

INTRODUCTION

Distal humeral fractures represent 2% of adult elbow fractures and are, in the vast majority, the result of either high energy trauma in young patients or low energy trauma in the elderly with osteoporotic bone.1 The low incidence and high complexity (the majority are AO type B and C) make for a demanding treatment issue.2,3 These type C fractures include dissociation of distal humeral columns, but coexisting fractures of the proximal ulna and radius are not uncommon. Due to high-energy mechanism of injury, such fractures are often open or associated with soft tissue injury (abrasions, contusion) that increase difficulty in treatment.3,4 Vascular and neurological evaluation of the injured upper extremity is important; distal humeral fractures are associated with vascular injuries which can lead to ischaemia demanding urgent treatment. Nerve injuries (mostly of the ulnar nerve) need surgical exploration.49

The diagnosis of this fracture is established by plain X-rays, but the radiographic evaluation alone is insufficient for preoperative planning. Computed tomography (CT) is used routinely for a thorough understanding of the morphology and complexity of distal humeral fractures. Two classification systems are used widely for distal humeral fractures. The AO or OTA classification describes the location and comminution better, while the Jupiter and Mehne classification focuses on the morphology of the fracture.10,11

Historically, conservative management with the ‘treat as a bag of bones’ technique was used, as proposed by Eastwood in 1937.12 This treatment requires prolonged immobilisation leading to elbow stiffness and heterotopic ossification. A high percentage of unsatisfactory results after conservative treatment have been reported in the literature. Better results from operative treatment are now published, leading to advancement in surgical techniques and outcomes.1315 Immobilisation can be used only in cases of nondisplaced fractures or as temporary treatment before arthroplasty. Nonsurgical treatment can also be chosen as definitive in cases of neurologic deficit, advanced osteoporosis and fractures with extensive bone loss, where there is acceptance of an unsatisfactory final result.3,16,17

Surgical treatment is the contemporary treatment of choice.1821 The goal of treatment for distal humerus fractures is restoration of a stable, painless and functional elbow. The effectiveness of surgical treatment will depend on various factors. The elbow joint is at risk of contractures and stiffness after both the initial injury and consequent surgical trauma. The surgical reconstruction of the distal humerus is often difficult due to its complex anatomy, fracture fragmentation and poor bone stock, especially in osteoporotic elderly patients. This requires a thorough understanding of ‘fracture personality’, knowledge of the available fixation techniques and available surgical skill. Evaluation of a patient’s medical status and expectations are important.22 Complications are associated with both the injury and surgical treatment and include nonunion, decreased elbow ROM (range of movement), implant failure, infection, ulnar nerve neuropathy, heterotopic ossification and post-traumatic arthritis. The operative outcome of distal humeral fractures can be unpredictable.22,23 The aim of this study is to report the outcomes of a 15-year, single-centre experience of operatively treated type C distal humerus fractures.

MATERIALS AND METHODS

This is a retrospective study of patients with a distal humeral fracture of AO type C treated with open reduction and internal fixation with two parallel plates. No ethical approval is required at our institution for retrospective studies. From January 2002 to September 2016, 37 patients with such a fracture were surgically treated in the orthopaedic department of a tertiary university hospital. This cohort was a consecutive series of patients with a type C humeral fracture. All had surgical management proposed for their fracture and were prepared and planned for surgery. Two patients were excluded due to a different modality of treatment [one total elbow arthroplasty (TEA) and one K-wire transfixation] carried out, while another one was considered as a high-risk patient and conservative treatment with elbow casting was chosen instead. Two other patients were lost in follow-up and were excluded as well. Descriptive statistics were used for the outcome variables.

Among the remaining 32 patients, 15 were males (47%) and 17 females (53%) with a mean age of 53.5 years (range 18–83). Right and left elbows were equally involved, and in 19 patients (59.4%), the dominant arm was injured. Three patients sustained open fractures (9.4%), two patients had an ipsilateral olecranon fracture, and one patient suffered from olecranon and radial head fracture. Mechanism of injury was simple fall in 22 patients (68.7%), a fall from a height in six cases (18.8%), and a motor vehicle accident in four cases (12.5%). Five patients sustained additional injuries.

The same operative technique was used by all senior surgeons in our department, with slight individual modifications. All had the posterior approach and olecranon osteotomy. Under general anaesthesia, the patient is positioned on the contralateral side with the affected arm hung across the chest allowing for elbow manipulation. A tourniquet was not used in order to achieve adequate access to the arm. The skin incision was placed posteriorly, curved slightly laterally in the middle, and the ulnar nerve is dissected for about 15–20 cm and protected throughout the operation.

Early administration of antibiotics, debridement, meticulous irrigation by low-to-medium pressure lavage devices, and wound cultures were the standard of care for open fractures. Plates of various types and length but preferably pre-contoured locking plates positioned in parallel and were used to support the reconstructed medial and lateral columns, often combined with free screws and K-wires. The olecranon was fixed using a tension band technique in 26 patients and by other techniques (screw, plate) in six (including the two patients with the associated olecranon fracture). Immediate wound closure was possible in all cases. At the end of the procedure, unrestricted full range of elbow motion is verified, and the stability of fixation confirmed. The wound is closed in layers with a suction drain and bulky dressing placed (Figs 1 and 2). The elbow is splinted in flexion of 90° for 2 weeks for the inflammation to subside.

Fig. 1A and B: Anteroposterior and lateral X-rays of distal humeral fracture of AO type C in a 50-year-old male

Fig. 2A and B: Two-column internal osteosynthesis and tension band fixation of olecranon osteotomy 11 years postoperatively

Postoperatively, a 90° back-slab was used for the first 3 weeks. Thereafter, patients’ elbow mobilisation was started under dynamic splint protection until the sixth postoperative week. An individualised approach was used, and all patients were compliant with physiotherapy.

A clinical and radiological examination was carried out at 1, 2, 3 and 6 months after surgery and annually thereafter. The Disabilities of the Arm, Shoulder and Hand (DASH) score and Mayo Elbow Performance Score (MEPS) were utilised for evaluating the functional outcome. Both are widely used and considered reliable methods for elbow function outcomes after humeral fractures.24,25 The mean follow-up time was 8.7 years (range 2–15.5 years, SD = 3.96).

RESULTS

Twenty-nine patients (90.6%) had clinical and radiological signs of fracture healing by 57.2 days on average (range 44–72 days). Radiological signs of healing were declared when bone defects were filled along with a restoration of cortical continuity cortex on plain X-rays. No postoperative computed tomography (CT) scans were performed as this was not needed clinically. Two independent orthopaedic surgeons evaluated the radiographs (DD and MH). Clinical union was determined when the elbow joint was clinically stable, and there was no pain or restriction during motion.

Three patients (9.4%) were diagnosed with a nonunion. This occurred at the metaphyseal level in two cases and of the lateral condyle in one case. Local biological factors were considered the main reason for these complications. Infection was ruled out in all by preoperative aspiration (dry aspiration) and intraoperative cultures. All underwent revision osteosynthesis 6 months following the initial procedure using longer plates along with autograft from the iliac crest. In nine cases, there was malunion of varying importance (28.1%). Malunions were cases where minor radiological angulation and slight decrease of the range of motion were detected. However, these were classed of miscellaneous importance because there was no statistically significant decrease in the postoperative outcomes as measured through the scoring systems, and no patient neither complained of poor function nor requested further treatment. Correspondingly, this subgroup was not included as complications. Other postoperative complications included postoperative ulnar neuropathy (one patient), deep infection (one patient) and complex regional pain syndrome (CRPS, one patient). Ulnar nerve compression neuropathy was treated operatively with surgical decompression and neurolysis, whereas CRPS was treated by four sessions of regional injection of corticosteroids and lidocaine. Infection, diagnosed 17 months postoperatively, was treated by implant removal, surgical debridement and application of antibiotic beads for 5 days. No further osteosynthesis was needed as the fracture was considered healed. In total, the reoperation rate was 18.7% (six patients). Seven patients (21.9%) underwent surgical removal of the olecranon tension band within 18 months postoperatively due to implant failure (K-wires migration, wire breakage) and soft tissue tethering. A postoperative ulnar palsy was present in three patients (9.4%), but recovered spontaneously within 3 months. Heterotopic ossification was found in three patients, but it was of minor degree and insignificant in terms of elbow function.

Restoration of the normal anatomy was defined by measuring the carrying angle, posterior angulation and intercondylar distance of the distal humerus from radiographs. The average carrying angle was 8° (range 5–17°, SD = 2.97), and the average posterior angulation was 45° (range 40–56°, SD = 4.96). The intercondylar distance, as an indicator of joint width restoration (significant factor of elbow function), was found normal (100%) in 23 patients (72%) and decreased by an average 16.7% (5–25%) in nine patients in comparison with the contralateral elbow. Radiological findings of osteoarthritis (joint space narrowing, bone sclerosis and osteophytes) were present in half of the patients (16/32) in a mean time of 4.5 years (range 2.5–10 years), corresponding to the poorer functional results.

Elbow function was also evaluated and recorded. The average range of motion (ROM) was 117° (range 75–150°). An extension lag ranged from 0 to 45° (average 21°). Better function was observed in flexion with 141° in average (range 120–150°). The average pronation was 78.8° (range 60–90°) and supination 73.3° (range 70–90°). Patients were assessed with the DASH score (mean value 22.5, range 10–79) and MEPS (mean value 83.3, range 25–100) (Fig. 3).

Fig. 3: Flowchart presenting cases according to union and outcome scores

DISCUSSION

There is a variety of surgical treatment approaches for distal humeral fractures of AO type C internal fixation. Our approach of choice was a posterior skin incision curved at the level of the medial epicondyle to avoid contractures over ulnar nerve and followed by an olecranon osteotomy. A triceps-splitting exposure, paratricipital exposure (Alonso-Llames), triceps-sparing exposure (Bryan-Morrey) or triceps-reflecting anconeous pedicle are all possible options.3,2628 The advantages of triceps-sparing vs triceps-splitting approaches are of less blood loss, less scar formation and less muscle trauma in order to reduce the postoperative contracture and stiffness.15,29,30 Trans-articular or extra-articular olecranon osteotomies are widely used. This is not a demanding technique and allows for satisfactory visualisation of the elbow joint. It is contraindicated in total elbow arthroplasty and precludes other approaches in the future. There are a few studies comparing triceps-splitting with olecranon osteotomy; most find no statistically significant differences in objective elbow strength, range of motion or functional outcomes. The re-operation rate in osteotomy for hardware removal due to implant complications ranged between 6 and 30% and olecranon nonunion rate ranged between 0 and 9%. However, nonunion after osteotomy is usually caused by inadequate fixation and thus can be prevented with stable fixation.19,3036 The evidence is stronger in support of the triceps-splitting approach when dealing with open fractures due to less disturbance of the blood supply.15

We prefer an olecranon osteotomy using intra-articular chevron technique at the bare spot of the olecranon (centre of the olecranon sulcus), performed using an oscillating saw until the subchondral layer of bone is reached and finished by an osteotome, thereby avoiding thermal injury to cartilage. In cases of associated olecranon fracture, no osteotomy was needed. Olecranon osteosynthesis is carried out at the end by a tension band technique, intramedullary screw or new anatomical olecranon plates. We find the tension band as an effective, simple and low-cost solution, and this was used for the majority of our cases (81.25%). Precontoured plates were used in three patients including the two with olecranon fracture. Pitfalls in osteotomy osteosynthesis may arise from surgeon fatigue after a demanding and time-consuming surgical reconstruction of distal humerus. Care must be taken to avoid malreduction, unstable fixation and implant-related complications (e.g. pronation-supination inability due to K-wires or screws of inappropriate length or from anterior interosseous nerve irritation) (Fig. 4).

Fig. 4: Tension band K-wires malpositioning or migration can cause soft tissue complications (e.g. skin irritation and anterior interosseous nerve pressure) leading to the necessity of implant removal surgery

Internal fixation of distal humeral fractures must restore the anatomy to maximise functional recovery; this is from re-establishing congruency of the articular surface of the trochlea and capitellum, the intercondylar width and orientation of the condyles, despite fracture fragmentation.3,21,37 Various plates with conventional or locking screws are available, but precontoured anatomical LCP plates have become a ‘gold standard’.38 After temporary stabilisation of bone fragments with K-wires (part of them can be left permanently in bone if needed), we prefer to use two precontoured locking plates to fix the medial and lateral columns. Plates must be of different lengths to avoid a stress-riser effect and risk of periprosthetic fracture. Locking plates are preferable as various locking screws inserted from both sides allow stabilisation of multiple intra-articular fragments, as well as stable fixation to the humeral shaft, with a lower incidence of loosening, especially in osteoporotic bone. Freehand application of screws is often inevitable to hold bone fragments in place and restore the articular surface. The distal humeral epiphysis triangle can be reconstructed first and then fixed en bloc to the shaft. The column with less comminution is attached first to restore length, although in cases of severe comminution and bone loss, supracondylar shortening maximises bone contact and improves stability. Bone defects must be replaced by bone graft, preferably autologous. This manner of osteosynthesis provides adequate stability to bending and rotational forces and permits early mobilisation of the elbow postoperatively.15,30,3942 Several randomised studies have shown that parallel (180°) placement of the two plates is biomechanically superior than perpendicular placement (90°). Posterior plating for the lateral column permits only for the insertion of short screws due to the small anteroposterior diameter of the humerus. Moreover, blood supply to the lateral column is mainly derived from posterior segmental vessels.3,39,4347 Sagittal plane plating reduces the risk of injuring these structures, improving the union rate, and it was the fixation method of choice in most of our cases except when fracture configuration did not allow for it.

Early mobilisation is vital to reduce stiffness, prevent heterotopic ossification and restore satisfactory function. Depending on the severity of comminution, the condition of soft tissue envelope and the stability of osteosynthesis, passive motion was started as soon as possible under protection of a dynamic splint. Elbow stiffness is the most common complication of distal humerus fractures. Joint incongruity, osteophytes, loose bodies, capsule adhesions and muscle contractures are common causes. Mild stiffness (<30°) can be treated by arthroscopic arthrolysis or limited open arthrolysis without hardware removal. Complex cases need open arthrolysis and hardware removal, or a total elbow arthroplasty (TEA).3,48 Four patients (12.5%) underwent closed arthrolysis due to elbow stiffness. The ROM was 117° with greater restriction in extension. Unsatisfactory function was related to poor restoration of anatomy of the humeral epiphysis. Of those patients who needed tension band removal, extension was improved in four and pronation–supination in two. Long-term functional results became increasingly worse due to osteoarthritic changes with corresponding changes in the DASH and MEP scores (Fig. 5).

Fig. 5: Radiographic osteoarthritic findings (osteophytes, subchondral bone sclerosis, joint space narrowing) of a then 45-year-old female patient treated for intra-articular distal humeral fracture, 11 years postoperatively

Nonunion (and malunion) of distal humeral fractures after ORIF is usually associated with implant failure. Nonunion can be located extra-articularly at the metaphyseal area of humerus or intra-articular. It ranges between 0 and 13% in published studies as a result of unstable fixation of severely comminuted fractures (high energy trauma), insufficient bone stock (osteoporosis), poor surgical technique or infection. Nonunions are treated with revision surgery to improve stability and biology (with autografts) and are very challenging procedures ending up with external fixation or TEA.3,19,4854 In our series, there were three cases of nonunion (9.4%, located at the distal metaphysis and epiphysis of humerus) after 6-month follow-up which were treated with mechanical and biological augmentation. Plates were exchanged for longer ones and autograft from the iliac crest used in the nonunion site after meticulous debridement of fibrous tissue. There was no case of nonunion of the olecranon osteotomy. Good osteotomy technique and fixation are essential for preventing complications.35,55

An iatrogenic neurological injury is a common complication of internal fixation of distal humeral fractures. An ulnar nerve injury is perhaps one of the most common complications following surgical fixation (0–15%). Careful preoperative neurological evaluation of the upper limb, meticulous dissection of the nerve and proper positioning of implants can reduce the risk. There is an ongoing controversy over the need for anterior transposition of ulnar nerve. Existing evidence does not support its use routinely. However, some authors suggest it in patients with pre-existing symptoms of ulnar neuropathy.6,49,5659 In our series, the ulnar nerve was transposed anteriorly in a subcutaneous fat envelope created with absorbable sutures in order to be kept away from the implants of the medial column, preventing irritation during elbow flexion–extension. However, attention must be paid to avoid firm anterior positioning of ulnar nerve and stretching during elbow extension. Postoperative ulnar neuropathy was present in four of our patients (12.5%). In three (75%), intraoperative nerve compression by surgical instruments and excessive traction caused postoperative ulnar neurapraxia with mild disruption in sensation; all recovered spontaneously within 3 months. Ulnar compression neuropathy, if not a pre-existing condition (which can be difficult to define in injured patients), can be the result of implant impingement and scar tissue formation. Second-time decompression and neurolysis can be effective intervention in cases of post-traumatic and postoperative ulnar neuropathy and was used in one of our patients with persistent neurological findings 6 months postoperatively.15,41,6063

Periarticular heterotopic ossification is a relatively common complication and adds to elbow stiffness and a poor functional result. The average published rate is 8.6% (range 0–21%) if no preventive treatment is used. High-energy open fractures, concomitant central nervous system injury, prolonged immobilisation and delay in surgical treatment are all recognised risk factors. Though published data are underpowered statistically to impose firm treatment recommendations, radiotherapy (e.g. one dose on the first postoperative day), indomethacin (e.g. 75 mg × 10–40 days) or both are treatment options.49,56,6466 Heterotopic ossification was present in three patients (9.4%) without impairing elbow function.

Deep infection ranges from 0 to 8% with increased incidence in open fractures, severe soft tissue injury and prolonged operation time. Implant removal, surgical debridement and antibiotic therapy (guided by tissue cultures) successfully eradicated deep infection in one of our patients (3.12%) that had healed 17 months postoperatively. If fracture had not healed, revision of ORIF or conversion to TEA is the proposed treatment choices as soon as infection is eradicated.19,36,49,51,67

This study is not without limitations. Despite the inherent flaws due to its retrospective nature, such as selection bias, data extraction from inadequate record keeping and no control group, this retrospective cohort study presents a wide variety of postoperative results, adding and expanding to what has already been published in recent literature.

CONCLUSION

The management of distal humeral fractures of AO type C is a challenging prospect that demands successful anatomic reconstruction for restoration of elbow function. The posterior approach with olecranon osteotomy allows a satisfactory exposure of the joint and preshaped locking compression plates achieve a stable fixation even in cases of excessive comminution. Early postoperative mobilisation is essential for prevention of elbow stiffness.

ORCID

Efstratios D Athanaselis https://orcid.org/0000-0002-5924-5868
Georgios Komnos https://orcid.org/0000-0002-6832-0014
Dimitrios Deligeorgis https://orcid.org/0000-0002-0724-0846
Michael Hantes https://orcid.org/0000-0001-9494-6048
Theofilos Karachalios https://orcid.org/0000-0002-9043-0535
Konstantinos N Malizos https://orcid.org/0000-0001-6594-3649
Sokratis Varitimidis https://orcid.org/0000-0003-3193-9566

REFERENCES

1. Morrey BF. Fractures and dislocations. In: Morrey BF, editor. The elbow and its disorders. 2nd ed. Philadelphia: WB Saunders; 1993. p. 293–329.

2. McCarty LP, Ring D, Jupiter JB. Management of distal humerus fractures. Am J Orthop 2005;34(9):430–438. PMID: 16250484.

3. Bégué T. Articular fractures of the distal humerus. Orthop Traumatol Surg Res 2014;100(1 Suppl):S55–S63. DOI: 10.1016/j.otsr.2013.11.002.

4. Hotchkiss RN, Green DP. Fractures and dislocations of the elbow. In: Rockwood CA Jr, Green DP, Bucholz RW, editors. Fractures in adults. Philadelphia: J.B. Lippincott; 1991. p. 739–841.

5. Min W, Anwar A, Ding BC, et al. Open distal humerus fractures-review of the literature. Bull NYU Hosp Jt Dis 2010;68(4):257–261. PMID: 21162702.

6. Ruan HJ, Liu JJ, Fan CY, et al. Incidence, management, and prognosis of early ulnar nerve dysfunction in type C fractures of distal humerus. J Trauma 2009;67(6):1397–1401. DOI: 10.1097/TA.0b013e3181968176.

7. Burczak JR. Median nerve palsy after operative treatment of intra-articular distal humerus fracture with intact supracondylar process. J Orthop Trauma 1994;8(3):252–254. PMID: 8027897.

8. Chen RC, Harris DJ, Leduc S, et al. Is ulnar nerve transposition beneficial duringopen reduction internal fixation of distal humerus fractures? J Orthop Trauma 2010;24(7):391–394. DOI: 10.1097/BOT.0b013e3181c99246.

9. Vazquez O, Rutgers M, Ring DC, et al. Fate of the ulnar nerve after operative fixation of distal humerus fractures. J Orthop Trauma 2010;24(7):395–399. DOI: 10.1097/BOT.0b013e3181e3e273.

10. Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium-2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma 2007;21(10):S1–S133. DOI: 10.1097/00005131-200711101-00001.

11. Jupiter JB, Mehne DK. Fractures of the distal humerus. Orthopedics 1992;15(7):825–833. DOI: 10.3928/0147-7447-19920701-07.

12. Eastwood WJ. The T-shaped fractures of the lower end of the humerus. J Bone Joint Surg 1937;19(2):364–369.

13. Horne G. Supracondylar fractures of the humerus in adults. J Trauma 1980;20(1):71–74. PMID: 7351683.

14. Zagorski JB, Jennings JJ, Burkhalter WE, et al. Comminuted intraarticular fractures of the distal humeral condyles. Surgical vs. nonsurgical treatment. Clin Orthop Relat Res 1986;202:197–204. PMID: 3955949.

15. Ul Islam S, Glover AW, Waseem M. Challenges and solutions in management of distal humerus fractures. Open Orthop J 2017;11:1292–1307. DOI: 10.2174/1874325001711011292.

16. Miller AN, Beingessner DM. Intra-articular distal humerus fractures. Orthop Clin North Am 2013;44(1):35–45. DOI: 10.1016/j.ocl.2012.08.010.

17. Hausman M, Panozzo A. Treatment of distal humerus fractures in the elderly. Clin Orthop Relat Res 2004;425:55–63. DOI: 10.1097/01.blo.0000131485.47685.8c.

18. Jupiter JB, Neff U, Holzach P, et al. Intercondylar fractures of the humerus. An operative approach. J Bone Joint Surg Am 1985;67(2):226–239. PMID: 3968114.

19. 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 Elbow Surg 2002;11(1):48–52. DOI: 10.1067/mse.2002.119390.

20. Ring D, Jupiter JB. Fractures of the distal humerus. Orthop Clin North Am 2000;31(1):103–113. DOI: 10.1016/s0030-5898(05)70131-0.

21. Ring D, Jupiter JB, Gulotta L. Articular fractures of the distal part of the humerus. J Bone Joint Surg Am 2003;85(2):232–238. DOI: 10.2106/00004623-200302000-00008.

22. Greiner S, Haas NP, Bail HJ. Outcome after open reduction and angular stable internal fixation for supra-intercondylar fractures of the distal humerus: preliminary results with the LCP distal humerus system. Arch Orthop Trauma Surg 2008;128(7):723–729. DOI: 10.1007/s00402-007-0428-2.

23. Ring D, Jupiter JB. Complex fractures of the distal humerus and their complications. J Shoulder Elbow Surg 1999;8(1):85–97. DOI: 10.1016/s1058-2746(99)90063-0.

24. Longo UG, Francheschi F, Loppini M, et al. Rating systems for evaluation of the elbow. Br Med Bull 2008;87:131–161. DOI: 10.1093/bmb/ldn023.

25. Vincent J, Macdermid J, King GJW, et al. Validity and sensitivity to change of patient-reported pain and disability measures for elbow pathologies. J Orthop Sports Phys Ther 2013;43(4):263–274. DOI: 10.2519/jospt.2013.4029.

26. Frankle MA, Herscovici D Jr, DiPasquale TG, et al. 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):473–480. DOI: 10.1097/00005131-200308000-00001.

27. Sanchez-Sotelo J, Torchia ME, O’driscoll SW. Principle-based internal fixation of distal humerus fractures. Tech Hand Up Extrem Surg 2001;5(4):179–187. DOI: 10.1097/00130911-200112000-00001.

28. Wajnsztejn A, de Albuquerque DD, Espinola I, et al. Submuscular double bridge plating for complex distal fractures of the humerus: an alternative, safe, and efficient treatment method. Eur J Orthop Surg Traumatol 2017;27(8):1069–1074. DOI: 10.1007/s00590-017-1987-8.

29. Schildhauer TA, Nork SE, Mills WJ, et al. Extensor mechanism-sparing paratricipital posterior approach to the distal humerus. J Orthop Trauma 2003;17(5):374–378. DOI: 10.1097/00005131-200305000-00009.

30. Zalavras CG, McAllister ET, Singh A, et al. Operative treatment of intra-articular distal humerus fractures. Am J Orthop (Belle Mead NJ) 2007;36(12 Suppl 2):8–12. PMID: 18264557.

31. McKee MD, Wilson TL, Winston L, et al. 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. DOI: 10.2106/00004623-200012000-00003.

32. Mejía Silva D, Morales de los Santos R, Ciénega Ramos MA, et al. Functional results of two different surgical approaches in patients with distal humerus fractures type C (AO). Acta Ortop Mex 2008;22(1):26–30. PMID: 18672749.

33. Henley MB, Bone LB, Parker B. Operative management of intra-articular fractures of the distal humerus. J Orthop Trauma 1987;1(1):24–35. DOI: 10.1097/00005131-198701010-00004.

34. Ring D, Gulotta L, Chin K, et al. Olecranon osteotomy for exposure of fractures and nonunions of the distal humerus. J Orthop Trauma 2004;18(7):446–449. DOI: 10.1097/00005131-200408000-00010.

35. Coles CP, Barei DP, Nork SE, et al. 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. DOI: 10.1097/00005131-200603000-00002.

36. Hewins EA, Gofton WT, Dubberly J, et al. Plate fixation of olecranon osteotomies. J Orthop Trauma 2007;21(1):58–62. DOI: 10.1097/01.bot.0000246467.32574.fe.

37. Jupiter JB, Morrey B. Fractures of the distal humerus in the adult. In: Morrey B, editor. The elbow and its disorders. Philadelphia: W.B. Sauders Ed; 1993. p. 328–366.

38. Lecestre P, Dupont JY, Lortat Jacob A, et al. Les fractures complexes de l’extrémité inférieure de l’humérus chez l’adulte. A propos de 66 cas, dont 55 opérés [Severe fractures of the lower end of the humerus in adults (author’s transl)]. Rev Chir Orthop Reparatrice Appar Mot 1979;65(1):11–23. PMID: 156383.

39. O’driscoll SW. Optimizing stability in distal humeral fracture fixation. J Shoulder Elbow Surg 2005;14(1 Suppl S):186S–194S. DOI: 10.1016/j.jse.2004.09.033.

40. Gupta RK, Gupta V, Marak DR. Locking plates in distal humerus fractures: study of 43 patients. Chin J Traumatol 2013;16(4):207–211. PMID: 23910671.

41. Schuster I, Korner J, Arzdorf M, et al. 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):113–120. DOI: 10.1097/BOT.0b013e3181632cf8.

42. O’driscoll SW, Sanchez-Sotelo J, Torchia ME. Management of the smashed distal humerus. Orthop Clin North Am 2002;33(1):19–33. DOI: 10.1016/s0030-5898(03)00070-1.

43. Zalavras CG, Vercillo MT, Jun BJ, et al. Biomechanical evaluation of parallel versus orthogonal plate fixation of intra-articular distal humerus fractures. J Shoulder Elbow Surg 2011;20(1):12–20. DOI: 10.1016/j.jse.2010.08.005.

44. Vennettilli M, Athwal GS. Parallel versus orthogonal plating for distal humerus fractures. J Hand Surg Am 2012;37(4):819–820. DOI: 10.1016/j.jhsa.2011.10.025.

45. Kaiser T, Brunner A, Hohendorff B, et al. 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):206–212. DOI: 10.1016/j.jse.2010.06.010.

46. Kimball JP, Glowczewskie F, Wright TW. Intraosseous blood supply to the distal humerus. J Hand Surg Am 2007;32(5):642–646. DOI: 10.1016/j.jhsa.2007.02.019.

47. Charissoux JL, Mabit C, Fourastier J, et al. Fractures articulaires complexes de l’extrémité distale de l’humérus chez le sujet âgé [Comminuted intra-articular fractures of the distal humerus in elderly patients]. Rev Chir Orthop Reparatrice Appar Mot 2008;94(4 Suppl):S36–S62. DOI: 10.1016/j.rco.2008.03.005.

48. Lindenhovius AL, Jupiter JB. The post-traumatic stiff elbow: a review of the literature. J Hand Surg Am 2007;32(10):1605–1623. DOI: 10.1016/j.jhsa.2007.09.015.

49. Sanchez-Sotelo J, Torchia ME, O’driscoll SW. Complex distal humeral fractures: internal fixation with a principle-based parallel-plate technique. J Bone Joint Surg Am 2007;89(5):961–969. DOI: 10.2106/JBJS.E.01311.

50. Aslam N, Willett K. Functional outcome following internal fixation of intraarticular fractures of the distal humerus (AO type C). Acta Orthop Belg 2004;70(2):118–122. PMID: 15165012.

51. Robinson CM, Hill RM, Jacobs N, et al. Adult distal humeral metaphyseal fractures: epidemiology and results of treatment. J Orthop Trauma 2003;17(1):38–47. DOI: 10.1097/00005131-200301000-00006.

52. Ali A, Douglas H, Stanley D. Revision surgery for nonunion after early failure of fixation of fractures of the distal humerus. J Bone Joint Surg Br 2005;87(8):1107–1110. DOI: 10.1302/0301-620X.87B8.15610.

53. Ring D, Gulotta L, Jupiter JB. Unstable nonunions of the distal part of the humerus. J Bone Joint Surg Am 2003;85(6):1040–1046. DOI: 10.2106/00004623-200306000-00008.

54. Helfet DL, Hotchkiss RN. Internal fixation of the distal humerus: a biomechanical comparison of methods. J Orthop Trauma 1990;4(3):260–264. DOI: 10.1097/00005131-199004030-00004.

55. Tak SR, Dar GN, Halwai MA, et al. Outcome of olecranon osteotomy in the trans-olecranon approach of intra-articular fractures of the distal humerus. Ulus Travma Acil Cerrahi Derg 2009;15(6):565–570. PMID: 20037874.

56. 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. DOI: 10.1016/j.jse.2009.05.003.

57. Wang KC, Shih HN, Hsu KY, et al. Intercondylar fractures of the distal humerus: routine anterior subcutaneous transposition of the ulnar nerve in a posterior operative approach. J Trauma 1994;36(6):770–773. PMID: 8014996.

58. Athwal GS, Hoxie SC, Rispoli DM, et al. Precontoured parallel plate fixation of AO/OTA type C distal humerus fractures. J Orthop Trauma 2009;23(8):575–580. DOI: 10.1097/BOT.0b013e3181aa5402.

59. McKee MD, Kim J, Kebaish K, et al. Functional outcome after open supracondylar fractures of the humerus. The effect of the surgical approach. J Bone Joint Surg Br 2000;82(5):646–651. DOI: 10.1302/0301-620x.82b5.10423.

60. Yamaguchi K, Sweet FA, Bindra R, et al. The extraosseous and intraosseous arterial anatomy of the adult elbow. J Bone Joint Surg Am 1997;79(11):1653–1662. DOI: 10.2106/00004623-199711000-00007.

61. Limthongthang R, Jupiter JB. Distal humerus fractures. Oper Tech Orthop 2013;23(4):178–187. DOI: 10.1016/j.ocl.2007.12.002.

62. Stoffel K, Cunneen S, Morgan R, et al. Comparative stability of perpendicular versus parallel double-locking plating systems in osteoporotic comminuted distal humerus fractures. J Orthop Res 2008;26(6):778–784. DOI: 10.1002/jor.20528.

63. McKee MD, Jupiter JB, Bosse G, et al. Outcome of ulnar neurolysis during post-traumatic reconstruction of the elbow. J Bone Joint Surg Br 1998;80(1):100–105. DOI: 10.1302/0301-620x.80b1.7822.

64. Srinivasan K, Agarwal M, Matthews SJ, et al. Fractures of the distal humerus in the elderly: is internal fixation the treatment of choice? Clin Orthop Relat Res 2005;(434):222–230. DOI: 10.1097/01.blo.0000154010.43568.5b.

65. 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. DOI: 10.1016/j.jse.2009.09.011.

66. Liu JJ, Ruan HJ, Wang JG, et al. Double-column fixation for type C fractures of the distal humerus in the elderly. J Shoulder Elbow Surg 2009;18(4):646–651. DOI: 10.1016/j.jse.2008.12.012.

67. Chen G, Liao Q, Luo W, et al. Triceps-sparing versus olecranon osteotomy for ORIF: analysis of 67 cases of intercondylar fractures of the distal humerus. Injury 2011;42(4):366–370. DOI: 10.1016/j.injury.2010.09.004.

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