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Name:
Optimising Outcomes in Fracture Distal Humerus
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Optimising Outcomes in Fracture Distal Humerus
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2024-05-31T00:00:00.0000000
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Language: EN.
Segment:0 .
Good afternoon, everyone. My name is Professor Bijayendra Singh, Consultant Orthopedic surgeon, and with a Upper Limb interest at Medway Maritime Hospital. Also Professor at Canterbury Christchurch University. The immediate past president of British Indian Orthopedic Society. I'm going to share with you my thoughts on distal humerus fractures.
As to how to improve the outcomes following fixation. I'm going to limit myself to this particular talk, not going in to details of arthroplasty and other injuries. At the outset, I would like to thank the Bangladesh Orthopedic Society for giving me this opportunity to talk on this. And I wish the organizers and the attendees a grand success. So without further ado, I'm going to present to you my thoughts.
So this is an example of the 35-year-old man who fell from about 10 foot high. No other medical problems except for being overweight. He presented in the early hours of morning with this injury. These are his images. And I will share with you what I did a bit later on.
So what I'm aiming to do briefly is talk to you about the anatomy, the fracture patterns, the approach fixation, and discuss some of my failures as I believe that is the best way to learn. Come up with some take home messages. So we know the distal humerus has got two columns the medial and the lateral which converge at about 45 degrees angle and they're connected with the arch so to say which is the trochlea most distal part of the humerus.
On the lateral side is the capitellum and on the medial side is the epicondyle. That articular segment's functionally acting as a tie arch, and it's vital to restore this for optimum outcomes and functions. So the evaluation of these injuries are vital. Obviously, once you've done the ATLS to see if there's any other injuries which may be life or limb threatening, then one focuses on the elbow injury.
Traction views are often useful. Certainly, we can see injury ones are not as great, then we could do a traction view even at the intra op phase before performing the surgical incision. A CT scan has certainly revolutionized the assessment of these injuries and the 3D images
comes in really handy to look at the fragments, which helps plan the approach as well as plan the fixation. Look at especially whether there's any fracture of the capitellum or the trochlea. The other piece of advice, if you're not doing it regularly, is to speak to your radiology department so that you get the orientation of these cuts proper.
So I'd like to think every treatment for any fracture, perhaps every condition, has got three elements to it. One is the fracture personality. So if you've got a duff fracture like this in a slightly older age group patient, which is very low with some comminution, perhaps an element of degenerative change, then in some sort of arthroplasty works well as one operation gives a predictably good outcome. Patient personality
beware of the elderly age group with the softer bones. And also, they have significant comminution. Or smokers, they have a risk of non-union and wound problems. There's an example of another patient who had this intra articular fracture. 40 year old, slightly overweight smoker and despite having good fixation and optimum fixation, the fracture failed at three months.
Surgeon personality is not to be meant in a bad way, but I think it's realizing the limitations of inventory that a surgeon may have, as well as the experience of dealing with these injuries. These do require highly specialized skills and somebody who's doing them regularly to undertake this kind of practice so this is not mine,
this is from a friend who sent me this across when he received those. This is a 50-year-old chap with the comminuted fracture, although it looks simple, but it's quite low. And certainly see there is some comminution in there. This is how it was fixed. You can see the comminution and obviously this was not going to work. Then had a revision surgery with an olecranon osteotomy and we can pick on how the olecranon osteotomy was fixed and other bits,
but this is what an optimum fixation would require. Classifications we know loads of them. One that is always found useful is that will describe the injury, help direct the treatment, perhaps give an idea of the prognosis. Be useful for research. Find how good in an inter and intro- observer reliability. Unfortunately, as we know, most classification do not help with these.
The two that I find of some benefit in the distal humerus fractures. The one described by the Jupiter. Simple ones is the low or the high T fractures. And you have the C or the Y fractures with them where the comminution shaped like a D or an H type of an injury. And then you have your what's described as a medial lambda and lateral lambda with comminution and beware of the metaphyseal comminution.
David Standley and his team describe something along the similar lines. So the type I was the extra articular going from an oblique with a larger fracture surface to a transverse, which makes it unstable to a comunition. You have your predominantly intra articular fractures, the distal humerus, and then you have just the articular or the predominantly articular fragment.
And we're not going to talk about the type 3 here today. We're going to focus mainly on the type 2 injuries and the type I. It's a surgical treatment. So I do them mainly in lateral position. People have recommended doing it in prone position as well as it provides better access and maybe imaging might be a bit easier, but it's a nightmare for the anesthetist.
Generally, I prefer to use a tourniquet as it provides a good bloodless field. I try and put the elbow into flexion about 90 to 120 degrees before inflating the tourniquet. This provides a good pull onto the triceps, especially if you're going to use a osteotomy. The approaches we'll discuss briefly. Imaging,
I bring the C Arm parallel to the table. I always stand in the axilla of the patient and the image screen is either at the back of the patient or towards the head end. Approaches should be one that will influence the outcomes that should be able to help you achieve reduction. And it would advise to use an approach that fits the fracture pattern. So the choice of approach will also be partly be based on the age of the patient.
So I said fracture the procedure that one is doing, i.e. a fixation or a replacement, any associated injury. And if there is an open wound, then that may need to be taken care of. So broadly, based on which side you go, you've got the medial, you have a posterior, anterior and lateral approach. For the purpose of this lecture and this type of fracture it's mainly going to be the posterior approach. Can have a triceps preserving which is an osteotomy or a para- tricipital approach.
Or you can have a triceps reflecting or triceps off, which is your Morey or your TRAP approach depending on which side of the elbow you approach it from the medial or the lateral. They have their own pluses and minuses. Not going to go into much detail of these. With any of the approach, there are a few things that you need to be thinking about. The ulnar nerve always advised to isolate and tag the ulnar nerve before proceeding to any bon procedures.
I never put any instrument to tag that vascular loop as it can get caught just tight around the ulnar nerve with a big loop. The other question is whether you transpose, and most literature suggests that there is no need for routine transposition. Treatment principles includes anatomic reduction, stable fixation of the articular surface. This is the key and then restoration of the articular axial alignment, stable fixation metaphysis to the diaphysis.
So they can mobilize and the fracture heal. Now with all the above, aim to get early range of motion of the elbow. So some of the fixation would be dependent on the fracture pattern. Extra-articular fractures depending on the level could be fixed by one or two on two plates. You may go for a lock and unlock place, but generally these days are locked in and plate is preferred. For intra- articular fractures
there's no doubt in my mind that the literature support needs two plates, locking plates, and the question is whether you do a 90/90 or a parallel plating. And we'll have a look into that briefly. The parallel concepts plates concept was described by the Mayo group, led by Dr. O'Driscoll, and he suggested that it provides an external scaffold.
A direct reduction and temporary fixation with K-wire or clamps is recommended, and then bone fragments are stabilized with locking screws. But these are the principles that he said one must try and adhere to. All screws pass through the plate. All fragments are engaged by the screws. Each group should engage a fragment on the opposite side. And it should be as long as possible.
And the idea that the screws inter-digitate within the distal fragment providing better fix hold. Your 90/90 plates again relies on an anatomic reduction of the articular fragment. And in direct reduction of the extra articular and is stabilized by spanning plates and generally these healed with an element of callus formation. If you look at the results, bio mechanically parallel plating is superior to the 90 /90 configuration, but clinically there is no difference in the outcome.
Perhaps because the numbers needed is significantly large. That would be required to establish a difference. Just showing you some of the examples that I've come across that are good. So this is a 60/ 65-year-old gentleman with this extra articular fracture, displaced, closed injury. And this I approached using a para-tricepular approach or a triceps on approach. Initial was held with clamps and two k-wires.
And then I used two parallel plates. And this has become my go to fixation technique, for these kind of injuries. The bad. This is an example of a young lady in her late 20s. who fell on her hen do, sustained this fracture of the distal humerus. As you can see, quite comminuted, both intra articular and over the metaphysis.
I use an olecranon osteotomy. And I make incisions on both sides of the ulnar, leaving a cuff of fascia to repair. The first step is to get your access to the osteotomy so drill using a 3.2 and I use a 6.5 tab and then screw lens should be long as long as is required and generally guided by the tap catching into the medullary canal of the ulna.
Most often it is above 100 millimeters. Mark your saw, I use a k-wire at the apex so that it doesn't split and the last bit of the osteotomy is carried out using a small osteotome in the bare surface or the bare area of the junction of the coronoid and the olecranon. Once you open it, you can see fracture fragments nicely seen. You reduce it with two plates and you can see the jigsaw is nicely fixed and then the 6.5 screw is inserted to hold the osteotomy and the final fixation with the tension band wire.
I always like to do double loops for the tension band. These are her x-rays at about four months. And this is the functional outcome. And as you can see, she is very happy with the results. The ugly ones are the ones that caused the problems. This is the same case that I showed to you. What we did this is about ten, 12 years ago, and we didn't have the anatomical plates then and we fixed with to 9090 technique.
And generally, overall, this looked quite good. We got two inter-articular screws to compress the articular fragment to place 9090. With a tension bend wire. And as you can see here, the screw threads are catching into the medullary canal, which allows a good fix. At three months, this looks that there was some callus formation, patient was getting on OK.
But unfortunately this failed because there was significant movement in the metaphyseal area. And I'll come to that a bit later as to why this happens. This was fixed again with the removal of that callus area shortening slightly and getting a good bone into bone and compression. And the fracture it finally healed. Unfortunately, about nine months, 12 months after the healing, had another fall, the olecranon became a lot worse,
although you can see it's further away from the original osteotomy site. This was then fixed with the tension band wire and although the fracture itself started to heal, unfortunately he developed infection, which took months to settle down and also continued to have long term issues with ulnar neuropathy. Another example of the ugly number two.
This is also an open fracture. This proximal end is going out. This was fixed. This was again ten, 12 years ago. And you can see that the fixation isn't adequate, although the principles have been followed of the 9090 plate but probably less than adequate. At 6/8 weeks this looks OK. But you can also really see that this is not going to do well.
And at about four months, This failed. Again, pointed to the tension band wire and the screw is cutting into the ulnar medullary canal. This was then revised with the anatomical lock plate. See plenty of metalwork there. And it looked good. Unfortunately, the patient started to develop infection and it, the bone stopped healing.
And eventually the decision was made to remove the metalwork. But on table, we found that the fracture had not healed fully. And he continued to be in pain. The patient ended up having an elbow replacement. And these are X-rays seven years down the line with now him developing into a topic ossification with significant restriction on the movement.
If you look at complications in the distal humerus fracture, this is paper published fairly recently in the GSAS where they looked at nearly 2500 elbows, mainly type C, some type B fractures of the EO classification, meaning and in inter-articular comminated fractures, significant complication rates re-operation rate one in five.
Interestingly it shows that the perpendicular. plating approach i.e. The 9090 had significantly lower rate of overall complication. If we look at what the complication and reoperation rate, so just over 50% complication rates and a variety of complications, some clinically less relevant, i.e. the osteoarthritis, the hardware malfunction, but certainly still neuropathy in
Nearly 10%, union problems is less. Especially with the availability of better implants under 2%. And stiffness as well. The total reoperation just over 20%. We'll dissect this further. You can see in type B type, this was a younger age group patient. Higher osteoarthritis, implant discomfort, elbow stiffness, AVN an overall increased risk of reoperation rates.
The type C the comminuted one was seen in older age-group patients at higher incidence of neuropathy and hardware malfunction. Based on the approach, the electron osteotomy was preferred in the older age group patients, had increased risk of a OA nonunion, mal union and implant removal. Look at the type of fixation. Overall complications, as I alluded earlier, does increase risk in the parallel place.
More than 50% patients had, especially with the neuropathy, the implant prominence and wound dehiscence significantly high, perhaps reflecting the fact that you need to do more soft tissue dissection than the perpendicular approach and the medial wound implant prominence. However, the re-operation rates were also high, but interestingly the revision surgery rate was significantly higher in the perpendicular plate, suggesting again that perhaps the parallel plates are superior.
If I look at my failures, there's a few things in common. Most interestingly, I found that if there is a lateral metaphyseal comminution, this should be an alarm signal, and I would definitely I definitely use a parallel plate in those, even if you're not used to doing that. So in summary, ORIF is indicated for most displaced patterns - fracture patterns. Total elbow arthroplasty is up and coming, but is limited
To patients with low functional demands and poor bone quality. Chevron osteotomy is the preferred approach if you need for the intra-articular fractures. Routine transposition of ulnar nerve is not recommended, and if you're starting off, choose the appropriate approach, safeguard the ulnar nerve. And if you're going hard, you may come across the radial nerve. Respect the soft tissues.
Familiarize with the particular approach. And beware of the metaphyseal comminution. Thank you very much. If there any questions, please do send them across.
Segment:0 .
Good afternoon, everyone. My name is Professor Bijayendra Singh, Consultant Orthopedic surgeon, and with a Upper Limb interest at Medway Maritime Hospital. Also Professor at Canterbury Christchurch University. The immediate past president of British Indian Orthopedic Society. I'm going to share with you my thoughts on distal humerus fractures.
As to how to improve the outcomes following fixation. I'm going to limit myself to this particular talk, not going in to details of arthroplasty and other injuries. At the outset, I would like to thank the Bangladesh Orthopedic Society for giving me this opportunity to talk on this. And I wish the organizers and the attendees a grand success. So without further ado, I'm going to present to you my thoughts.
So this is an example of the 35-year-old man who fell from about 10 foot high. No other medical problems except for being overweight. He presented in the early hours of morning with this injury. These are his images. And I will share with you what I did a bit later on.
So what I'm aiming to do briefly is talk to you about the anatomy, the fracture patterns, the approach fixation, and discuss some of my failures as I believe that is the best way to learn. Come up with some take home messages. So we know the distal humerus has got two columns the medial and the lateral which converge at about 45 degrees angle and they're connected with the arch so to say which is the trochlea most distal part of the humerus.
On the lateral side is the capitellum and on the medial side is the epicondyle. That articular segment's functionally acting as a tie arch, and it's vital to restore this for optimum outcomes and functions. So the evaluation of these injuries are vital. Obviously, once you've done the ATLS to see if there's any other injuries which may be life or limb threatening, then one focuses on the elbow injury.
Traction views are often useful. Certainly, we can see injury ones are not as great, then we could do a traction view even at the intra op phase before performing the surgical incision. A CT scan has certainly revolutionized the assessment of these injuries and the 3D images
comes in really handy to look at the fragments, which helps plan the approach as well as plan the fixation. Look at especially whether there's any fracture of the capitellum or the trochlea. The other piece of advice, if you're not doing it regularly, is to speak to your radiology department so that you get the orientation of these cuts proper.
So I'd like to think every treatment for any fracture, perhaps every condition, has got three elements to it. One is the fracture personality. So if you've got a duff fracture like this in a slightly older age group patient, which is very low with some comminution, perhaps an element of degenerative change, then in some sort of arthroplasty works well as one operation gives a predictably good outcome. Patient personality
beware of the elderly age group with the softer bones. And also, they have significant comminution. Or smokers, they have a risk of non-union and wound problems. There's an example of another patient who had this intra articular fracture. 40 year old, slightly overweight smoker and despite having good fixation and optimum fixation, the fracture failed at three months.
Surgeon personality is not to be meant in a bad way, but I think it's realizing the limitations of inventory that a surgeon may have, as well as the experience of dealing with these injuries. These do require highly specialized skills and somebody who's doing them regularly to undertake this kind of practice so this is not mine,
this is from a friend who sent me this across when he received those. This is a 50-year-old chap with the comminuted fracture, although it looks simple, but it's quite low. And certainly see there is some comminution in there. This is how it was fixed. You can see the comminution and obviously this was not going to work. Then had a revision surgery with an olecranon osteotomy and we can pick on how the olecranon osteotomy was fixed and other bits,
but this is what an optimum fixation would require. Classifications we know loads of them. One that is always found useful is that will describe the injury, help direct the treatment, perhaps give an idea of the prognosis. Be useful for research. Find how good in an inter and intro- observer reliability. Unfortunately, as we know, most classification do not help with these.
The two that I find of some benefit in the distal humerus fractures. The one described by the Jupiter. Simple ones is the low or the high T fractures. And you have the C or the Y fractures with them where the comminution shaped like a D or an H type of an injury. And then you have your what's described as a medial lambda and lateral lambda with comminution and beware of the metaphyseal comminution.
David Standley and his team describe something along the similar lines. So the type I was the extra articular going from an oblique with a larger fracture surface to a transverse, which makes it unstable to a comunition. You have your predominantly intra articular fractures, the distal humerus, and then you have just the articular or the predominantly articular fragment.
And we're not going to talk about the type 3 here today. We're going to focus mainly on the type 2 injuries and the type I. It's a surgical treatment. So I do them mainly in lateral position. People have recommended doing it in prone position as well as it provides better access and maybe imaging might be a bit easier, but it's a nightmare for the anesthetist.
Generally, I prefer to use a tourniquet as it provides a good bloodless field. I try and put the elbow into flexion about 90 to 120 degrees before inflating the tourniquet. This provides a good pull onto the triceps, especially if you're going to use a osteotomy. The approaches we'll discuss briefly. Imaging,
I bring the C Arm parallel to the table. I always stand in the axilla of the patient and the image screen is either at the back of the patient or towards the head end. Approaches should be one that will influence the outcomes that should be able to help you achieve reduction. And it would advise to use an approach that fits the fracture pattern. So the choice of approach will also be partly be based on the age of the patient.
So I said fracture the procedure that one is doing, i.e. a fixation or a replacement, any associated injury. And if there is an open wound, then that may need to be taken care of. So broadly, based on which side you go, you've got the medial, you have a posterior, anterior and lateral approach. For the purpose of this lecture and this type of fracture it's mainly going to be the posterior approach. Can have a triceps preserving which is an osteotomy or a para- tricipital approach.
Or you can have a triceps reflecting or triceps off, which is your Morey or your TRAP approach depending on which side of the elbow you approach it from the medial or the lateral. They have their own pluses and minuses. Not going to go into much detail of these. With any of the approach, there are a few things that you need to be thinking about. The ulnar nerve always advised to isolate and tag the ulnar nerve before proceeding to any bon procedures.
I never put any instrument to tag that vascular loop as it can get caught just tight around the ulnar nerve with a big loop. The other question is whether you transpose, and most literature suggests that there is no need for routine transposition. Treatment principles includes anatomic reduction, stable fixation of the articular surface. This is the key and then restoration of the articular axial alignment, stable fixation metaphysis to the diaphysis.
So they can mobilize and the fracture heal. Now with all the above, aim to get early range of motion of the elbow. So some of the fixation would be dependent on the fracture pattern. Extra-articular fractures depending on the level could be fixed by one or two on two plates. You may go for a lock and unlock place, but generally these days are locked in and plate is preferred. For intra- articular fractures
there's no doubt in my mind that the literature support needs two plates, locking plates, and the question is whether you do a 90/90 or a parallel plating. And we'll have a look into that briefly. The parallel concepts plates concept was described by the Mayo group, led by Dr. O'Driscoll, and he suggested that it provides an external scaffold.
A direct reduction and temporary fixation with K-wire or clamps is recommended, and then bone fragments are stabilized with locking screws. But these are the principles that he said one must try and adhere to. All screws pass through the plate. All fragments are engaged by the screws. Each group should engage a fragment on the opposite side. And it should be as long as possible.
And the idea that the screws inter-digitate within the distal fragment providing better fix hold. Your 90/90 plates again relies on an anatomic reduction of the articular fragment. And in direct reduction of the extra articular and is stabilized by spanning plates and generally these healed with an element of callus formation. If you look at the results, bio mechanically parallel plating is superior to the 90 /90 configuration, but clinically there is no difference in the outcome.
Perhaps because the numbers needed is significantly large. That would be required to establish a difference. Just showing you some of the examples that I've come across that are good. So this is a 60/ 65-year-old gentleman with this extra articular fracture, displaced, closed injury. And this I approached using a para-tricepular approach or a triceps on approach. Initial was held with clamps and two k-wires.
And then I used two parallel plates. And this has become my go to fixation technique, for these kind of injuries. The bad. This is an example of a young lady in her late 20s. who fell on her hen do, sustained this fracture of the distal humerus. As you can see, quite comminuted, both intra articular and over the metaphysis.
I use an olecranon osteotomy. And I make incisions on both sides of the ulnar, leaving a cuff of fascia to repair. The first step is to get your access to the osteotomy so drill using a 3.2 and I use a 6.5 tab and then screw lens should be long as long as is required and generally guided by the tap catching into the medullary canal of the ulna.
Most often it is above 100 millimeters. Mark your saw, I use a k-wire at the apex so that it doesn't split and the last bit of the osteotomy is carried out using a small osteotome in the bare surface or the bare area of the junction of the coronoid and the olecranon. Once you open it, you can see fracture fragments nicely seen. You reduce it with two plates and you can see the jigsaw is nicely fixed and then the 6.5 screw is inserted to hold the osteotomy and the final fixation with the tension band wire.
I always like to do double loops for the tension band. These are her x-rays at about four months. And this is the functional outcome. And as you can see, she is very happy with the results. The ugly ones are the ones that caused the problems. This is the same case that I showed to you. What we did this is about ten, 12 years ago, and we didn't have the anatomical plates then and we fixed with to 9090 technique.
And generally, overall, this looked quite good. We got two inter-articular screws to compress the articular fragment to place 9090. With a tension bend wire. And as you can see here, the screw threads are catching into the medullary canal, which allows a good fix. At three months, this looks that there was some callus formation, patient was getting on OK.
But unfortunately this failed because there was significant movement in the metaphyseal area. And I'll come to that a bit later as to why this happens. This was fixed again with the removal of that callus area shortening slightly and getting a good bone into bone and compression. And the fracture it finally healed. Unfortunately, about nine months, 12 months after the healing, had another fall, the olecranon became a lot worse,
although you can see it's further away from the original osteotomy site. This was then fixed with the tension band wire and although the fracture itself started to heal, unfortunately he developed infection, which took months to settle down and also continued to have long term issues with ulnar neuropathy. Another example of the ugly number two.
This is also an open fracture. This proximal end is going out. This was fixed. This was again ten, 12 years ago. And you can see that the fixation isn't adequate, although the principles have been followed of the 9090 plate but probably less than adequate. At 6/8 weeks this looks OK. But you can also really see that this is not going to do well.
And at about four months, This failed. Again, pointed to the tension band wire and the screw is cutting into the ulnar medullary canal. This was then revised with the anatomical lock plate. See plenty of metalwork there. And it looked good. Unfortunately, the patient started to develop infection and it, the bone stopped healing.
And eventually the decision was made to remove the metalwork. But on table, we found that the fracture had not healed fully. And he continued to be in pain. The patient ended up having an elbow replacement. And these are X-rays seven years down the line with now him developing into a topic ossification with significant restriction on the movement.
If you look at complications in the distal humerus fracture, this is paper published fairly recently in the GSAS where they looked at nearly 2500 elbows, mainly type C, some type B fractures of the EO classification, meaning and in inter-articular comminated fractures, significant complication rates re-operation rate one in five.
Interestingly it shows that the perpendicular. plating approach i.e. The 9090 had significantly lower rate of overall complication. If we look at what the complication and reoperation rate, so just over 50% complication rates and a variety of complications, some clinically less relevant, i.e. the osteoarthritis, the hardware malfunction, but certainly still neuropathy in
Nearly 10%, union problems is less. Especially with the availability of better implants under 2%. And stiffness as well. The total reoperation just over 20%. We'll dissect this further. You can see in type B type, this was a younger age group patient. Higher osteoarthritis, implant discomfort, elbow stiffness, AVN an overall increased risk of reoperation rates.
The type C the comminuted one was seen in older age-group patients at higher incidence of neuropathy and hardware malfunction. Based on the approach, the electron osteotomy was preferred in the older age group patients, had increased risk of a OA nonunion, mal union and implant removal. Look at the type of fixation. Overall complications, as I alluded earlier, does increase risk in the parallel place.
More than 50% patients had, especially with the neuropathy, the implant prominence and wound dehiscence significantly high, perhaps reflecting the fact that you need to do more soft tissue dissection than the perpendicular approach and the medial wound implant prominence. However, the re-operation rates were also high, but interestingly the revision surgery rate was significantly higher in the perpendicular plate, suggesting again that perhaps the parallel plates are superior.
If I look at my failures, there's a few things in common. Most interestingly, I found that if there is a lateral metaphyseal comminution, this should be an alarm signal, and I would definitely I definitely use a parallel plate in those, even if you're not used to doing that. So in summary, ORIF is indicated for most displaced patterns - fracture patterns. Total elbow arthroplasty is up and coming, but is limited
To patients with low functional demands and poor bone quality. Chevron osteotomy is the preferred approach if you need for the intra-articular fractures. Routine transposition of ulnar nerve is not recommended, and if you're starting off, choose the appropriate approach, safeguard the ulnar nerve. And if you're going hard, you may come across the radial nerve. Respect the soft tissues.
Familiarize with the particular approach. And beware of the metaphyseal comminution. Thank you very much. If there any questions, please do send them across.
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