Challenges in selecting surgical approaches for intra- and juxta-articular fractures of the distal humerus

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Abstract

Fractures of the distal metaepiphysis of the humerus are relatively common injuries affecting the bones of the elbow joint. These fractures are often associated with soft tissue damage, including tendon and muscle injuries, which is a typical feature of trauma to these structures. In current trauma practice, surgical methods are preferred for distal humerus fractures, typically involving open reduction of bone fragments and stable functional osteosynthesis. However, despite advances in surgical techniques for managing long bone fractures, the disability rate following distal humerus fractures remains high, particularly among individuals of working age.

The choice of an optimal surgical approach is a critical factor in osteosynthesis of this fracture type, as it must minimize soft tissue trauma while providing adequate visualization of the bone fragments. Despite extensive experience in managing these fractures, the global orthopedic community still lacks a unified algorithm for selecting the most appropriate surgical approach for distal humerus osteosynthesis.

This review aims to summarize data from the international literature on various aspects of managing distal humerus fractures, with a particular focus on surgical approaches and criteria for selecting the optimal treatment strategy.

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BACKGROUND

Fractures of the distal metaphysis of the humerus are very common injuries to the bones that form the elbow joint; they can occur in people of all age groups [1, 2]. In adults, intra-articular fractures of the distal humerus (DH) account for up to 10.0% of all joint injuries [3, 4].

Despite the progress gained in the development of surgical treatment methods for intra- and juxta-articular DH fractures, their treatment is still a challenge for surgeons [2, 5, 6]. Contributing to the development of combined contractures in the postimmobilization period, concomitant damage to ligaments of the elbow joint is a common issue associated with this fracture. Many authors noted that options to prevent these complications include early internal osteosynthesis with low-trauma surgical approaches together with an appropriate rehabilitation treatment program for a specific patient [2, 7, 8].

EPIDEMIOLOGY

Fractures of the distal metaphysis of the humerus account for 0.5% to 5% of musculoskeletal injuries in people over 18 years of age [1–4]. In 18% to 85% of cases, patients develop various complications after treatment (such as elbow joint contracture, heterotypic ossification, posttraumatic arthrosis, etc.); approximately 30% of patients become disabled due to persistent elbow dysfunction [5–7].

According to different sources, intra- and juxta-articular DH fractures in adult patients account for 0.5% to 2% of DH fractures and 3% to 24% of all fractures of the upper limbs [8–11]. The incidence of DH fractures has a bimodal structure, peaking both in elderly patients with low-energy injuries and concomitant osteoporosis and young patients with high-energy injuries [12, 13]. Being more common in people of working age, this type of injury leads to disability in approximately 30% of cases [14–16]. Such a high disability rate is explained by frequent elbow joint contractures, heterotopic ossification, and posttraumatic arthrosis [17–20].

TREATMENT CHALLENGES AND COMPLICATIONS

Axial load transmitted through the elbow joint when the elbow is flexed more than 90° is a common cause of fractures of the distal metaphysis of the humerus [17]. Acting like a wedge, the olecranon process is pressed between the two columns of the distal metaphysis of the humerus, splitting and displacing them. All this explains the fact that the vast majority of fractures in the lower third of the shoulder in adults are intra-articular and affect both columns of the humerus [20, 21].

Challenges that surgeons face in treating fractures of the bones that form the elbow joint are related to its structural and biomechanical characteristics, the proximity of neural structures, and a high probability of heterotopic ossification in this area. Various complications in the postoperative period of DH fractures are often associated with poor functional results, thus requiring revision surgery [22]. Therefore, developing minimally invasive methods for surgical treatment of DH fractures with reduced surgical aggression in the surgical area is still relevant in modern traumatology and orthopedics [23].

A relatively high rate of complications in the treatment of DH fractures can be explained both by their intra-articular localization and high patients’ requirements for elbow function [24]. The most common complications associated with this injury include ulnar nerve neuropathy, elbow joint contractures, delayed repair, pseudoarthrosis, olecranon osteotomy-associated complications, osteoarthritis, and infections [6, 15, 25, 26]. High variability of DH fracture types and forms makes their surgical treatment difficult and often requires an extended surgical approach, anatomical reduction of intra-articular fragments, and stable fixation. Due to the multi-fragment nature of these fractures, which often occur in patients with systemic osteoporosis, anatomical reduction can be challenging even for experienced surgeons [26–28].

EVOLUTION OF TREATMENT METHODS

Classification of DH fractures by Arbeitsgemeinschaft für Osteosynthesefragen or the Association of the Study of Internal Fixation (AO/ASIF) includes three types [27–29]:

  • A, extra-articular (supracondylar) fractures;
  • B, juxta-articular (unicondylar) fractures;
  • C, complete intra-articular (bicondylar) fractures.

Key prerequisites for good treatment outcomes in patients with DH fractures include early qualified trauma care within the first 24 h from the injury, adequate and final choice of the treatment method depending on the fracture type, restoration of joint congruence during osteosynthesis, and elimination of displacements, diastasis of bone fragments, and interposition of soft tissues.

Treatment for patients with DH fractures should be chosen on the basis of their history, fracture type, displacement of bone fragments, and integrity of the skin, blood vessels, and nerves of the upper limb. In most cases, an X-ray in two standard projections is usually enough for competent preoperative planning. However, computed tomography also may be useful in understanding the nature of the fracture, especially when coronal plane injuries such as humeral head and trochlea fractures are suspected [9, 30].

The treatment methods that were previously used for intra-articular fractures of the distal metaphysis of the humerus (plaster immobilization and skeletal traction) do not allow completely restoring the anatomy of the elbow joint and are associated with complications; therefore, they can be recommended only in exceptional cases for patients with absolute contraindications to osteosynthesis [2, 31–33].

Surgical treatment options for intra-articular fractures of the distal metaphysis of the humerus are dominant in many aspects; they are based on the principles proposed by the AO/ASIF group [23, 34].

The triangular shape of the distal humerus consists of medial and lateral bony columns with the intervening trochlea. In the treatment of DH fractures, the stable fixation of all three components is a prerequisite for good functional results [35].

To restore elbow joint function during surgery, normal anatomical relationships should be achieved in the joint with absolute stability between bone fragments, thus allowing early active movements in the postoperative period [36–38]. Functional treatment results can be assessed using the criteria recommended by Morrey [39–41].

A special niche in the treatment of elbow fractures is taken by compression distraction osteosynthesis, which was developed by Ilizarov et al. [42]. This method is effectively used in Gustillo–Andersen type II and III open fractures, gunshot fractures, and fractures with suppurative septic complications [43].

In multifragmentary fractures of the distal metaphysis of the humerus, where open reduction and internal fixation are contraindicated due to the small size of the fragments or poor bone quality, total elbow arthroplasty is a treatment of choice. This method is especially suitable for patients with preexisting elbow osteoarthritis. Absolute contraindications for total elbow arthroplasty include neurologic compromise affecting hand function and the demented or noncompliant patient. Relative contraindications include open fractures or if the patient does not want to limit weight bearing through their upper extremity [44].

Summarizing all of the above, we can conclude that various devices to ensure stability in the fracture area, a need for careful selection of plates, screws, spokes, wire, spoke-rod external fixation devices, and orthopedic implants for arthroplasty require multiple aspects of the stability of bone fragment fixation, which is an important element for achieving good and excellent functional treatment results [23].

CHOOSING OPTIMAL SURGICAL APPROACH

The global orthopedic community still lacks a unified algorithm for selecting a surgical approach that would take into account both the nature and type of displacement in DH fractures and individual patient’s characteristics. Based on the fracture nature, displacement of bone fragments, and joint incongruence, different approaches can be chosen: lateral, posterior, medial, or anterior [6, 45].

According to modern literature, we can conclude that the optimal choice of the surgical approach is based on the following basic principles [46]:

1) the approach should ensure ample visualization to perform manipulations in the surgical site;

2) the approach technique should consider a likelihood of an intraoperative need to extend the approach in different directions;

3) the risk of damage to important anatomical structures during the approach should be as low as possible;

4) if the surgical site is extended, reliable hemostasis and adequate drainage should be ensured;

5) the approach can be considered safe if the dissection is performed along the natural layers of soft tissues and not through muscles, tendons, or ligaments;

6) the approach should allow recreating normal anatomy after stitching the wound; exit from the approach should be performed without tensioning the soft tissues, thus allowing early rehabilitation.

The approach for any specific fracture should be based on both the patient’s anatomical findings and requirements for functional results.

APPROACHES TO THE LATERAL COLUMN OF THE DISTAL HUMERUS

Approaches to the lateral elbow include the Kocher approach, the Kaplan approach, the Mayo modification of the extended posterolateral approach, and the modified lateral m. extensor digitorum communis split approach.

Indications for these approaches include surgery for fractures of the radial head, removal of intra-articular loose bodies, DH fractures, resection of osteophytes, excision of the synovial membrane during synovectomy, and total elbow arthroplasty [47, 48].

Kocher Approach

A modified Kocher approach is the most common in traumatology practice. This approach provides visualization for surgical manipulations both on the lateral column of the humeral condyles and the entire elbow joint. This approach is performed between m. anconeus and m. extensor carpi ulnaris, thus minimizing the risk of damage to the deep branch of the radial nerve. This interval is also located anteriorly to the lateral ulnar collateral ligament, thus minimizing the risk of its damage when the joint capsule is dissected [48].

The advantages of this approach also include early elbow mobility after osteosynthesis, improved range of motion in the postoperative period, and a low risk of posterior interosseous nerve injury (as compared with Kaplan). The Kocher approach may be extended both proximally and distally, thus allowing surgical manipulations along the whole DH. However, when extending this approach proximally, the surgeon should consider that the posterior interosseous nerve passes in this area [48, 49].

Kaplan Approach

Indications for the Kaplan approach include radial head fractures that require its resection, osteosynthesis, or arthroplasty [50, 51].

The incision is made from the apex of the lateral epicondyle of the humerus towards Lister’s tubercle, with the length of the approach of approximately 4 to 5 cm. The surface of the head of the radius is isolated between m. extensor digitorum communis and m. extensor carpi radialis brevis.

Due to the proximity of the radial nerve, this approach should be performed with forearm pronation and elbow flexion at an angle of 90°, which ensures the displacement of the radial nerve from the surgical intervention area [51].

In a study in cadavers, Barnes et al. showed that the modified lateral Kaplan approach afforded significantly greater visible surface area of the proximal radius than the Kocher approach [52].

The Boyd approach to the elbow joint has been also described in literature. This approach is used for the surgical treatment of fractures affecting the proximal radius and ulna, including the coronoid process, capitulum humeri, and lateral column of the distal humerus. This approach gives good visualization of the lateral elbow joint surface, thus minimizing the risk of posterior interosseous nerve damage [53, 54].

All these surgical approaches allow performing any reconstructive surgery on the elbow joint.

POSTERIOR APPROACH TO THE ELBOW JOINT

Four posterior approaches to the DH have been classified: triceps-splitting, paratricipital (described by Alonso–Llames), triceps-preserving, and transolecranon (Table 1) [55, 56].

 

Table 1. Comparison of posterior approaches to the elbow joint

Approach

Indications

Contraindications

Advantages

Disadvantages

Posterior transolecranon approach to the elbow joint

Open reduction and internal fixation of fractures involving both columns of the humeral condyles

Total elbow arthroplasty

Good visualization of the posterior articular surface of the distal humerus

Olecranon osteosynthesis is required after exit from the approach

Poor visualization of humerus head

Posterior approach with direct dissection of the triceps

Open reduction and internal fixation for fractures involving both columns of the humeral condyles, total elbow arthroplasty

Use of olecranon osteotomy

Factors associated with poor healing of soft tissues (diabetes mellitus, soft tissue defect, severe edema)

Avoiding complications related to olecranon osteotomy

Poor visualization of the articular surface for osteosynthesis

Risk of triceps avulsion

Posterior paratricipital approach with triceps abduction

Open reduction and internal fixation of juxta-articular fractures of the distal humerus

Use of olecranon osteotomy

Factors associated with poor healing of soft tissues (diabetes mellitus, soft tissue defect, severe edema)

Preservation of the extensor apparatus of the forearm without complications associated with osteotomy of the olecranon process

Difficult reduction in intra-articular fractures of the trochlea and capitate eminence of the humerus, limited visualization of the anterior articular surface of the elbow joint

Posterior triceps-sparing approach

Bone defect of the lower third of the humerus, primary and revision total elbow arthroplasty, pseudoarthrosis

Use of olecranon osteotomy

Factors associated with poor healing of soft tissues (diabetes mellitus, soft tissue defect, severe edema)

Elbow arthroplasty can be performed; stabilizing function of the elbow muscle is preserved

Incomplete visualization of the articular surface of the humerus, damage to the extensor apparatus of the forearm

Risk of triceps avulsion

 

The posterior approach to the elbow joint is universal and provides optimal visualization of the articular surface of the elbow joint, regardless of whether the surgery is performed for fractures or orthopedic conditions [57]. Different authors noted that almost all types of elbow surgery can be performed with this approach [57–63].

Wilkinson et al. showed that the percentage of visible distal humeral articular surface for the triceps-splitting, paratricipital, and transolecranon posterior approaches was 35%, 46%, and 57%, respectively [64].

Indications for the posterior approach with olecranon osteotomy include DH fractures below the line connecting the epicondyles of the humerus. Of note, this approach is not suitable for total elbow arthroplasty because the repair of the osteotomy site would be impaired by the cemented ulna component [48].

A triceps-sparing modified Mayo approach is also known where the triceps is mobilized from the olecranon according to the procedure that was firstly described by Bryan et al. in 1982 [65]. This approach has been widely used mainly for elbow arthroplasty. Although it is associated with postoperative elbow extensor weakness, other complications such as infection, revision surgery, or loss of muscle strength are rare. Guerroudj et al. compared in vitro mechanical properties of the triceps tendon after simulation of three common exposures. All approaches resulted in a weakening of the triceps; however, the Bryan–Morrey lateral triceps-reflecting technique provided statistically better strength than V-Yor longitudinal splitting [66]. Indications for this modified approach include DH fractures, surgical interventions for elbow contractures and ankyloses, as well as revision elbow arthroplasty [35, 67].

Compared with the Bryan–Morrey approach, the olecranon osteotomy approach to total elbow arthroplasty provides adequate visualization, saves operative time, reduces bleeding, provides better flexion activity, effectively improves elbow function, and achieves satisfactory functional results [69].

A modified Mayo posterior transolecranon approach is also known. A universal posterior approach with one long skin incision is used, with medial and lateral skin flaps stitched to the edges of the surgical field. The ulnar nerve is identified proximally in the medial intermuscular septum, decompressed, and protected. Standard olecranon osteotomy does not allow preserving the fixation site of the m. anconeus, which provides dynamic stability to the lateral elbow. The Mayo modification of this approach addresses this problem: the m. anconeus is identified and elevated from its bed by sharp dissection, preserving its attachment to the triceps. This modified approach is attractive because the dissection of the elbow muscle can be performed quickly and safely [69]. This approach also preserves triceps continuity and the attachment site of the hand extensors.

APPROACHES TO THE MEDIAL COLUMN OF THE ELBOW JOINT

Approaches to the medial surface of the elbow joint are used for osteosynthesis of coronoid process fractures, reconstruction, and restoration of the medial collateral ligament and release of the joint capsule in contractures and ankyloses.

Modified medial approaches include the Hotchkiss anteromedial approach and the Taylor and Scham posteromedial approach. Good visualization of the coronoid process is an advantage of these approaches. The disadvantage is a relatively high risk of injury to the ulnar and medial cutaneous nerves of the forearm [70, 71].

The Taylor–Scham posteromedial approach is used for basilar fractures of the coronoid with plate fixation. When performing this approach, the surgeon should be careful with respect to the ulnar nerve and the medial cutaneous nerve of the forearm [71].

During the Hotchkiss approach, the lower third of the humerus is isolated by subperiosteal separation of the brachial and triceps muscles. Indications include fractures of the coronoid process and removal of anterior surface osteophytes of the elbow joint [72, 73].

CONCLUSION

Conservative treatment methods for fractures in the lower third of the humerus that were used previously cannot completely preserve the function of the upper limb after the end of the immobilization period, and, at the current stage of medicine, they should be used only for patients with contraindications to surgical treatment.

Although methods for surgical treatment of elbow fractures are developing, contractures and ankyloses of the elbow joint develop quite often. Patients have to undergo long-term treatment in outpatient and hospital settings, but their functional results may be poor. Treatment often consists of simply changing the abnormal position of the limb, although it is necessary not only to correct the limb position but also to restore its shape and function.

The recovery period after osteosynthesis of humeral condyle fractures requires monitoring the duration of immobilization and normalization of muscle tone.

Despite significant progress in the development of osteosynthesis methods for juxta- and intra-articular fractures, choosing the optimal approach to the DH during osteosynthesis is still challenging. Treatment methods and surgical approaches should be chosen on the basis of the patient’s X-ray findings, the surgeon’s experience, and patient’s requirements for functional results.

ADDITIONAL INFORMATION

Author contributions. D.V. Kvasov — development of the strategy and design of the scientific work, search for literary sources on the topic of the work, their translation from English; E.I. Solod — writing the text of the article and final editing; K.K. Bekshokov — search for literary sources on the topic of the work, their translation from English, and formation of an electronic database. All authors have approved the manuscript (version for publication) and have also agreed to be responsible for all aspects of the work, ensuring that issues related to the accuracy and integrity of any part of it are properly addressed and resolved.

Ethics approval. Not applicable.

Funding sources. No funding.

Disclosure of interests. The authors have no relationships, activities or interests for the last three years related with for-profit or not-for-profit third parties whose interests may be affected by the content of the article.

Statement of originality. In creating this work, fragments of the author’s own text published earlier were used (doi: 10.60797/IRJ.2024.144.73, doi: 10.25881/20728255_2024_19_3_58).

Data availability statement. All data obtained in this study are available in the article.

Generative AI. Generative AI technologies were not used for this article creation.

Provenance and peer-review. This paper was submitted to the journal on an initiative basis and reviewed according to the usual procedure. Two members of the editorial board and the scientific editor of the publication participated in the review.

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About the authors

Dmitry V. Kvasov

Tula Regional Clinical Hospital

Author for correspondence.
Email: doctor.kvasov@yandex.ru
ORCID iD: 0009-0009-8950-3758
SPIN-code: 4280-5870
Russian Federation, Tula

Eduard I. Solod

Peoples’ Friendship University of Russia

Email: doctorsolod@mail.ru
ORCID iD: 0000-0001-7807-8981
SPIN-code: 4964-3457

MD, Dr. Sci. (Medicine), Professor

Russian Federation, Moscow

Kazbek K. Bekshokov

Peoples’ Friendship University of Russia

Email: kazbek.bekshokov.99@mail.ru
ORCID iD: 0000-0002-2667-341X
SPIN-code: 8906-6553
Russian Federation, Moscow

References

  1. Alekseeva OS. Endoprosthesis of the shoulder joint in fractures of the proximal humerus in elderly patients age [dissertation abstract]. Moscow; 2017. (In Russ.) EDN: ZQFLNJ
  2. Kvasov DV, Solod EI, Bekshokov KK. Selection of surgical treatment of intra-articular fractures of the distal humerus. International Research Journal. 2024;(6):78. doi: 10.60797/IRJ.2024.144.73 EDN: CUSSPL
  3. Zalavras CG, Papasoulis E. Intra-articular fractures of the distal humerus-a review of the current practice. Int Orthop. 2018;42(11):2653–2662. doi: 10.1007/s00264-017-3719-4
  4. Shuisky AA. Combined osteosynthesis of intra-articular fractures of the distal metaepiphysis of the humerus [dissertation]. Moscow; 2022. (In Russ.) EDN: ZARNXZ
  5. Klenin AA. Operative treatment of epiphyseal fractures of the distal humerus and their consequences [dissertation]. Samara; 2017. (In Russ.) EDN: LUBLZA
  6. Ratyev AP. Treatment of injuries of the elbow joint area [dissertation]. Moscow; 2015. (In Russ.) EDN: ELYCAW
  7. Kozlov ES, Soldatov YuP, Shen SV. Errors and complications in the treatment of patients with intra-articular fractures of the distal humerus. Sovremennye problemy nauki i obrazovanija. 2023;(2):92. doi: 10.17513/spno.32562 EDN: ZFLLVU
  8. Crean TE, Nallamothu SV. Distal humerus fractures [Internet]. Treasure Island (FL): StatPearls Publishing; 2023. Available from: https://www.statpearls.com/point-of-care/23045
  9. Lee HJ. Surgical treatment strategy for distal humerus intra-articular fractures. Clin Shoulder Elb. 2019;22(2):113–117. doi: 10.5397/cise.2019.22.2.113
  10. Attum B, Thompson JH. Humerus fractures overview [Internet]. Treasure Island (FL): StatPearls Publishing; 2023. Available from: https://www.statpearls.com/point-of-care/23047
  11. Holte AJ, Dean RE, Chang G. Distal humerus fractures: review of literature, tips, and tricks. JSES Rev Rep Tech. 2023;4(3):639–646. doi: 10.1016/j.xrrt.2023.11.004 EDN: BBFRFE
  12. Galano GJ, Ahmad CS, Levine WN. Current treatment strategies for bicolumnar distal humerus fractures. J Am Acad Orthop Surg. 2010;18(1):20–30. doi: 10.5435/00124635-201001000-00004
  13. Nauth A, McKee MD, Ristevski B, et al. Distal humeral fractures in adults. J Bone Joint Surg Am. 2011;93(7):686–700. doi: 10.2106/JBJS.J.00845
  14. Mellstrand Navarro C, Brolund A, Ekholm C, et al. Treatment of humerus fractures in the elderly: A systematic review covering effectiveness, safety, economic aspects and evolution of practice. PLoS One. 2018;13(12):e0207815. doi: 10.1371/journal.pone.0207815
  15. Han SH, Park JS, Baek JH, et al. Complications associated with open reduction and internal fixation for adult distal humerus fractures: a multicenter retrospective study. J Orthop Surg Res. 2022;17(1):399. doi: 10.1186/s13018-022-03292-1
  16. Sanchez-Sotelo J, O'Driscoll S, Morrey BF. Periprosthetic humeral fractures after total elbow arthroplasty: treatment with implant revision and strut allograft augmentation. J Bone Joint Surg Am. 2002;84(9):1642–1650. doi: 10.2106/00004623-200209000-00019
  17. Benelhafi H. Prevention of posttraumatic elbow joint contractures in the treatment of periarticular and intraarticular fractures of the distal humerus [dissertation]. Yaroslavl; 2010. (In Russ.) EDN: ZOCSUF
  18. Worden A, Ilyas AM. Ulnar neuropathy following distal humerus fracture fixation. Orthop Clin North Am. 2012;43(4):509–514. doi: 10.1016/j.ocl.2012.07.019
  19. Miller AN, Beingessner DM. Intra-articular distal humerus fractures. Orthop Clin North Am. 2013;44(1):35–45. doi: 10.1016/j.ocl.2012.08.010
  20. Jupiter JB, Mehne DK. Fractures of the distal humerus. Orthopedics. 1992;15(7):825–833. doi: 10.3928/0147-7447-19920701-07
  21. Yetter TR, Weatherby PJ, Somerson JS. Complications of articular distal humeral fracture fixation: a systematic review and meta-analysis. J Shoulder Elbow Surg. 2021;30(8):1957–1967. doi: 10.1016/j.jse.2021.02.017 EDN: EOUBTY
  22. Nosivets DS, Vinnik AA. Analysis of the results of surgical and conservative treatment of humeral condyle fractures. Orthopaedic Genius. 2022;28(5):636–642. doi: 10.18019/1028-4427-2022-28-5-636-642 EDN: QVBSKV
  23. Kvasov DV, Solod EI, Bekshokov KK. New possibilities of osteosynthesis of the distal humerus. Bulletin of Pirogov National Medical & Surgical Center. 2024;19(3):58–64. doi: 10.25881/20728255_2024_19_3_58 EDN: QGRGQQ
  24. De Crescenzo A, Garofalo R, Pederzini LA, Celli A. Malunion of distal humeral fractures: Current concepts. J ISAKOS. 2024;9(4):744–749. doi: 10.1016/j.jisako.2024.05.009 EDN: CVJHMZ
  25. Giuseppe G, Sebastien P, Giorgio IQ, Villani C. Sequelae of distal humeral fractures. Lo Scalpello. 2020;34(1):21–31. doi: 10.36149/0390-5276-003 EDN: PJBTVV
  26. Saini R, Sharma A, Rathore KS, Sidhu SS. Clinical and functional outcomes of anatomical plating in distal humerus fractures in adults. Cureus. 2023;15(2):e35581. doi: 10.7759/cureus.35581 EDN: IZLPKM
  27. Al-Dorami MAM. Treatment of fractures of the distal shoulder with percutaneous fixators [dissertation]. Moscow; 2010. (In Russ.) EDN: QERBZL
  28. Wang C, Zhu Y, Long H, et al. Three-dimensional mapping of distal humerus fracture. J Orthop Surg Res. 2021;16(1):545. doi: 10.1186/s13018-021-02691-0
  29. Muller M, Nazarian J, Koch P. Fracture and dislocation compendium. Orthopaedic Trauma Association Committee for Coding and Classification. J Orthop Trauma. 1996;10(1):1–154.
  30. Mehlhoff TL, Bennett JB. Distal humeral fractures: fixation versus arthroplasty. J Shoulder Elbow Surg. 2011;20(2 Suppl):S97–S106. doi: 10.1016/j.jse.2010.11.012
  31. Desloges W, Faber KJ, King GJ, Athwal GS. Functional outcomes of distal humeral fractures managed nonoperatively in medically unwell and lower-demand elderly patients. J Shoulder Elbow Surg. 2015;24(8):1187–1196. doi: 10.1016/j.jse.2015.05.032
  32. Aitken SA, Jenkins PJ, Rymaszewski L. Revisiting the 'bag of bones': functional outcome after the conservative management of a fracture of the distal humerus. Bone Joint J. 2015;97-B(8):1132–1138. doi: 10.1302/0301-620X.97B8.35410
  33. Ritali A, Guerra E, Ricciarelli M, et al. Fratture dell’omero distale: trattamento con protesi di gomito. Lo Scalpello. 2019;33(1):76–83. doi: 10.1007/S11639-019-00298-z
  34. O'Driscoll SW. Optimizing stability in distal humeral fracture fixation. J Shoulder Elbow Surg. 2005;14(1 Suppl. S):186S–194S. doi: 10.1016/j.jse.2004.09.033
  35. Limthongthang R, Jupiter JB. Distal humerus fractures. Operative Techniques in Orthopaedics. 2013;23(4):178–187. doi: 10.1053/j.oto.2013.07.011
  36. Gabel GT, Hanson G, Bennett JB, et all. Intraarticular fractures of the distal humerus in the adult. Clin Orthop Relat Res. 1987;(216):99–108. doi: 10.1097/00003086-198703000-00016
  37. Fornasiéri C, Staub C, Tourné Y, et all. Biomechanical comparative study of three types of osteosynthesis in the treatment of supra and intercondylar fractures of the humerus in adults. Rev Chir Orthop Reparatrice Appar Mot. 1997;83(3):237–242. (In French.) doi: 10.1016/s1058-2746(96)80346-6
  38. Beazley JC, Baraza N, Jordan R, Modi CS. Distal humeral fractures-current concepts. Open Orthop J. 2017;11:1353–1363. doi: 10.2174/1874325001711011353
  39. Morrey B. Joint replacement arthroplasty. New-York: Churchill Livingstone; 1991. doi: 10.1016/0266-7681(91)90033-K
  40. Morrey BF, An KN. Functional anatomy of the ligaments of the elbow. Clin Orthop Relat Res. 1985;(201):84–90. doi: 10.1097/00003086-198512000-00015
  41. Morrey BF. Post-traumatic contracture of the elbow. Operative treatment, including distraction arthroplasty. J Bone Joint Surg Am. 1990;72(4):601–618. doi: 10.2106/00004623-199072040-00019
  42. Ilizarov GA, Karagodin GE, Shved SI. Cranial osteosynthesis of elbow joint bone fractures. Grekov's Bulletin of Surgery. 1985;(7):79–81.
  43. Kömürcü M, Yanmiş I, Ateşalp AS, et all. Treatment results for open comminuted distal humerus intra-articuler fractures with Ilizarov circular external fixator. Mil Med. 2003;168(9):694–697. doi: 10.1093/milmed/168.9.694
  44. Morrey ME, Morrey BF, Sanchez-Sotelo J, et al. A review of the surgical management of distal humerus fractures and nonunions: From fixation to arthroplasty. J Clin Orthop Trauma. 2021;20:101477. doi: 10.1016/j.jcot.2021.101477 EDN: OWDFTH
  45. Pierce TD, Herndon JH. The triceps preserving approach to total elbow arthroplasty. Clin Orthop Relat Res. 1998;(354):144–152. doi: 10.1097/00003086-199809000-00017
  46. Gogna R, Bhabra G, Modi CS. Fractures of the proximal humerus: overview and non-surgical management. Orthopaedics and Trauma. 2019;33(5):315–321. doi: 10.1016/j.mporth.2019.07.007
  47. Charissoux JL, Vergnenegre G, Pelissier M, et al. Epidemiology of distal humerus fractures in the elderly. Orthop Traumatol Surg Res. 2013;99(7):765–769. doi: 10.1016/j.otsr.2013.08.002
  48. Aggarwal S, Paknikar K, Sinha J, et al. Comprehensive review of surgical approaches to the elbow. J Clin Orthop Trauma. 2021;20:101482. doi: 10.1016/j.jcot.2021.101482 Erratum in: J Clin Orthop Trauma. 2021;30;20:101539. doi: 10.1016/j.jcot.2021.101539 EDN: AVFXKU
  49. Desloges W, Louati H, Papp SR, Pollock JW. Objective analysis of lateral elbow exposure with the extensor digitorum communis split compared with the Kocher interval. J Bone Joint Surg Am. 2014;96(5):387–393. doi: 10.2106/JBJS.M.00001
  50. Kaplan EB, Emanuel B. Surgical approach to the proximal end of the radius and its use in fractures of the head and neck of the radius. The Journal of Bone & Joint Surgery. 1941;23(1):86–92.
  51. Kaplan AV, Lirtzman VM. Comparative evaluation and indications for different methods of osteosynthesis in closed fractures of limb bones. Ortopedija, travmatologija i protezirovanie. 1975;(10):1–6. (In Russ.)
  52. Barnes LF, Lombardi J, Gardner TR, et al. Comparison of exposure in the kaplan versus the kocher approach in the treatment of radial head fractures. Hand (N Y). 2019;14(2):253–258. doi: 10.1177/1558944717745662
  53. Robinson PM, Li MK, Dattani R, Van Rensburg L. The boyd interval: a modification for use in the management of elbow trauma. Tech Hand Up Extrem Surg. 2016;20(1):37–41. doi: 10.1097/BTH.0000000000000112
  54. Sain A, Garg S, Wattage K, et al. Functional outcome of complex elbow fracture managed with the boyd approach. Cureus. 2024;16(1):e52993. doi: 10.7759/cureus.52993 EDN: FOVITV
  55. 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(6):479–490. doi: 10.3109/17453677208991270
  56. Cheung EV, Steinmann SP. Surgical approaches to the elbow. J Am Acad Orthop Surg. 2009;17(5):325–333. doi: 10.5435/00124635-200905000-00007
  57. McKee MD, Jupiter JB, Bamberger HB. Coronal shear fractures of the distal end of the humerus. J Bone Joint Surg Am. 1996;78(1):49–54. Erratum in: J Bone Joint Surg Am. 1998;80(4):604. doi: 10.2106/00004623-199601000-00007
  58. Karrasch CK, Smith EJ, Armstrong AD. Distal humerus articular malunion after an open reduction-internal fixation of a capitellum-trochlea shear fracture: a case report. J Shoulder Elbow Surg. 2016;25(3):e55–60. doi: 10.1016/j.jse.2015.12.013
  59. Ray PS, Kakarlapudi K, Rajsekhar C, Bhamra MS. Total elbow arthroplasty as primary treatment for distal humeral fractures in elderly patients. Injury. 2000;31(9):687–692. doi: 10.1016/s0020-1383(00)00076-0
  60. Ring D, Jupiter JB. Complex fractures of the distal humerus and their complications. J Shoulder Elbow Surg. 1999;8(1):85–97. doi: 10.1016/s1058-2746(99)90063-0
  61. Jupiter JB, Ring D. Treatment of unreduced elbow dislocations with hinged external fixation. J Bone Joint Surg Am. 2002;84(9):1630–1635. doi: 10.2106/00004623-200209000-00017
  62. Ring D, Jupiter JB, Gulotta L. Articular fractures of the distal part of the humerus. J Bone Joint Surg Am. 2003;85(2):232–238. doi: 10.2106/00004623-200302000-00008
  63. Ring D, Jupiter JB. Fractures of the distal humerus. Orthop Clin North Am. 2000;31(1):103–113. doi: 10.1016/s0030-5898(05)70131-0
  64. Wilkinson JM, Stanley D. Posterior surgical approaches to the elbow: a comparative anatomic study. J Shoulder Elbow Surg. 2001;10(4):380–382. doi: 10.1067/mse.2001.116517
  65. Bryan RS, Morrey BF. Extensive posterior exposure of the elbow. A triceps-sparing approach. Clin Orthop Relat Res. 1982;(166):188–192. doi: 10.1097/00003086-198206000-00033
  66. Guerroudj M, de Longueville JC, Rooze M, et al. Biomechanical properties of triceps brachii tendon after in vitro simulation of different posterior surgical approaches. J Shoulder Elbow Surg. 2007;16(6):849–853. doi: 10.1016/j.jse.2007.02.137
  67. Rosado N, Ryznar E, Flaherty EG. Understanding humerus fractures in young children: Abuse or not abuse? Child Abuse Negl. 2017;73:1–7. doi: 10.1016/j.chiabu.2017.09.013
  68. Xue Z, Huang X, Guo W, et al. Comparison of clinical outcomes between the olecranon osteotomy approach and the Bryan–Morrey approach for total elbow arthroplasty. J Shoulder Elbow Surg. 2023;32(7):1505–1513. doi: 10.1016/j.jse.2023.02.128 EDN: FOOOIW
  69. Athwal GS, Rispoli DM, Steinmann SP. The anconeus flap transolecranon approach to the distal humerus. J Orthop Trauma. 2006;20(4):282–285. doi: 10.1097/00005131-200604000-0000
  70. Huh J, Krueger CA, Medvecky MJ, et al. Medial elbow exposure for coronoid fractures: FCU-split versus over-the-top. J Orthop Trauma. 2013;27(12):730–734. doi: 10.1097/BOT.0b013e31828ba91c Erratum in: J Orthop Trauma. 2014;28(10):611.
  71. Taylor TK, Scham SM. A posteromedial approach to the proximal end of the ulna for the internal fixation of olecranon fractures. J Trauma. 1969;9(7):594–602. doi: 10.1097/00005373-196907000-00004
  72. Rydell N, Balazs EA. Effect of intra-articular injection of hyaluronic acid on the clinical symptoms of osteoarthritis and on granulation tissue formation. Clin Orthop Relat Res. 1971;80:25–32. doi: 10.1097/00003086-197110000-00006
  73. Shin SJ, Sohn HS, Do NH. A clinical comparison of two different double plating methods for intraarticular distal humerus fractures. J Shoulder Elbow Surg. 2010;19(1):2–9. doi: 10.1016/j.jse.2009.05.003

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