الفهرس 
Anatomy ofthe DistalHumerusOnly 14 pages are availabe for public view
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Abstract
Fractures of the distal humerus represent challenging problems to the modern orthopaedic surgeon. Important factors to consider are the 3-dimensional geometry, limited peri-articular bone stock for internal fixation, intra-articular comminution, and the need for early mobilization. The increasing incidence of this fracture in the elderly patient in association with poor bone quality and comminution has introduced a significant challenge to the reconstructive surgeon.
Historically, distal humeral fractures were treated nonoperatively due to the poor results of surgery. Surgery was complicated by high infection rates and poor fixation due to rudimentary implants. Although nonoperative care may be appropriate in some situations, the modern literature strongly supports ORIF of intra-articular distal humerus fractures. The surgical goals are to obtain anatomic restoration of the articular surface and recreation of joint alignment with stable internal fixation, secure enough to allow early range of motion.
Every attempt should be made to achieve ORIF for the distal humeral fracture in the young patient. TEA is not an option for this group. Good bone stock is expected, despite displacement, rotation, or comminution. Intra-articular fragments are well addressed with headless screw fixation, achieving high healing rates with a low incidence of avascular necrosis. If necessary, third-plate fixation for posterior and lateral comminution should be considered.
Fractures of the distal humerus in the elderly patient group (>65 years) present the greatest challenges. The consideration is not age but rather the degree of comminution, osteoporotic bone, poor quality of soft tissue, intolerance for joint immobilization, and demands for weight bearing with the arm.
Good outcomes for ORIF have been reported in the literature for distal humeral fractures in the elderly patient when well performed. Bone quality is often more adequate than expected, and as experience with these fractures increases. Bicolumnar fixation with precontoured plates, locking screw technology, and headless screw fixation of small articular fragments has expanded the indications for ORIF in osteoporotic bone and should always be the first preference for the adult elderly patient however, some fractures of the distal humerus in the older osteoporotic patient just cannot be fixed. The bone will not hold screws, even with cement. There are too many articular fragments for the joint surface to be assembled. So TEA has been shown to be a viable optionThe patient must be able to live with a 5-lb lifting restriction. The surgeon must be able to live with the knowledge that disaster is only one fall away for the patient, and must be prepared to perform a future revision arthroplasty for loosening or a periprosthetic fracture. Distal humeral hemiarthroplasty may later prove to be another alternative but as of yet has an unproven record.
Patients with pre-existing inflammatory arthropathy, such as rheumatoid arthritis, should not be fixed and should be considered for primary TEA if they sustain a distal humeral fracture. Even the best-performed ORIF will not address the arthritis of the joint. TEA for this fracture group has shown excellent results in the literature, probably because of lower patient demand postoperatively.
Hardware failure or nonunion in the elderly patient after ORIF can still be later addressed with TEA, if needed. The outcomes for salvage TEA after nonunion or failed internal fixation can equal those for primary TEA after fracture.