Rationale

Numerous surgical approaches have been described for the fixation of distal humerus fractures. With the exception of approach strategies for coronal shear fractures, all of these involve a posterior skin incision with various strategies of working through, or around, the triceps. Described approaches include the triceps‐splitting, olecranon osteotomy, triceps‐reflecting (Bryan–Morrey), triceps‐reflecting anconeus pedicle (TRAP), and para‐tricipital approaches. Surgeon opinion regarding the optimal surgical approach to distal humerus fractures is widely divergent.

Clinical comment

One goal of surgical fixation of distal humerus fractures is achieving an upper extremity with functional range of motion and strength. The surgical approach of choice would ideally provide the maximum visualization of the joint surface while minimizing negative effects on function postoperatively.

Available literature and quality of the evidence

• Level III: 4 studies^1–4
  
• Level IV: 11 studies.^5–15

The evidence to answer this important question is limited to multiple level III and level IV studies.

Findings

Four level III studies retrospectively compared the triceps‐splitting approach and the olecranon osteotomy approach for distal humerus fractures fixation. Three of these studies showed no statistically significant differences between the approaches with regards to either objective elbow strength, range of motion (ROM), or functional outcomes (n = 62 patients).^1,2,4 Other level IV series of patients treated with olecranon osteotomy have reported rates of hardware removal ranging from 6 to 30% and nonunion of the olecranon osteotomy in 0–9% of patients.^5–9 One level III study compared the two approaches for the fixation of open distal humerus fractures and found better functional outcomes and a trend toward improved ROM in the triceps‐splitting group (n = 26 patients).³ Mayo Elbow Performance Score (MEPS) were 84.5 versus 73.5 (p = 0.05), and Disabilities of the Arm, Shoulder, and Hand (DASH) scores were 29.5 versus 64.1 (p = 0.05). Authors hypothesized that this effect was due to the fact that open fractures had a large tear in the triceps that was easily incorporated into the triceps splitting approach. Multiple level IV studies have reported satisfactory results using the olecranon osteotomy, triceps‐splitting,¹⁰ triceps‐reflecting,^11,12 and triceps sparing^13–15 approaches. A meta‐analysis of the literature looked at both the triceps‐splitting and Bryan–Morrey approaches independently compared to an olecranon osteotomy.¹⁶ The authors noted the overall low quality of evidence currently available. When comparing the Brian–Morrey approach with olecranon osteotomy, the MEPS showed no significant difference (standardized mean difference [SMD]: 0.20; 95% confidence interval [CI]: −0.40, 0.80; I² = 55%). Similarly, using the flexion extension arc as the performance outcome, there was no significant difference noted between the triceps‐splitting approach and olecranon osteotomy (SMD: −0.22; 95% CI: −1.53 to 1.08; I² = 86%). Analysis revealed no significant differences in terms of ulnar nerve injury, heterotopic ossification, infection, or post‐traumatic arthrosis. They did note a higher rate of re‐operation with olecranon osteotomy for hardware removal, although this finding was heavily weighted by one study in the analysis.

Resolution of clinical scenario

In patients with an intra‐articular distal humerus fracture, who are considered candidates for operative fixation of the fracture, it is the authors’ approach to use a triceps‐splitting technique (Figure 82.2) except in cases where there is extensive articular comminution, particularly those with a coronal shear component to the articular fracture. In these cases, the authors recommend an olecranon osteotomy to improve visualization based on the evidence that suggests a triceps‐splitting approach gives equivalent functional outcomes and a decreased need for removal of hardware when compared to olecranon osteotomy (overall quality: low).

Rationale

Since the introduction of AO techniques involving dual column plating for the fixation of distal humerus fractures, significant improvements in surgical outcomes have been observed. Evidence shows that plate fixation is superior compared to minimal fixation with screws and/or Kirschner wires (K‐wires).^17,18 However, controversy remains regarding the position/orientation of plate fixation and the role of locked plating systems.

Clinical comment

Fixation for distal humerus fractures must achieve anatomic and absolute stability of the articular surface. Fixation strategies must also bridge metaphyseal comminution while allowing for early ROM to avoid significant postoperative stiffness. Research has focused on identifying the ideal dual plating construct to resist early failure while achieving reliable union rates.

Available literature and quality of the evidence

• Level II: 1 study¹⁹
  
• Level IV: 22 studies.^20–23

Limited clinical evidence is available to answer this question. Most data come from a variety of biomechanical studies using various fracture models to analyze the properties of these two constructs.

Findings

One level II study compared parallel plating to perpendicular plating in a prospective, randomized fashion (n = 35 patients).¹⁹ Although no statistically significant differences were found between the two groups, there were two nonunions in the perpendicular plating group versus no nonunions in the parallel plating group. This study may have been underpowered to detect a clinically significant difference in union rates. Multiple level IV series have reported satisfactory results with perpendicular plating techniques²⁰

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