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SUMMARY
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Distal Humerus Fractures are traumatic injuries to the elbow that comprise of supracondylar fractures, single column fractures, column fractures or coronal shear fractures.
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Diagnosis is made with plain radiographs of the humerus and elbow. CT scan is helpful for intra-articular assessment and operative planning.
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Treatment is usually open reduction and internal fixation.
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EPIDEMIOLOGY
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Incidence
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accounts for 2% of all fractures
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accounts for 30% of elbow fractures
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incidence has been steadily increasing
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Demographics
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most common in young males and older females
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Anatomic location
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distal intercondylar fractures are the most common fracture pattern
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ETIOLOGY
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Pathophysiology
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distal humerus fractures are traumatic injuries that include
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supracondylar fractures
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single column (condyle) fractures
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bicolumnar fractures
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coronal shear fractures
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mechanism
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low energy falls in elderly
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high energy impact in younger population
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pathoanatomy
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elbow position affects fracture type
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elbow flexed < 90°
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axial load leads to transcolumnar fracture
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direct posterior blow leads to olecranon fracture with or without distal humerus involvement
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elbow flexed > 90°
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may lead to intercondylar fracture
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Associated injuries
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elbow dislocation
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terrible triad injury
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floating elbow
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Volkmann contracture
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results from missed forearm compartment syndrome
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ANATOMY
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Osteology
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elbow is a hinged joint
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articular surface is in
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6 degrees of valgus
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5 degrees of external rotation
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30 degrees of flexion
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trochlea
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articulates with sigmoid notch
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allows for flexion and extension
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capitellum
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articulates with proximal radius
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allows for forearm rotation
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Muscles
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common flexors (originate from medial epicondyle)
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pronator teres
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flexor carpi radialis
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palmaris longus
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FDS
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FCU
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common extensors (originate from lateral epicondyle)
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anconeus
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ECRL
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ECRB
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extensor digitorum comminus
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EDM
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ECU
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Ligaments
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medial collateral ligament
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anterior bundle originates from distal medial epicondyle
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inserts on sublime tubercle
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primary restraint to valgus stress at the elbow from 30-120°
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tight in pronation
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lateral collateral ligament
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originates from distal lateral epicondyle
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inserts on crista supinatorus
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stabilizer against posterolateral rotational instability
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tight in supination
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Nerves
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ulnar nerve
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resides in the cubital tunnel in a subcutaneous position posterior to the medial condyle
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- radial nerve
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anatomic landmarks
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in the spiral groove 15cm proximal to distal humeral articular surface
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10cm from the medial edge of the olecranon
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7.5cm from the lateral edge of the olecranon
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3.9 cm (two finger-breadths) proximal to the triceps aponeurosis
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runs between brachioradialis and brachialis proximal to elbow
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divides into PIN and superficial radial nerve at the level of the radial head
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Blood supply
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intraosseous and extraosseous blood supplies that may be compromised by the injury
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CLASSIFICATION
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Can be classified as
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supracondylar fractures
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distal single column fractures
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5% of fractures
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subclassified using Milch classification system (see table)
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lateral condyle more common than medial
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distal bicolumnar fractures
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classified using Jupiter classification system (see table)
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5 major articular fragments have been identified
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capitellum/lateral trochlea
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lateral epicondyle
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posterolateral epicondyle
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posterior trochlea
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medial trochlea/epicondyle
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AO/OTA Classification of Distal Humerus Fractures
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Type A
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Extra-articular (supracondylar fracture), 80% are extension type; epicondyle
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Type B
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Intraarticular- Single column (partial articular-isolated condylar, coronal shear, epicondyle with articular extension).
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Type C
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Intraarticular- Both columns fractured and no portion of the joint is contiguous with the shaft (complete articular)
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Each type further divided by degree and location of fracture comminution
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Milch Classification of Single Column Condyle Fractures
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Milch Type I
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Lateral trochlear ridge intact
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Milch Type II
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Fracture through lateral trochlear ridge
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Jupiter Classification of Two-Column Distal Humerus Fractures
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High-T
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Transverse fx proximal to or at upper olecranon fossa
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Low-T
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Transverse fx just proximal to trochlea (common)
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Y
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Oblique fx line through both columns with distal vertical fx line
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H
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Trochlea is a free fragment (risk of AVN)
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Medial lambda
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Proximal fx line exists medially
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Lateral lambda
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Proximal fx line exists laterally
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Multiplane T (not pictured)
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T type with an additional fracture in coronal plane
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PRESENTATION
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Symptoms
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elbow pain and swelling
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Physical exam
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check for open wounds, especially posteriorly
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gross instability often present
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avoid ROM due to risk of neurovascular damage
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neurovascular exam
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check function of radial, ulnar, and median nerves
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check distal pulses
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brachial artery may be injured
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if pulse decreased, obtain noninvasive vascular studies and consult vascular surgery if abnormal
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monitor carefully for forearm compartment syndrome
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IMAGING
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Radiographs
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recommended views
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AP
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ideally taken with 40 deg of flexion
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lateral
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additional views
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humerus and forearm radiographs
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wrist radiographs
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obtain if elbow injury present or distal tenderness on exam
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oblique radiographs
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specifically used to evaluate if there is continuity of the trochlear fragment with the medial epicondylar fragment, this can influence hardware choice
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traction radiograph
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may assist with surgical planning
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CT
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indications
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often obtained for surgical planning
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especially helpful when shear fractures of the capitellum and trochlea are suspected
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MRI
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indications
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usually not indicated in acute injury
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TREATMENT
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Nonoperative
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cast immobilization
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indications
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nondisplaced Milch Type I fractures
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technique
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above elbow cast with close follow-up due to risk of displacement
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short period of immobilization and followed by early range of motion ("bag of bones" technique)
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indications
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elderly patients
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with significant medical comorbidities precluding surgery
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unable to comply with postoperative protocol
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Operative
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closed reduction percutaneous pinning (CRPP)
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indications
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displaced Mich Type I fractures
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open reduction internal fixation (ORIF)
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indications
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supracondylar fractures
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intercondylar / bicolumnar fractures
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Milch Type II fractures
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total elbow arthroplasty
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indications
- distal comminuted bicolumnar fractures in low demand elderly patients
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must be able to comply with weightbearing restriction
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- distal comminuted bicolumnar fractures in low demand elderly patients
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TECHNIQUES
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Cast Immobilization
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technique
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immobilize in supination for lateral condyle fractures
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immobilize in pronation for medial condyle fractures
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Open reduction internal fixation (ORIF)
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approach
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posterior superficial approach
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exposures
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triceps-splitting (Campbell)
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technique
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split triceps tendon in midline down to olecranon
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for open fractures, approach using the defect leads to better results than an osteotomy
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triceps-sparing (paratricipital, Alonso-Llames, medial and lateral windows)
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indications
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extra-articular fractures
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fractures with a simple articular split
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technique
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elevate triceps from the humerus using medial and lateral windows
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can be converted to olecranon osteotomy if needed
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olecranon osteotomy
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complex intra-articular fractures
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fractures with a coronal splint
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contraindications
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total elbow arthroplasty is planned/may be required
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technique
- perform chevron (apex distal) osteotomy
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fixation of osteotomy performed using a combination of screws, K wires, tension band or plate
- perform chevron (apex distal) osteotomy
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complications
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AIN nerve injury
- check ability to flex thumb interphalangeal joint in recovery
- check ability to flex thumb interphalangeal joint in recovery
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symptomatic hardware (6-30%)
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osteotomy nonunion (0-9%)
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- indications
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triceps-reflecting (Bryan-Morrey)
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technique
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reflect triceps tendon, forearm fascia, and periosteum off the olecranon from medial to lateral
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repair through transosseous drill holes
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immobilize to protect triceps repair for 4-6 weeks postoperatively
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triceps-reflecting anconeus pedicle (O'Driscoll)
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technique
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elevate anconeous subperiosteally from proximal ulna
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lateral muscles interval
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technique
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elevate the ECRB and part of the ECRL off of the supracondylar ridge
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fixation
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perform provisional reduction with k-wires
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if metaphyseal injury is not comminuted, reducing one column to the metaphysis first may be beneficial
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perform fixation of articular fragments with countersunk/headless screws
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consider using positional screws when reducing trochlea to avoid narrowing it with compression
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perform fixation of condyles and epitrochlear ridge
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fix the lateral epicondyle using a tension band wire or plate
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fix the articular segment to the shaft using two plates in orthogonal planes
- new literature supports parallel plates for increased biomechanics strength
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no difference in clinical outcomes between 90-90 and parallel plating
- new literature supports parallel plates for increased biomechanics strength
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if the ulnar nerve contacts medial hardware during flexion/extension, can perform an ulnar nerve transposition
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no difference between rates of post-operative ulnar neuritis with in situ release compared to transposition
- no difference in patient-reported outcomes between transposition and in-situ release
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locking plates are preferred for poor bone quality or comminution
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postoperative
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splint elbow in 70° of flexion
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remove splint within 7-10 days post-operatively and initiate ROM exercises
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if osteotomy performed
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active and active-assisted flexion and extension for 6 weeks
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no active extension against gravity or resistance
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no restrictions to rotation
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if osteotomy not performed
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active motion against gravity without restrictions
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no restrictions to rotation
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start gentle strengthening program at 6 weeks and full strengthening program at 3 months
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Semiconstrained Total Elbow Arthroplasty
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indications
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comminuted articular fractures in osteoporotic bone
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inflammatory conditions (e.g. RA)
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complications specific to this treatment
- activity restrictions (e.g. can not lift more than 10 pounds)
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implant loosening
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polyethylene wear
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periprosthetic fracture
- activity restrictions (e.g. can not lift more than 10 pounds)
- functional outcomes similar to salvage arthroplasty following failed ORIF
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COMPLICATIONS
- Elbow stiffness
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most common (3-42%)
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mean arc of motion is 90-106 degrees
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treatment
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static-progressive splinting
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Heterotopic ossification
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seen in 8%
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routine prophylaxis is not warranted due to increased rate of nonunion in patients treated with indomethacin
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risk factors
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head injury
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floating elbow injury
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Type A and B fractures
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delayed surgical fixation
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- Nonunion
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low incidence (0-11%)
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risk factors
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excessive soft-tissue stripping
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open fractures
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comminution
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low transcondylar or intercondylar fractures
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treatment
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revision ORIF with bone graft
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Malunion
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avoided by proper surgical technique
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cubitus valgus (lateral column fractures)
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cubitus varus (medial column fractures)
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Anterior interosseous nerve injury
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can be seen with olecranon osteotomy
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Ulnar nerve injury (10-38%)
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Postoperative ulnar nerve palsies are most often secondary due to traction during open reduction and internal fixation
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Wound complications (up to 16%)
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due to poor soft tissue envelope over posterior elbow
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Infection
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occurs in 0-14% of patients
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Posttraumatic Arthritis
- Elbow stiffness
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PROGNOSIS
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ORIF
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majority of patients regain 75% of elbow motion and strength
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goal is to restore elbow ROM 30-130° of flexion
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Total elbow arthroplasty
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has rates of implant survival >75% at 10 years if used with appropriate indications
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expected ROM is 26-125 degrees
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in patients > 65 years old functional outcomes were higher with TEA than ORIF at 2-year follow-up
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"Bag of bones"
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goal is a painless pseudoarthrosis
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only fair functional outcomes
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high rate of nonunion and later surgery
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Unsatisfactory outcomes in up to 25%
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treatment of these fractures is complex due to
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low fracture line of one or both columns
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metaphyseal fragmentation of one or both columns
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articular comminution
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poor bone quality
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