Frakturen des distalen Humerus

Zusammenfassung

Frakturen des distalen Humerus stellen mit ca. 2–3 % eine seltenere Fraktur dar. Aufgrund der komplexen Gelenkgeometrie und Frakturmuster gilt die distale Humerusfraktur hinsichtlich Diagnostik, Therapie und Nachbehandlung als eine Herausforderung für den behandelnden Arzt. Neben extraartikulären und partiell artikulären Frakturen finden sich zunehmend intraartikuläre Frakturformen. Durch die demografische Entwicklung ist in Zukunft mit einer Zunahme der im Senium typischen, mehrfragmentären artikulären Frakturen bei begleitend schlechter Knochenqualität zu rechnen. Die konservative Therapie durch Immobilisation führt regelhaft zu erheblichen posttraumatischen Bewegungseinschränkungen. Das Ziel einer stabilen und schmerzfreien Gelenkfunktion ist nur durch offene Reposition und unmittelbare übungsstabile Osteosynthese zu erreichen. Zur differenzierten Therapie dieser komplexen Gelenkfrakturen sind detaillierte Kenntnisse der Anatomie und Biomechanik, der operativen Zugangswege und verfügbaren Implantate als auch des Nachbehandlungsregimes erforderlich.

Abstract

Fractures of the distal humerus are rare and count only for a small number of all fractures in mature patients. Due to demographic changes surgeons will be faced with an increasing number of complex multifragmentary fractures with diminished bone quality. As conservative treatment frequently leads to limited and painful elbow function, open reduction and stable internal fixation with early range of motion exercises are considered the gold standard. Detailed knowledge of the complex articular anatomy, the biomechanics, operative approaches and available implants is needed for the proper management of these complex fractures.

Key words

distaler Humerus - Fraktur - operative Zugänge - Osteosynthese - Winkelstabilität

Key words

distal humerus - fracture - surgical exposures - osteosynthesis - angular stability

Literatur

• 1 McCarty L P, Ring D, Jupiter J B. Management of distal humerus fractures.  Am J Orthop (Belle Mead NJ). 2005;  34 430-438
• 2 Diederichs G, Issever A S, Greiner S et al. Three-dimensional distribution of trabecular bone density and cortical thickness in the distal humerus.  J Shoulder Elbow Surg. 2009;  18 399-407
• 3 Park S H, Kim S J, Park B C et al. Three-dimensional osseous micro-architecture of the distal humerus: implications for internal fixation of osteoporotic fracture.  J Shoulder Elbow Surg. 2010;  19 244-250
• 4 Dunham C E, Takaki S E, Johnson J A et al. Mechanical properties of cancellous bone of the distal humerus.  Clin Biomech. 2005;  20 834-838
• 5 Halls A A, Travill A. Transmission of pressures across the elbow joint.  Anat Rec. 1964;  150 243-247
• 6 Ring D, Jupiter J B. Fracture-dislocation of the elbow.  J Bone Joint Surg Am. 1998;  80 566-580
• 7 Yamaguchi K, Sweet F A, Bindra R et al. The extraosseous and intraosseous arterial anatomy of the adult elbow.  J Bone Joint Surg Am. 1997;  79 1653-1662
• 8 Kimball J P, Glowczewskie F, Wright T W. Intraosseous blood supply to the distal humerus.  J Hand Surg Am. 2007;  32 642-646
• 9 Robinson C M, Hill R M, Jacobs N et al. Adult distal humeral metaphyseal fractures: epidemiology and results of treatment.  J Orthop Trauma. 2003;  17 38-47
• 10 Amis A A, Miller J H. The mechanisms of elbow fractures: an investigation using impact tests in vitro.  Injury. 1995;  26 163-168
• 11 Armstrong A D, Yamaguchi K. Total elbow anthroplasty and distal humerus elbow fractures.  Hand Clin. 2004;  20 475-483
• 12 Pajarinen J, Bjorkenheim J M. 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
• 13 Palvanen M, Kannus P, Niemi S et al. Secular trends in the osteoporotic fractures of the distal humerus in elderly women.  Eur J Epidemiol. 1998;  14 159-164
• 14 Palvanen M, Kannus P, Niemi S et al. Secular trends in distal humeral fractures of elderly women: nationwide statistics in Finland between 1970 and 2007.  Bone. 2010;  46 1355-1358
• 15 Court-Brown C M, Caesar B. Epidemiology of adult fractures: a review.  Injury. 2006;  37 691-697
• 16 Doornberg J, Lindenhovius A, Kloen P et al. Two and three-dimensional computed tomography for the classification and management of distal humeral fractures. Evaluation of reliability and diagnostic accuracy.  J Bone Joint Surg Am. 2006;  88 1795-1801
• 17 Müller M, Nazarian S, Koch P. The AO classification of long bones.. Heidelberg: Springer; 1987
• 18 Bryan R S, Morrey B F. Fractures of the distal humerus.. In: Morrey B F, ed. The Elbow and its Disorders.. Philadelphia: WB Saunders; 1985: 325-333
• 19 McKee M D, Jupiter J B, Bamberger H B. Coronal shear fractures of the distal end of the humerus.  J Bone Joint Surg Am. 1996;  78 49-54
• 20 Riseborough E J, Radin E L. Intercondylar T fractures of the humerus in the adult. A comparison of operative and non-operative treatment in twenty-nine cases.  J Bone Joint Surg Am. 1969;  51 130-141
• 21 Jupiter J B, Mehne D K. Fractures of the distal humerus.  Orthopedics. 1992;  15 825-833
• 22 Gustilo R B, Anderson J T. 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;  58 453-458
• 23 Tscherne H, Oestern H J. A new classification of soft-tissue damage in open and closed fractures (author's transl.).  Unfallheilkunde. 1982;  85 111-115
• 24 Südkamp N. Soft-tissue injury: pathophysiology, evaluation and classification.. In: Rüedi T, Buckley R, Moran C, eds. AO Principles of Fracture Management.. Davos Platz: AO Publishing; 2007: 87-115
• 25 Reising K, Hauschild O, Strohm P C et al. Stabilisation of articular fractures of the distal humerus: early experience with a novel perpendicular plate system.  Injury. 2009;  40 611-617
• 26 Korner J, Lill H, Muller L P et al. Distal humerus fractures in elderly patients: results after open reduction and internal fixation.  Osteoporos Int. 2005;  16 (Suppl. 2) S73-S79
• 27 Athwal G S, Hoxie S C, Rispoli D M et al. Precontoured parallel plate fixation of AO/OTA type C distal humerus fractures.  J Orthop Trauma. 2009;  23 575-580
• 28 Schmidt-Horlohe K, Bonk A, Wilde P et al. Functional results after osteosynthesis of the distal humerus fracture with an anatomically precontoured, angular-stable double plate system.  Z Orthop Unfall. 2010;  148 300-308
• 29 Morrey B F. Current concepts in the treatment of fractures of the radial head, the olecranon, and the coronoid.  Instr Course Lect. 1995;  44 175-185
• 30 Eastwood J. The T-shaped fracture of the lower end of the humerus.  J Bone Joint Surg Am. 1937;  19 364-369
• 31 Raschke M J. Supra- und perkondyläre Humerusfrakturen.. In: Stöckle U, Hrsg. Ellenbogenchirurgie.. München: Elsevier; 2010: 84-87
• 32 Papaioannou N, Babis G C, Kalavritinos J et al. Operative treatment of type C intra-articular fractures of the distal humerus: the role of stability achieved at surgery on final outcome.  Injury. 1995;  26 169-173
• 33 Kundel K, Braun W, Wieberneit J et al. Intraarticular distal humerus fractures. Factors affecting functional outcome.  Clin Orthop Relat Res. 1996;  332 200-208
• 34 Dowdy P A, Bain G I, King G J et al. The midline posterior elbow incision. An anatomical appraisal.  J Bone Joint Surg Br. 1995;  77 696-699
• 35 Chen R C, Harris D J, Leduc S et al. Is ulnar nerve transposition beneficial during open reduction internal fixation of distal humerus fractures?.  J Orthop Trauma. 2010;  24 391-394
• 36 Uhl R L, Larosa J M, Sibeni T et al. Posterior approaches to the humerus: when should you worry about the radial nerve?.  J Orthop Trauma. 1996;  10 338-340
• 37 Alonso-Llames M. Bilaterotricipital approach to the elbow. Its application in the osteosynthesis of supracondylar fractures of the humerus in children.  Acta Orthop Scand. 1972;  43 479-490
• 38 Pollock J W, Athwal G S, Steinmann S P. Surgical exposures for distal humerus fractures: a review.  Clin Anat. 2008;  21 757-768
• 39 MacAusland W. Ankylosis of the elbow: with report of 4 cases treated by arthroplasty.  JAMA. 1915;  64 312-318
• 40 Patterson S D, Bain G I, Mehta J A. Surgical approaches to the elbow.  Clin Orthop Relat Res. 2000;  370 19-33
• 41 Gainor B J, Moussa F, Schott T. Healing rate of transverse osteotomies of the olecranon used in reconstruction of distal humerus fractures.  J South Orthop Assoc. 1995;  4 263-268
• 42 Wilkinson J M, Stanley D. Posterior surgical approaches to the elbow: a comparative anatomic study.  J Shoulder Elbow Surg. 2001;  10 380-382
• 43 Dakoure P W, Ndiaye A, Ndoye J M et al. Posterior surgical approaches to the elbow: a simple method of comparison of the articular exposure.  Surg Radiol Anat. 2007;  29 671-674
• 44 McKee M D, 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;  82 646-651
• 45 Bryan R S, Morrey B F. Extensive posterior exposure of the elbow. A triceps-sparing approach.  Clin Orthop Relat Res. 1982;  166 188-192
• 46 Lewicky Y M, Sheppard J E, Ruth J T. The combined olecranon osteotomy, lateral paratricipital sparing, deltoid insertion splitting approach for concomitant distal intra-articular and humeral shaft fractures.  J Orthop Trauma. 2007;  21 133-139
• 47 Archdeacon M T. Combined olecranon osteotomy and posterior triceps splitting approach for complex fractures of the distal humerus.  J Orthop Trauma. 2003;  17 368-373
• 48 Korner J, Diederichs G, Arzdorf M et al. A biomechanical evaluation of methods of distal humerus fracture fixation using locking compression plates versus conventional reconstruction plates.  J Orthop Trauma. 2004;  18 286-293
• 49 O'Driscoll S W. Optimizing stability in distal humeral fracture fixation.  J Shoulder Elbow Surg. 2005;  14 186S-194S
• 50 O'Driscoll S W, Sanchez-Sotelo J, Torchia M E. Management of the smashed distal humerus.  Orthop Clin North Am. 2002;  33 19-33 VII
• 51 Helfet D L, Hotchkiss R N. Internal fixation of the distal humerus: a biomechanical comparison of methods.  J Orthop Trauma. 1990;  4 260-264
• 52 Jupiter J B, Neff U, Holzach P et al. Intercondylar fractures of the humerus. An operative approach.  J Bone Joint Surg Am. 1985;  67 226-239
• 53 Self J, Viegas S F, Buford jr. W L et al. A comparison of double-plate fixation methods for complex distal humerus fractures.  J Shoulder Elbow Surg. 1995;  4 10-16
• 54 John H, Rosso R, Neff U et al. Distal humerus fractures in patients over 75 years of age. Long-term results of osteosynthesis.  Helv Chir Acta. 1993;  60 219-224
• 55 Gupta R, Khanchandani P. Intercondylar fractures of the distal humerus in adults: a critical analysis of 55 cases.  Injury. 2002;  33 511-515
• 56 Korner J, Lill H, Muller L P et al. The LCP-concept in the operative treatment of distal humerus fractures – biological, biomechanical and surgical aspects.  Injury. 2003;  34 (Suppl. 2) B20-B30
• 57 Siebenlist S, Stöckle U, Lucke M. Problematik osteoporotischer Frakturen am Ellenbogen.  Obere Extremität. 2009;  4 160-167
• 58 Rubberdt A, Surke C, Fuchs T et al. Preformed plate-fixation system for type AO 13C3 distal humerus fractures: Clinical experiences and treatment results taking access into account.  Unfallchirurg. 2008;  111 308-322
• 59 Greiner S, Haas N P, Bail H J. 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;  128 723-729
• 60 Frigg R. Locking compression plate (LCP). An osteosynthesis plate based on the dynamic compression plate and the point contact fixator (PC-Fix).  Injury. 2001;  32 (Suppl. 2) 63-66
• 61 Sanchez-Sotelo J, Torchia M E, O'Driscoll S W. Complex distal humeral fractures: internal fixation with a principle-based parallel-plate technique.  J Bone Joint Surg Am. 2007;  89 961-969
• 62 Prasad N, Dent C. Outcome of total elbow replacement for distal humeral fractures in the elderly: a comparison of primary surgery and surgery after failed internal fixation or conservative treatment.  J Bone Joint Surg Br. 2008;  90 343-348
• 63 Cobb T K, Morrey B F. Total elbow arthroplasty as primary treatment for distal humeral fractures in elderly patients.  J Bone Joint Surg Am. 1997;  79 826-832
• 64 Ali A, Shahane S, Stanley D. Total elbow arthroplasty for distal humeral fractures: indications, surgical approach, technical tips, and outcome.  J Shoulder Elbow Surg. 2010;  19 (2 Suppl.) 53-58
• 65 Lill H, Korner J, Josten C. Distale Humerusfrakturen.. In: Josten C, Lill H, Hrsg. Ellenbogenverletzungen.. Darmstadt: Steinkopf Verlag; 2002: 163-182
• 66 Morrey B F, Askew L J, Chao E Y. A biomechanical study of normal functional elbow motion.  J Bone Joint Surg Am. 1981;  63 872-877
• 67 Raiss P, Rettig O, Wolf S et al. Range of motion of shoulder and elbow in activities of daily life in 3D motion analysis.  Z Orthop Unfall. 2007;  145 493-498
• 68 Sodergard J, Sandelin J, Bostman O. Mechanical failures of internal fixation in T and Y fractures of the distal humerus.  J Trauma. 1992;  33 687-690
• 69 Lob G, Burri C, Feil J. Operative treatment of distal intra-articular humerus fractures; results of 412 follow-up cases (AO-collected statistics).  Langenbecks Arch Chir. 1984;  364 359-361
• 70 Proust J, Oksman A, Charissoux J L et al. Intra-articular fracture of the distal humerus: outcome after osteosynthesis in patients over 60.  Rev Chir Orthop Reparatrice Appar Mot. 2007;  93 798-806
• 71 Vazquez O, Rutgers M, Ring D C et al. Fate of the ulnar nerve after operative fixation of distal humerus fractures.  J Orthop Trauma. 2010;  24 395-399
• 72 McKee M D, Jupiter J B, Bosse G et al. Outcome of ulnar neurolysis during post-traumatic reconstruction of the elbow.  J Bone Joint Surg Br. 1998;  80 100-105
• 73 Helfet D L, Schmeling G J. Bicondylar intraarticular fractures of the distal humerus in adults.  Clin Orthop Relat Res. 1993;  292 26-36
• 74 Gupta R. Intercondylar fractures of the distal humerus in adults.  Injury. 1996;  27 569-572
• 75 Holdsworth B J, Mossad M M. Fractures of the adult distal humerus. Elbow function after internal fixation.  J Bone Joint Surg Br. 1990;  72 362-365
• 76 Henley M B, Bone L B, Parker B. Operative management of intra-articular fractures of the distal humerus.  J Orthop Trauma. 1987;  1 24-35
• 77 McKee M D, Veillette C J, Hall J A et al. A multicenter, prospective, randomized, controlled trial of open reduction – internal fixation versus total elbow arthroplasty for displaced intra-articular distal humeral fractures in elderly patients.  J Shoulder Elbow Surg. 2009;  18 3-12
• 78 Müller L P, Dietz S-O, Rommens P M et al. Total elbow replacement as primary treatment for complex fractures of the distal osteopenic humerus.  European J Trauma. 2003;  29 63-67