In our study the most common anatomical fracture location was the ulnar coronoid process in 27 patients (18 % ,21-B1 type) ) ,radial head in 26 patients (17%,
22-B2 type).16 patients had a multrifragmentary articular fracture of the distal humerus ( (11,9%, 13-C3 type).The diagnostic acccuracy of the MDCT images provided valuable information on the mechanisms of injury ,on the morphology of the fractures and origin of the fragments.
Two are the most common injury mechanisms of the elbow.
The most common mechanism involves valgus and pronation stress which typically occurs during a fall onto an outstretched hand.
During these injuries a combination of distraction forces around the medial elbow and concomitant compression of the lateral elbow is produced usually leading to radial head and neck fracture.
The second,
but not so usual,
injury mechanism has to do with direst blow that leads to fracture or dislocation of any bone that is part of the elbow.
The surgical approach is the gold standard for treating distal humerus fractures whereas the conservative treatment is only playing a minor role in managing them.
Non operative treatment seems only to be advisable in cases of non-displaced fractures for patients who are being assessed as not fitting for surgery or as a temporary solution in the elderly before arthroplasty to avoid stiffening and heterotopic ossification.
Successful management of distal humerus fractures means correct reduction of the fracture,
reconstruction of the articular surface if needed,
stability and rigidity of the fixation,
and appropriate rehabilitation and it depends on the clear radiological imaging and understanding of the fractures lines and surfaces.
According to the literature,
based on the OTA/AO classification,
each type of fracture seems to need its appropriate exposure after appropriate surgical approach.
The most frequently performed approaches in the surgical treatment of distal humerus fractures are olecranon osteotomy,
triceps–reflecting (elevating),
triceps-splitting,
triceps-sparing,
and triceps-lifting.
Olecranon osteotomy (Chevron osteotomy) is the traditional standard approach for the distal humerus and elbow joint.
The surgeon has a wide exposure of the articular surface of the distal humerus and make reduction and internal fixation of complex type fractures.
Specifically the OTA/AO type C3 fractures are best managed by this approach.
Maybe this approach has a relative contraindication for very anterior articular fractures (OTA/AO type B3),
which can be difficult to visualize through an osteotomy.
The triceps–reflecting (elevating) (Bryan–Morrey) approach allows the surgeon a widespread view of the joint without olecranon osteotomy-and is used for arthroplasty and internal fixation of intraarticular fractures.
According to the triceps-sparing approach,
the view of the distal articular surface is relatively impaired.
It is indicated for open reduction and internal fixation (ORIF) in extra-articular (A) or simple articular fractures.
Specifically,
the several advantages of this approach certainly indicate its use for OTA/AO types A2,
A3,
B1,
B2 and possibly C1 and C2 fractures.
This approach may not provide sufficient exposure for type C3 fractures.
The triceps-lifting approach,
has been evaluated and established for intraarticular fractures (OTA/AO type B3 and C).
This approach has been indicated as the treatment for distal diaphyseal fractures and less for intraarticular fractures (OTA/AO type C),
due to the prementioned limited visibility of the articular surface.
The triceps flexor carpi ulnaris approach,
which is a modification of the triceps-reflecting approach,
has been described to be used for extra and intra-articular fractures.
Finally,
for selected partial articular fractures (OTA/AO Type B fractures) of the distal humerus,
the usage of minimal invasive approaches has proven to be sufficient for successful fracture reduction and fixation.
Specifically,
for OTA/AO type B1 fractures a lateral approach has been shown to be feasible and safe.
For OTA/AO type B2 fractures,
after mobilization of the ulnar nerve and release of the medial intermuscular septum,
the flexor carpi ulnaris and pronator teres are pulled anteriorly to display the joint capsule,
thus enabling fracture reduction after incision of the capsule.
For OTA/AO type B3 fractures,
fragment excision should only be performed in case of a very small bony fragments or thin cartilaginous bowls.
Excision of bigger capitellar fragments may lead to valgus instability,
especially in medial collateral ligament insufficient elbow.
It must be underlined that there are several additional injury situations that will affect the management and the prognosis of the fractures of the radial head but are not consistently accounted for in this classification system.
In particular,
initially based on the OTA/AO classification which shows radial head or neck fracture,
it must be actively sought and excluded three important injuries.
These are Essex-Lopresti injury (a combination of a radial head fracture and an injury to the distal radio-ulnar joint,),
Monteggia fracture dislocation (a combination of a radial head dislocation,
with or without head fracture and ulnar fracture,) and ‘‘terrible triad’’ injury (after elbow dislocation there is combination of radius head fracture,
coronoid process fracture and medial collateral ligament injury).
Based on them,
the surgeon can have a clear image as a guide for the treatment of the olecranon fracture (collar and cuff for rest or splint,
tension band technique or intramedullary fixation or excision of the fragment with triceps reattachment,
or plate and screws osteosynthesis) and coronoid process fractures (closed reduction,
brief splinting and gentle mobilization or internal fixation with screws or transossoeous suture and fixation of disrupted ligaments and fractures of radial head and neck OR hinged external fixation).
In conclusion the MDCT analysis of elbow fracture according to ΑΟ/OTA trauma system seem to be necessary for the assessment of specific injury patterns and for the guiding of the appropriate treatment.