Abstract
Background: Severe comminution, bone loss, and osteopenia at the
site of a distal humeral fracture increase the risk of an unsatisfactory
result, often secondary to inadequate fixation. The purpose of this study was
to determine the outcome of treating these fractures with a principle-based
technique that maximizes fixation in the articular fragments and stability at
the supracondylar level.
Methods: Thirty-four consecutive complex distal humeral fractures
were fixed with two parallel plates applied (medially and laterally) in
approximately the sagittal plane. The technique was specifically designed to
satisfy two principles: (1) fixation in the distal fragments should be
maximized and (2) screw fixation in the distal segment should contribute to
stability at the supracondylar level. Twenty-six fractures were AO type C3,
and fourteen were open. Thirty-two fractures were followed for a mean of two
years. The patients were assessed clinically with use of the Mayo Elbow
Performance Score (MEPS) and radiographically.
Results: Neither hardware failure nor fracture displacement occurred
in any patient. Union of thirty-one of the thirty-two fractures was achieved
primarily. Five patients underwent additional surgery to treat elbow
stiffness. There was one deep infection that resolved without hardware removal
and did not impede union. At the time of the most recent follow-up,
twenty-eight elbows were either not painful or only mildly painful, and the
mean flexion-extension arc was 99°. The mean MEPS was 85 points. The
result was graded as excellent for eleven elbows, good for sixteen, fair for
two, and poor for three.
Conclusions: Stable fixation and a high rate of union of complex
distal humeral fractures can be achieved when a principle-based surgical
technique that maximizes fixation in the distal segments and stability at the
supracondylar level is employed. The early stability achieved with this
technique permits intensive rehabilitation to restore elbow motion.
Level of Evidence: Therapeutic Level IV. See Instructions
to Authors for a complete description of levels of evidence.
Restoration of painless and satisfactory elbow function after a fracture of
the distal part of the humerus requires anatomic reconstruction of the
articular surface and stable fixation of the fracture fragments to ensure that
early motion does not compromise fracture
union1-7.
These goals are now widely accepted by the orthopaedic community; however,
they can sometimes be technically difficult to achieve, especially in patients
with a high-energy fracture, substantial comminution, and associated
soft-tissue injuries or in elderly patients with
osteoporosis7.
Most consider the guidelines proposed by the AO/ASIF group to represent the
standard technique for fixation of complex distal humeral
fractures5,7,8.
Their recommended technique includes initial fixation of the articular
fragments with screws and column stabilization with two plates applied at a
90° angle to one
another5,8,9.
However, various authors have found this technique to yield unsatisfactory
results in some
patients1-6.
The limiting factor with the AO/ASIF technique is inadequate fixation of
the distal fragments and, therefore, insufficient stability between the distal
fragments and the shaft. If early motion is attempted in the face of tenuous
fixation, nonunion at the supracondylar level may
occur10.
Alternatively, prolonged immobilization used to prevent failure of
insufficient fixation may result in elbow
stiffness7. Thus, a
poor outcome after these fractures, whether due to nonunion or stiffness, can
usually be attributed to inadequate fixation in the distal fragments. Korner
et al.11 stated:
"Seventy-five percent of malunion or nonunion cases are caused by
inadequate initial fracture fixation, providing clear evidence that optimal
stable implant fixation is difficult to achieve." Thus, improvements in
the outcomes of treatment of these fractures are most likely to result from
technical advances that improve fixation in the articular region.
In an effort to reproducibly obtain stable fixation in the presence of
osteoporosis or comminution, we developed, and used for the past fifteen
years, a fixation technique for fractures of the distal part of the humerus
based on the principles of (1) enhancing fixation in the distal fragments and
(2) achieving stability at the supracondylar
level12-15.
The key to achieving stability with this technique is to link the columns
together distally with use of a construct that is similar in concept to that
of an arch (Fig. 1). The
rigidity of the construct allows routine commencement of an intensive
rehabilitation program without external protection immediately after
surgery.
The purpose of this study was to describe the surgical technique that we
use for fixation of fractures of the distal part of the humerus and to
demonstrate its efficacy in providing and maintaining fracture stability. To
do so, we retrospectively reviewed the results of this principle-based
internal fixation technique in a consecutive series of distal humeral
fractures complicated by severe comminution, bone loss, and/or osteopenia.
Patients
From December 1992 to January 2002, the senior authors (S.W.O'D. and
M.E.T.) treated thirty-four consecutive complex fractures of the distal part
of the humerus in thirty-three patients using the principle-based internal
fixation technique described in this paper. The procedure was used in all
patients with a distal humeral fracture that had been judged to be complex
because of extensive comminution, missing bone, poor bone quality, an initial
failed attempt at internal fixation, or any combination of those factors. The
majority of the patients had been referred to us by orthopaedic surgeons who
thought that stable fracture fixation was going to be difficult to achieve
because of the reasons noted above. While several patients had been referred
for total elbow arthroplasty, we believed that they could be treated with this
technique of fracture fixation.
There were nineteen male patients and fourteen female patients with an
average age at the time of the surgery of fifty-eight years (range, sixteen to
ninety-nine years). Eighteen fractures involved the right elbow and sixteen,
the left elbow. The dominant upper extremity was involved in twenty-three
cases. The only patient with a bilateral distal humeral fracture had
underlying rheumatoid arthritis that involved both elbows; no other patient
had a preexisting pathological condition affecting the elbow. Nine fractures
were the result of a motor-vehicle accident; seven, the result of a
high-energy fall from a height; and eighteen, the result of a moderate-energy
fall in the street or at home. Fourteen fractures (41%) were open, and
according to the system of Gustilo and
Anderson16 three of
them were classified as grade I; three, as grade II; seven, as grade IIIA; and
one, as grade IIIB.
Sixteen patients had between one and five associated injuries (mean, 2.2
associated injuries). One patient had a radial nerve injury, one had an open
transection of the triceps with loss of muscle and tendon, one had a partial
triceps laceration, and one had a disruption of the medial collateral
ligament. Other associated injuries included combined head, chest, and
abdominal trauma with visceral damage (two patients) as well as fractures of
the femoral diaphysis (four), femoral trochanteric region (three), patella
(two), tibia (two), ankle (two), scapula (two), ipsilateral radial head (two),
distal part of the ipsilateral radius (two), ulna (one), metacarpals (one),
talus (one), mandible (one), and ribs (one). One patient had an acute cervical
disc herniation.
Of the thirty-four elbows, only seven were seen primarily by one of us and
thus available to undergo definitive fixation at our institution within the
first twenty-four hours after the injury. The other twenty-seven elbows were
treated by us after a delay of up to ten days (twenty-two elbows) or more than
ten days (five elbows). The factors responsible for the delays included
referral from an outside institution, prior surgery, medical comorbidities
that prevented early treatment of the elbow, or a combination of those
reasons. Nine of the twenty-seven elbows had undergone one, two, or three
operations (mean, 1.5 operations) before definitive fracture fixation by us.
Four patients with an open fracture underwent surgical débridement
prior to definitive fracture fixation, with one patient undergoing one
débridement, two undergoing two, and one undergoing three. The initial
débridement was performed two, four, eleven, or eighteen days after the
injury. Five elbows had undergone aborted attempts at internal fixation at
another institution, and they were treated with definitive fixation at our
institution between three and fifty-two days (mean, twenty-three days) after
the initial injury. Three of these fractures were open and had been
immobilized in a cast during the time between the aborted and definitive
fixation procedures. The remaining eighteen fractures underwent definitive
fixation at our institution at a mean of two days (range, one to ten days)
after the injury. The seven open fractures that had not undergone prior
surgery were stabilized at the time of the first surgical
débridement.
Surgical Technique
Exposure
A sterile tourniquet was used only for dissection of the ulnar nerve, which
was transposed anteriorly in a subcutaneous pocket in every patient. The TRAP
(triceps-reflecting anconeus pedicle)
approach15 was used
in seventeen elbows; an olecranon osteotomy, in five; a Bryan-Morrey
approach3, in two;
and exposure through a traumatic triceps detachment, in
two17,18.
Eight fractures could be stabilized by working on both sides of the
triceps.
Reconstruction
The principles behind our method of stabilization were (1) to maximize
fixation in the distal fragments and (2) to maximize fracture stability at the
supracondylar level. These principles were satisfied with the technique of
parallel plate fixation, which permits insertion of at least four long screws
through the plate and across the distal fragments from one side to the other.
These screws interdigitate, thereby creating a fixed-angle structure and
greatly increasing the stability of the construct.
The lateral column was fixed with a Dupont plate (Howmedica, Rutherford,
New Jersey) in twenty-nine cases, with a Mayo Clinic Congruent Elbow Plate
(Acumed, Hillsboro, Oregon) in three, and with a pelvic reconstruction plate
(Synthes USA, Paoli, Pennsylvania) in two. The medial column was fixed with a
pelvic reconstruction plate in twenty-six cases, with a dynamic compression
plate in five, and with a Mayo Clinic Congruent Elbow Plate in three. No
locking screws were used in this series of patients.
Interfragmentary compression was obtained both between articular fragments
and at the metaphyseal level through the use of large bone clamps that
provided compression during the insertion of the screws. Fully threaded screws
inserted in this manner provide maximum thread purchase in the distal
fragments. Additional compression at the metaphyseal level results from slight
undercontouring of the plates and the use of dynamic compression holes in the
plates. The specific steps of the surgical technique have been reported
previously14,15.
All of the fractures in this series were stabilized with use of the
technique described above. We primarily used 3.5-mm fully threaded cortical
screws, but 4.0-mm fully threaded cancellous screws were occasionally employed
to increase purchase in osteopenic bone. The distal screw fixation was
augmented with polymethylmethacrylate in one case. A mean of 4.5 screws were
placed through the plates to interdigitate in the distal fragments: three
screws were used in two cases; four, in eighteen; five, in ten; and six, in
four. Fine-threaded Kirschner wires or bioabsorbable pins (Orthosorb; DePuy
ACE Medical Company, Warsaw, Indiana) were used for sixteen fractures to
provide additional fixation of the articular fragments. Two fractures were so
comminuted that they required supplemental suture fixation of small pieces. In
nine cases with supracondylar bone loss, 1 to 2 cm of supracondylar shortening
was performed to achieve supracondylar compression
(Fig. 2). This technique is
especially useful when there is combined soft-tissue and bone loss. Shortening
by =1 cm has only a slight effect on triceps strength in terminal
extension14,19.
Eleven of the fourteen open fractures were fixed acutely at the time of
initial débridement and lavage. The wounds were left open and were
closed two or more days later. Antibiotic-loaded polymethylmethacrylate beads
were temporarily placed in two grade-IIIA open fractures, which were packed
open and then stabilized at the time of delayed wound closure two days later.
The two triceps injuries and the disruption of the medial collateral ligament
were repaired at the time of fracture fixation. The only associated radial
nerve injury was treated with nerve exploration; the nerve was found to be
contused but in continuity, and the patient eventually recovered complete
radial nerve function.
Postoperative Management
Immediately after closure, the elbow was placed in a bulky noncompressive
Jones dressing with an anterior plaster slab to maintain the elbow in
extension, and the upper extremity was kept elevated. The initial
rehabilitation was planned according to the extent of soft-tissue damage. When
the fracture was associated with severe soft-tissue damage, as were most of
the open fractures and high-energy closed fractures, the extremity was kept
immobilized and elevated with the elbow in extension for three to seven days
postoperatively. When the fracture was closed and there was no severe swelling
or fracture blisters, the Jones dressing was removed after two days and an
elastic nonconstrictive sleeve was applied over an absorbent dressing placed
on the wound. A physical therapy program including active and passive motion
was then initiated. All patients were permitted active use of the hand and
were instructed not to lift (or push or pull) anything heavier than a glass of
water or a telephone receiver for the first six weeks. No form of external
protection, such as a cast or brace, was used by any patient; only a sling was
provided for comfort and was used by the patients as needed. Continuous
passive motion, including a home program, was used for eighteen of the
thirty-four
fractures20. The
soft-tissue injuries in association with the other fractures were thought to
be severe enough to preclude safe use of continuous passive motion. In
addition to breaks for bathroom use and hygiene, the patients were instructed
to remove the arm from the machine for five minutes every hour to prevent
pressure sores or nerve palsies. After discharge from the hospital, the
patients were instructed to wean themselves from use of the continuous passive
motion machine by determining each day the amount of time that the upper
extremity could be out of the machine without losing motion once it was back
in the machine. On the average, the patients used the continuous passive
motion machine for approximately four weeks.
If postoperative motion failed to progress as expected, a program of
patient-adjusted static flexion and extension splints was implemented as soon
as the soft tissues had healed. Eight of the elbows included in this study
were treated with such a program, which typically was begun after the third or
fourth week.
Clinical and Radiographic Evaluation
Two elderly patients (one seventy-seven-year-old and one
ninety-three-year-old) with associated intertrochanteric fractures died
twenty-nine and fourteen days after fracture fixation as a result of massive
pulmonary embolism and respiratory failure, respectively. The remaining
thirty-two elbows were followed with periodic clinical and radiographic
evaluations for a mean of two years (range, one to five years). Elbow flexion
and extension were measured with a long handheld goniometer. Pronation and
supination were estimated visually.
The overall clinical results were rated with use of the Mayo Elbow
Performance Score
(MEPS)21 and the
system of Jupiter et
al.5,10,
in which a result is graded as excellent if the patient has no pain, extension
to at least 15°, and flexion to at least 130°.
The preoperative radiographs were reviewed to classify the fractures
according to the AO/ASIF system as modified by the Orthopaedic Trauma
Association22.
There were twenty-six C3 fractures, five C2 fractures, and three A3 fractures.
Postoperative radiographs were evaluated for fracture union, changes in
hardware position, subchondral collapse, heterotopic ossification, and the
development of degenerative changes, which were graded according to the method
of Broberg and
Morrey23.
Heterotopic ossification was classified according to the classification
described by Brooker et
al.24, which was
modified to refer to the humerus (instead of the pelvis) and the radius and/or
ulna (instead of the femur).
Statistical Analyses
Associations between continuous or ordinal variables and discrete variables
were assessed with use of the Wilcoxon ranksum test. Associations between
pairs of discrete variables were assessed with use of the Fisher exact test.
Associations between pairs of continuous or ordinal variables were assessed
with use of the Spearman rank correlation coefficient. A significance level of
0.05 was used for all tests.
Clinical Results
At the time of the most recent follow-up, seventeen elbows were not
painful, eleven were mildly painful, and four were moderately painful (see
Appendix). Elbow extension averaged 26° (range, 0° to 55°), with
twenty-three elbows (72%) having extension to 30° or better and
twenty-eight (88%) having extension to 40° or better. Flexion averaged
125° (range, 80° to 150°), with fifteen elbows (47%) having
=130° of flexion and twenty-five (78%) having =120°. The total
flexion-extension arc averaged 99° (range, 50° to 150°). Thirteen
elbows (41%) could extend to at least 30° and flex to at least 130°.
Twenty-two elbows (69%) could extend to at least 40° and flex to at least
120°. These data include the final ranges of motion after the reoperations
in the five elbows that had additional surgery to restore motion lost as a
result of severe heterotopic ossification. Patients with no heterotopic
ossification had a mean flexion-extension arc of 106° (mean extension [and
standard deviation], 21° ± 12°; flexion, 127° ±
20°), whereas patients with heterotopic ossification had a mean
flexion-extension arc of 59° (extension, 45° ± 13°;
flexion, 105° ± 23°). The differences in flexion, extension,
and the total arc of motion between the patients with and those without
heterotopic ossification were all significant (p < 0.001). Motion improved
in the five patients who had undergone resection of heterotopic
ossification.
Twenty-nine elbows (91%) were stable as determined subjectively and
objectively. Moderate instability was present in one patient with
posttraumatic arthritis, in one following excision of heterotopic ossification
and a capsular release, and in a third patient in whom a deep infection had
developed after excision of heterotopic ossification and osseous
ankylosis.
At the most recent evaluation, the mean MEPS was 85 points (range, 50 to
100 points). According to this score, the result was graded as excellent for
eleven elbows, good for sixteen, fair for two, and poor for three. According
to the grading system of Jupiter et
al.5,10,
the result was graded as excellent for five elbows, good for fourteen, fair
for nine, and poor for four.
Radiographic Results
Union of thirty-one fractures was achieved primarily, and one fracture
united after one additional procedure consisting of bone-grafting and
fixation. There was no evidence of hardware failure in any of the elbows. In
one of the five elbows in which an olecranon osteotomy had been used for a
surgical approach, the osteotomy site failed to unite.
Heterotopic ossification developed in twelve elbows (38%). Nine of these
elbows had had an open fracture, whereas only four of the twenty elbows
without heterotopic ossification had had an open fracture (p < 0.01). The
heterotopic ossification was severe (Brooker Stage III or IV) and required
surgical excision to restore motion in five elbows. Three elbows had a
moderate amount of heterotopic ossification (Brooker Stage II), and four had a
mild amount (Brooker Stage I).
Radiographically, moderate degenerative changes were seen in one elbow and
severe changes were seen in one. Two elbows, including the one that had a deep
infection, had localized collapse of a portion of the articular surface
without failure of fixation and with an intact joint line. We interpreted
these two cases as representing osteonecrosis of osteochondral fragments that
had no soft-tissue attachment.
Complications and Reoperations
Two patients underwent additional surgery for the purpose of definitive
wound closure following an open fracture. Complications requiring a
reoperation occurred in nine additional patients
(Table I and Appendix). Two
patients underwent a reoperation for the treatment of wound-healing
complications, and one had a surgical débridement to treat a deep
infection. Five patients underwent excision of severe heterotopic
ossification. A reoperation was also necessary to treat a nonunion in one
patient three and a half years postoperatively, and this procedure resulted in
union. Two additional patients had permanent ulnar neuropathies, which were
not treated surgically. Finally, posttraumatic osteoarthritis developed in two
patients, and osteonecrosis developed in one.
Prognostic Factors
Open fractures were associated with higher rates of residual pain (p =
0.005) and worse MEPS (mean, 77 ± 16 points compared with 90 ±
13 for closed fractures, p = 0.042) at the time of the most recent follow-up.
The prevalence of heterotopic ossification was greater following open
fractures (69% compared with 16% for closed fractures, p = 0.003) and for
elbows that had undergone surgery prior to definitive fixation by us (25%
compared with 8% for those without prior surgery, p = 0.048). Heterotopic
ossification resulted in significant impairments of flexion, extension, and
the total range of motion (p < 0.001). With the numbers available, gender,
age, a delay in definitive fracture fixation of more than ten days after the
original injury, and supracondylar shortening were not associated with
differences in the most recent pain score, range of motion, or overall
rating.
The main challenge in the management of distal humeral fractures is to
obtain an anatomic reduction of the joint surface and sufficient stability to
allow intense rehabilitation to restore elbow motion without failure of
fixation10,11,25-35.
In this series, adequate stability was achieved to permit both active and
passive motion in every case, without the use of splints, braces, or casts to
protect the fixation (Figs. 3-A and
3-B, 3-C and
3-D).
The technique proposed by the AO/ASIF
group3,5,6,32,33,
in which fixation of the articular fragments with one or two screws is
followed by application of two plates at a 90° angle to one another, can
result in suboptimal anchorage of the articular fragments to the shaft due to
the limited number and length of screws that can be placed in the distal
fragments. In the presence of severe comminution, osteoporosis, or bone loss,
the fixation can fail. Various authors have reported 20% to 25% rates of
unsatisfactory results after the use of this technique for internal fixation
of distal humeral
fractures1-6
(see Appendix). The fixation failed in five of the thirty-three patients in
the series of Henley et
al.2, five of the
eighty-eight fractures in the series of Letsch et
al.6, three of the
fifty-seven patients reported on by Holdsworth and
Mossad3, nine of the
seventy-two fractures included in the series of Wildburger et
al.35, and sixteen
of the ninety-six fractures reported on by Sodergard et
al.31. There were
no failures of fixation in our series.
When fixation fails, it does so at the supracondylar level. For this
reason, any improvement in fixation must satisfy two principles: there should
be enhanced fixation in the distal fragments, and fixation in the distal
segment should contribute to fracture stability at the supracondylar level.
The technique that we used achieves these objectives by following
architectural principles, in which two columns are anchored at their base (on
the shaft of the humerus) and are linked together at the top (by long screws
from the plates on each side interdigitating within the articular segment).
Fixation of the bone fragments thus relies not on screw purchase in the bone,
but on the stability of the hardware superstructure. The screws in the distal
segment are converted into fixed-angle screws by two of the technical
objectives. First, several long screws in the distal fragments lock together
by interdigitation. Second, these screws pass through a plate on one side and
into a bone fragment on the other side, which itself is also anchored by a
plate. This technique enhances fixation in the distal fragments and stability
between the distal segment and the shaft.
Of the five biomechanical studies of distal humeral fracture fixation in
the literature of which we are
aware9,11,32,36,37,
only three compared so-called 90-90 plate fixation (medial and posterolateral
plates perpendicular to each other) to parallel plate fixation (medial and
lateral plates in the sagittal
plane)9,36,37.
Of these three studies, two showed parallel plate fixation to be substantially
more stable than 90-90 plate
fixation9,37,
and one demonstrated no
difference36.
Schemitsch et al.37
reported the biomechanical superiority of a lateral Dupont plate combined with
a medial reconstruction plate, applied exactly as described in this report,
compared with medial and posterolateral reconstruction plates placed in the
traditional manner according to the AO/ASIF technique. In the presence of a
supracondylar gap created to model comminution or bone loss, parallel plate
fixation was found to be substantially more stable than 90-90 plates in all
directions tested. We have found no data in the literature to support the
claim that placing the lateral plate posteriorly is biomechanically superior
to placing it laterally.
Several features distinguish the series of patients in the present report
from those in previous reports. First, only complex fractures with severe
comminution and/or very low transcondylar fractures in osteopenic bone were
included. Second, our patients were mostly referred to our tertiary care
center by other orthopaedic surgeons who anticipated difficulty in achieving
stable fixation. Finally, the majority of the patients had other injuries and
almost half of the fractures were open, with most of the open fractures
associated with severe soft-tissue injuries. Neither hardware failure nor
fracture displacement occurred in any of the patients included in the present
study despite the complexity of the fractures and the intensive early
rehabilitation to restore elbow motion. Union was achieved primarily in
thirty-one of the thirty-two elbows, and the one fracture that required an
additional procedure to achieve union had not displaced at the time of the
repeat surgery.
Although fracture stability was achieved in all patients, the final outcome
was still compromised in some by the consequences of the soft-tissue trauma or
extensive cartilage damage. Several patients had delayed or inadequate
wound-healing. In addition, five patients underwent excision of heterotopic
ossification that blocked motion. Appropriate rehabilitation was delayed or
contraindicated for half of our patients because of the need to protect
severely damaged soft tissues, the presence of associated injuries that
precluded elbow motion, or the inability of the patient to comply with the
protocol as a result of cognitive or medical impairment. The severity of the
soft-tissue and cartilage injuries that are commonly associated with
high-energy fractures also plays a definite role in the final outcome of these
injuries. In fact, in our study, open fractures were associated with
significantly more pain, worse functional outcomes, and more complications,
including heterotopic ossification and the need for a reoperation, than were
closed fractures. Fractures that had been treated surgically prior to referral
were also associated with significantly higher rates of heterotopic
ossification. In the absence of severe heterotopic ossification, no
reoperations were performed in these patients for the purpose of improving
motion.
In conclusion, the principle-based technique for internal fixation of
distal humeral fractures described in this study allows an intensive program
of elbow motion immediately after surgery and is associated with a high union
rate. When elbow rehabilitation can be pursued postoperatively, restoration of
painless and satisfactory elbow function can be expected. The key to achieving
these principles is the creation of a construct with the features and
stability of an arch, with the two columns locked together.
Tables summarizing the clinical data on all fractures in this study and
listing the findings of other reports on surgical treatment of similar
fractures are available with the electronic versions of this article, on our
web site at
(go to
the article citation and click on "Supplementary Material") and on
our quarterly CD-ROM (call our subscription department, at 781-449-9780, to
order the CD-ROM). ?
Gabel GT, Hanson G, Bennett JB, Noble
PC, Tullos HS. Intra-articular fractures of the distal humerus in the adult.
Clin Orthop Relat Res.
1987;216:
99-108.21699Â
1987Â
[PubMed] Â
Henley MB, Bone LB, Parker B. Operative
management of intra-articular fractures of the distal humerus. J Orthop
Trauma. 1987;1:
24-35.124Â
1987Â
[CrossRef] Â
Holdsworth BJ, Mossad MM. Fractures of
the adult distal humerus. Elbow function after internal fixation. J
Bone Joint Surg Br. 1990;72:
362-5.72362Â
1990Â
Â
John H, Rosso R, Neff U, Bodoky A,
Regazzoni P, Harder F. Operative treatment of distal humeral fractures in the
elderly. J Bone Joint Surg Br.
1994;7:
793-6.7793Â
1994Â
Â
Jupiter JB, Neff U, Holzach P, Allgower
M. Intercondylar fractures of the humerus. J Bone Joint Surg
Am. 1985;67:
226-39.67226Â
1985Â
Â
Letsch R, Schmit-Neuerburg KP, Sturmer
KM, Walz M. Intraarticular fractures of the distal humerus. Surgical treatment
and results. Clin Orthop Relat Res.
1989;241:
238-44.241238Â
1989Â
[PubMed] Â
Ring D, Jupiter JB. Fractures of the
distal humerus. Orthop Clin North Am.
2000;31:
103-13.31103Â
2000Â
[PubMed][CrossRef] Â
Helfet DL, Schmeling GJ. Bicondylar
intraarticular fractures of the distal humerus in adults. Clin Orthop
Relat Res. 1993;292:
26-36.29226Â
1993Â
Â
Self J, Viegas SF, Buford WL Jr,
Patterson RM. A comparison of double-plate fixation methods for complex distal
humerus fractures. J Shoulder Elbow Surg.
1995;4:
10-6.410Â
1995Â
[PubMed][CrossRef] Â
Ackerman G, Jupiter JB. Non-union of
fractures of the distal end of the humerus. J Bone Joint Surg
Am. 1988;70:
75-83.7075Â
1988Â
Â
Korner J, Diederichs G, Arzdorf M, Lill
H, Josten C, Schneider E, Linke B. A biomechanical evaluation of methods of
distal humerus fracture fixation using locking compression plates versus
conventional reconstruction plates. J Orthop Trauma.
2004;18:
286-93.18286Â
2004Â
[PubMed][CrossRef] Â
O'Driscoll SW. Optimizing stability in
distal humeral fracture fixation. J Shoulder Elbow Surg.
2005;14(1 Suppl S):
186S-194S.14186SÂ
2005Â
[PubMed][CrossRef] Â
O'Driscoll SW, Jupiter JB, Cohen MS,
Ring D, McKee MD. Difficult elbow fractures: pearls and pitfalls. Instr
Course Lect. 2003;52:
113-34.52113Â
2003Â
Â
O'Driscoll SW, Sanchez-Sotelo J, Torchia
ME. Management of the smashed distal humerus. Orthop Clin North
Am. 2002;33:
19-33, vii.3319Â
2002Â
[CrossRef] Â
Sanchez-Sotelo J, Torchia ME, O'Driscoll
SW. Principle-based internal fixation of distal humerus fractures. Tech
Hand Up Extrem Surg. 2001;5:
179-87.5179Â
2001Â
[CrossRef] Â
Gustilo RB, Anderson JT. Prevention of
infection in the treatment of one thousand and twenty-five open fractures of
long bones: retrospective and prospective analyses. J Bone Joint Surg
Am. 1976;58:
453-8.58453Â
1976Â
Â
Bryan RS, Morrey BF. Extensive posterior
exposure of the elbow. A triceps-sparing approach. Clin Orthop Relat
Res. 1982;166:
188-92.166188Â
1982Â
Â
O'Driscoll SW. The triceps-reflecting
anconeus pedicle (TRAP) approach for distal humeral fractures and nonunions.
Orthop Clin North Am.
2000;31:
91-101.3191Â
2000Â
[PubMed][CrossRef] Â
Hughes RE, Schneeberger AG, An KN,
Morrey BF, O'Driscoll SW. Reduction of triceps muscle force after shortening
of the distal humerus: a computational model. J Shoulder Elbow
Surg. 1997;6:
444-8.6444Â
1997Â
[CrossRef] Â
O'Driscoll SW, Giori NJ. Continuous
passive motion (CPM): theory and principles of clinical application. J
Rehabil Res Dev. 2000;37:
179-88. Erratum in: J Rehabil Res Dev.
2000;38:291.37179Â
2000Â
Â
Morrey BF, An KN. Functional evaluation
of the elbow. In: Morrey BF, editor. The elbow and its
disorders. 3rd ed. Philadelphia: WB Saunders; 2000. p
74 -83.74Â
2000Â
Â
Fracture and dislocation compendium. Orthopaedic Trauma Association
Committee for Coding and Classification. J Orthop Trauma.
1996;10Suppl 1:
v-ix, 1-154.10vÂ
1996Â
[PubMed] Â
Broberg MA, Morrey BF. Results of
treatment of fracture-dislocations of the elbow. Clin Orthop Relat
Res. 1987;216:
109-19.216109Â
1987Â
Â
Brooker AF, Bowerman JW, Robinson RA,
Riley LH Jr. Ectopic ossification following total hip replacement. Incidence
and a method of classification. J Bone Joint Surg Am.
1973;55:
1629-32.551629Â
1973Â
[PubMed] Â
Haas N, Hauke C, Schutz M, Kaab M,
Perren SM. Treatment of diaphyseal fractures of the forearm using the Point
Contact Fixator (PC-Fix): results of 387 fractures of a prospective
multicentric study (PC-Fix II). Injury.
2001;32Suppl 2:
B51-62.32B51Â
2001Â
[PubMed][CrossRef] Â
Kellam J. Editorial perspective. To
Jacobson SR, Glisson RR, Urbaniak JR: Comparison of distal humerus fracture
fixation. A biomechanical study. J South Orthop Assoc.
1997;6:
249.6249Â
1997Â
Â
Morrey BF. Fractures of the distal
humerus: role of the elbow replacement. Orthop Clin North Am.
2000;31:
145-54.31145Â
2000Â
[PubMed][CrossRef] Â
Robinson CM, Hill RM, Jacobs N, Dall G.
Court-Brown CM. Adult distal humeral metaphyseal fractures: epidemiology and
results of treatment. J Orthop Trauma.
2003;17:
38-47.1738Â
2003Â
[PubMed][CrossRef] Â
Ring D, Jupiter JB. Complex fractures of
the distal humerus and their complications. J Shoulder Elbow
Surg. 1999;8:
85-97.885Â
1999Â
[CrossRef] Â
Sodergard J, Sandelin J, Bostman O.
Mechanical failures of internal fixation in T and Y fractures of the distal
humerus. J Trauma. 1992;33:
687-90.33687Â
1992Â
[PubMed][CrossRef] Â
Sodergard J, Sandelin J, Bostman O.
Postoperative complications of distal humeral fractures. 27/96 adults followed
up for 6 (2-10) years. Acta Orthop Scand.
1992;63:
85-9.6385Â
1992Â
[PubMed][CrossRef] Â
Helfet DL, Hotchkiss RN. Internal
fixation of the distal humerus: a biomechanical comparison of methods.
J Orthop Trauma. 1990;4:
260-4.4260Â
1990Â
[PubMed][CrossRef] Â
Safran O, Mosheiff R, Segal D,
Liebergall M. Surgical treatment of intercondylar fractures of the humerus in
adults. Am J Orthop.
1999;28:
659-62.28659Â
1999Â
[PubMed] Â
Waddell JP, Hatch J, Richards R.
Supracondylar fractures of the humerus—results of surgical treatment.
J Trauma. 1988;28:
1615-21.281615Â
1988Â
[PubMed][CrossRef] Â
Wildburger R, Mahring M, Hofer HP.
Supraintercondylar fractures of the distal humerus: results of internal
fixation. J Orthop Trauma.
1991;5:
301-7.5301Â
1991Â
[PubMed][CrossRef] Â
Jacobson SR, Glisson RR, Urbaniak JR.
Comparison of distal humerus fracture fixation: a biomechanical study.
J South Orthop Assoc.
1997;6:
241-9.6241Â
1997Â
[PubMed] Â
Schemitsch EH, Tencer AF, Henley MB.
Biomechanical evaluation of methods of internal fixation of the distal
humerus. J Orthop Trauma.
1994;8:
468-75.8468Â
1994Â
[PubMed] Â
Sanders RA, Raney EM, Pipkin S.
Operative treatment of bicondylar intraarticular fractures of the distal
humerus. Orthopaedics.
1992;15:
159-63.15159Â
1992Â
Â
McKee MD, Jupiter JB. A contemporary
approach to the management of complex fractures of the distal humerus and
their sequelae. Hand Clin.
1994;10:
479-94.10479Â
1994Â
[PubMed] Â
McKee MD, Wilson TL, Winston L,
Schemitsch EH, Richards RR. Functional outcome following surgical treatment of
intra-articular distal humeral fractures through a posterior approach.
J Bone Joint Surg Am.
2000;82:
1701-7.821701Â
2000Â
[PubMed] Â
Pajarinen J, Bjorkenheim 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:
48-52.1148Â
2002Â
[CrossRef] Â
Gofton WT, Macdermid JC, Patterson SD,
Faber KJ, King GJ. Functionoutcome of AO type C distal humeral fractures.
J Hand Surg [Am]. 2003;28:
294-308.28294Â
2003Â
[PubMed][CrossRef] Â
Soon JL, Chan BK, Low CO. Surgical
fixation of intra-articular fractures of the distal humerus in adults.
Injury. 2004;35:
44-54.3544Â
2004Â
[PubMed][CrossRef] Â