Documente Academic
Documente Profesional
Documente Cultură
Jeffrey Anglen, MD
F ractures of the elbow constitute
about 7% of adult fractures; dis-
tal humerus fractures account for
teopenia and/or comminution of the
joint surface in which stable recon-
struction cannot be achieved, total
less than half of all elbow fractures. elbow arthroplasty using a semi-
There is evidence, however, that in- constrained linked prosthesis may
cidence is increasing. Investigators be preferable to other options.4 For
in Finland performed a retrospective most displaced unstable fractures in
The video that accompanies this article
review of hospital admission records patients with functional arms, open
is “Open Reduction and Internal Fixa-
tion,” available on the Orthopaedic
between 1970 and 1995 and found reduction and internal fixation
Knowledge Online website, at
that the age-adjusted increase in in- (ORIF) is indicated to restore opti-
http://www5.aaos.org/oko/trauma/jaaos. cidence in women older than 60 mal elbow function.
years had more than doubled.1
The Orthopaedic Trauma Associ-
Contraindications
ation (OTA)/AO classification sys-
tem divides distal humerus fractures Contraindications to ORIF of distal
into type A, nonarticular; type B, humerus fractures include inability
partial articular; and type C, com- to tolerate surgery because of health
plete articular2 (Fig. 1). Additional status, inability to benefit from sur-
levels of classification are based on gery because of neurologic impair-
position and orientation of the frac- ment of the limb, and inability to
ture line and degree of comminu- achieve stability because of severe
tion. osteopenia or deficient bone. In addi-
The partial articular fractures can tion, ORIF is contraindicated in pa-
be described as “unicolumnar” frac- tients with excessively high risk for
tures; they are rare in adults (2% to local complications because of in-
3%) and are more common in chil- fected or deficient soft tissues.
dren and adolescents. Fractures of
the lateral column are more com-
Surgical Technique
mon than those of the medial col-
umn. Capitellar fractures are a spe- The surgical approach and implant
cial instance of partial articular strategy for ORIF of a distal humer-
Dr. Anglen is Professor and Chairman,
fractures (OTA/AO B3.1) represent- us fracture are guided by the classi-
Department of Orthopaedics, Indiana
University School of Medicine, Indianap-
ing a shearing injury with very little fication of the fracture.
olis, IN.
soft-tissue attachment to the anteri- Nonarticular fractures (type A):
or fragment. Three types of lateral These usually can be fixed through a
Neither Dr. Anglen nor the department column fractures have been de- triceps-splitting approach (Fig. 2) or
with which he is affiliated has received scribed by Bryan and Morrey.3 triceps-sparing approach (Fig. 3) with
anything of value from or owns stock in a restoration of alignment and bico-
commercial company or institution re- lumnar fixation. Isolated epicondy-
lated directly or indirectly to the subject Indications
lar fractures in many cases can be
of this article.
Nonsurgical treatment is appropri- fixed with lag screws alone.
Reprint requests: Dr. Anglen, Indiana ate for stable, nondisplaced fractures Partial articular fractures (type B):
University School of Medicine, Suite and in patients with neurologic im- In the uncommon adult unicolum-
600, 540 Clinical Drive, Indianapolis IN pairment or otherwise nonfunction- nar fracture, lag screws alone may be
46202. al extremities. Hinged or static ex- adequate fixation when the bone
ternal fixation can be used for either quality is good. Otherwise, a but-
J Am Acad Orthop Surg 2005;13:291-
temporary or definitive treatment in tress or antiglide plate should be
297
patients with severely contaminated used. Some capitellar fractures can
Copyright 2005 by the American open wounds or extensive soft-tissue be fixed through a lateral or posteri-
Academy of Orthopaedic Surgeons. defects. In older patients with os- or approach with lag screws placed