Triceps Sparing Research Articles

Effects of surgical approach on functional outcomes of open reduction and internal fixation of intra-articular distal humeral fractures: a systematic review

Fractures of the distal humerus are uncommon injuries, constituting between 0.5% and 7% of all fractures and 30% of all elbow fractures. Up to 96% of these injuries are intercondylar, or AO type C, distal humeral fractures involving the articular surface. These fractures are notoriously difficult to treat, presenting the surgeon with multiple challenges including the complex anatomy of the elbow joint itself, articular surface comminution, and frequently, osteopenic or osteoporotic bone stock. Anatomic reduction of the joint surface, restoration of the overall anatomic axes of the extremity, and stable fixation allowing for early elbow mobilization are keys to achieving a good surgical outcome. Early motion is critically important after open reduction and internal fixation (ORIF) of these fractures because the elbow joint capsule is very prone to scarring, and immobilization past 3 weeks has been linked with poorer outcomes. A number of well-described approaches are at the surgeon’s disposal for exposure of the distal humerus. These include the olecranon osteotomy, triceps-reflecting anconeus pedicle (TRAP), BryanMorrey (triceps reflecting), paratricipital (AlonsoLlames, bilaterotricipital, triceps sparing), triceps

Paratricipital-Triceps Splitting “Two-Window” Approach for Distal Humerus Fractures

Commonly, distal transcondylar and intra-articular distal humerus fractures are treated through a transolecranon approach. Other options for exposure, open reduction, and internal fixation exist to prevent the reported complications of olecranon osteotomy. The technique of triceps sparing access, as it has been reported before by others, allow adequate exposure in most of distal humerus fractures except for multifragmentary, mainly intra-articular types. We demonstrate the technique of the "two-window" approach, which combines a paratricipital posteromedial access with splitting the triceps lateral to the triceps tendon. Through a posteromedial incision, all surfaces of the distal humerus were accessed without muscle detachment from the olecranon. This approach does not compromise the ligamentous joint stability. In addition, the stabilizing effect of the anconeus muscle is not impaired because continuity with the lateral portion of the triceps is preserved, and denervation is avoided. It is extensile and provides adequate exposure of articular fracture comminution with the added advantage of the intact olecranon as a template for reduction. However, because the triceps is still in continuity it permits conversion to a transolecranon approach as necessary. The two-window approach is our preferred approach for all distal humerus fractures inclusively C3 fractures according to the ASIF/AO classification, except for complex volar shear fractures.

Treatment of type C intercondylar fractures of distal humerus using dual plating

To evaluate the clinical outcome of dual plating in the treatment of humeral intercondylar type-C fractures in adults. From June 2004 to October 2007, 38 cases of type-C distal humeral fractures were stabilised with dual plating. There were 21 males and 17 females. The average age was 43 years with a range from 21 to 71 years. According to the AO classification, 9 cases were of type C1, 17 of C2 and 12 of C3. The posterior midline approach was selected. Twenty-one cases were exposed through the trans-olecranon osteotomy, 11 through the Campbell (Van Gorder) approach, 6 through triceps sparing approach. Autogenous bone graft was performed in 5 cases because of severe comminution. Thirty-five patients were followed-up for 14-30 months (mean 24.2 months). At the latest follow-up, the elbow flexion averaged 119 degrees (range 90 degrees - 135 degrees ), and the loss of extension averaged 16.2 degrees (range 5 degrees - 25 degrees ). All the patients got bony healing, the average healing period was 14 weeks. The patients were evaluated using the criteria of Aitken and Rorabeek and the scores were 13 excellent, 16 good, 6 fair. Twenty-nine patients (82.9%) had a good or excellent results. Complications included 4 cases of traumatic osteoarthritis, 2 heterotopic ossification, 1 ulnar neuropathy. Infection as well as loosening or breakage of the implant was not found. The dual plating is able to provide rigid fixation for the humeral intercondylar fractures. In addition, it can allow early functional exercise after operation, decrease the related complications significantly, and improve the functional results.

Surgical Treatment of Intercondylar Fracture of the distal Humerus through the Modified Triceps Sparing Approach

Purpose: We evaluated the therapeutic results of intercondylar fractures of the distal humerus that were treated through the modified triceps sparing approach. Materials and Methods: From February, 1997 to september, 2001, we reviewed sixteen cases of intercondylar fracture of the distal humerus, which were treated by surgical treatment. The follow up period ranged from one year to three years, averaging 1 year 8 months. The articular surface of the distal humerus was exposed through elevation of the triceps from the medial and the lateral intermuscular septum. The ulna nerve was identified and protected, and then, the fracture sites were fixed with double plates. The functional results were evaluated using Broberg and Morrey's functional scale. Results: All united at 14.5 weeks in an average. The functional results were as follows; three excellent, ten good, two fair and one poor. The range of the elbow joint motion was flexion contracture 11 degree to further flexion 130 degree in average. The one patient presented poor result had coronal shear fracture of the capitulum combined with severe comminution. The incomplete ulnar nerve palsy developed in one case. Conclusion: The modified triceps sparing approach provided sufficient exposure for rigid fixation of intercondylar fracture of the humerus. But in cases with severe comminution or coronal shear fracture, additional anterior approach or olecranon osteotomy should be considered.