Described as having 2 columns with a tie arch connecting the 2
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Incidence of radial nerve palsy in distal humerus fractures?
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Rare but reported, particularly in cases with posteromedial displacement of the distal articular fragment.
Most cases recover spontaneously
Can explore through fracture site from intermuscular septum down to radiocapitellar joint anteriorly
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Classification for Distal Humerus fractures?
AO Trauma - 1.3
A = extra-articular
B = partial articular
C = complete articular
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Investigations?
X-rays and CT scan
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Definitive management options for distal humerus fractures?
ORIF
Bag of bones approach for low-demand, medically unfit patients
Total Elbow Replacement
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What are your goals for treatment?
The goals are to achieve a pain-free, stable joint with a reduced articular surface to minimize the risk of secondary osteoarthritis, while allowing early range of motion through a blood supply-preserving approach.
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What is your approach and strategy?
For complex intra-articular fractures, use an olecranon osteotomy approach
Anatomically reduce the articular joint surface
Secure the articular block to the shaft with K-wires, then apply plates
If planning for replacement, avoid osteotomy—instead use Bryan-Morrey, TRAP, or triceps-sparing approach
Distal Humerus Fractures - What is your plating strategy?
There is no consensus on the optimal plating configuration, with studies supporting both parallel plating and octagonal plating (medial side remains constant at the epicondyle)
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Parallel plating
O'Driscoll's 8 principles –
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6 screw factors -
As many as possible
As long as possible
As many fragments as possible
Catch far fragments
Interdigitate
Every screw must pass through plate
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2 Plate factors
Stiff plates
Compression configuration
Advantage: Better resistance to varus stress (tension side), particularly important when shoulder is abducted during seemingly minimal activities
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Octagonal Plating
Advantage: Better torsional resistance
Disadvantage: More soft tissue stripping of posterior aspect → affects main blood supply of lateral humerus (Yamaguchi et al. 1997 JBJS)
Definitive indications for octagonal plating: coronal shear fractures of capitellum
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Other plating considerations?
Use different plate lengths to prevent stress risers. The medial plate is typically longer, though this requires more extensive ulnar nerve mobilization
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Aware of any evidence for either plating strategy?
Biomechanical studies are conflicting:
JHS 2012 by Christopher Got found perpendicular plating had greater torque to failure, but no difference in AP stiffness
JSES 2011 by Charamlampos showed parallel plating had higher stiffness and ultimate torque than 90/90 plating
Clinical comparison by Sand-Jin et al. in JSES 2010 found no significant differences in ROM, nonunion, or complications
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Will you transpose the ulnar nerve?
Higher risk of neuritis with routine transposition (Chen et al.) – 33% vs 9%
Chen's cohort study of 89 patients found that ulnar neuritis occurred in 33% of transposition cases compared to 9% in non-transposition cases. Routine transposition is not recommended.
I will assess intraoperatively for excessive friction over the medial implant
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What are the types of ulnar nerve transposition?
Subcutaneous
Intramuscular - a gutter is cut into the flexor pronator muscle group, the nerve is placed within it, and the fascia is sutured over the nerve
Submuscular - the flexor pronator muscle group is released from the medial epicondyle, the nerve is transposed underneath, and the muscles are reattached
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Post op rehabilitation?
No back slab needed; allow immediate full range of motion
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Post op considerations?
HO prophylaxis - traditionally indomethacin 75mg once daily for 6 weeks
Recent literature suggests selective COX-2 inhibitors have similar efficacy with better gastrointestinal tolerance
Considerations if considering TEA in a very comminuted elderly fracture?
When planning for possible intraoperative conversion from ORIF to TEA, use extensor mechanism-sparing approaches extensor mechanism sparing approaches such as the Alonso-Llames approach. Avoid olecranon osteotomy.
While TEA requires a small olecranon osteotomy, it differs from the standard ORIF osteotomy approach
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TEA vs ORIF in elderly patient?
Elderly patients (> 65 yo) may benefit from TEA
McKee et al. JSES 2009 RCTcomparing ORIF vs TEA showed:
TEA was superior to ORIF based on DASH scores
TEA had shorter operative time, showed trends toward fewer reoperations and improved ROM in the TEA group
Advantages over TEA: greater weight-bearing capacity, preservation of ulnar bone stock, potential for TEA as salvage procedure, and suitability for younger, more active patients
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Hemiarthroplasty vs TEA for elderly patients - Range of motion and function are superior with hemiarthroplasty
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Blessings are on the head of the righteous, but the mouth of the wicked conceals violence. Proverbs 10:6