Copyright © 2006 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
David P. Barei, MD, FRCS(C), and Douglas P. Hanel, MD*,
Department of Orthopaedic Surgery, Harborview Medical Center, Seattle, Washington
Posted November 2006
This nonrandomized retrospective comparative study by Jawa
and colleagues evaluates selected outcomes of operative and nonoperative
treatment of extra-articular distal-third fractures of the humerus. This study
confirms several general points that have been suspected by many. First,
functional bracing achieves excellent union rates without sacrificing elbow or
shoulder motion. Angulatory alignment, however, is less predictable with
bracing than with operative treatment, with some degree of varus being the most
common resultant deformity. Second, surgical treatment also appears to
facilitate restoration of shoulder and elbow motion, but with risks of sepsis
and iatrogenic radial nerve palsy. Last, surgical treatment is commonly used
for managing these injuries in patients with associated injuries.
The authors describe the critical features that are required
for the successful functional bracing of these fractures. These features were initially
described and popularized by Sarmiento et al.1. Importantly,
maintenance of proper brace application, avoidance of early shoulder elevation
and abduction, and minimization of external elbow support are intended to
minimize the tendency to varus angulation. Despite this, a number of patients
still demonstrated residual varus deformity. Although not addressed in the
current study, the long-term consequences of supracondylar varus deformity on
elbow function and stability may not be as benign as previously thought, and these
consequences should be considered when choosing a treatment method2.
One of the key features for the successful operative
treatment of these injuries is secure fracture fixation, particularly of the
distal segment. As illustrated by the authors, numerous techniques are
available, including dual and single-plate constructs with or without the use
of locking screws. The choice of surgical exposure and type of definitive
implant is dependent on several factors, including the fracture pattern,
associated wounds and injuries, and bone quality, among others. Whichever
implant(s) and surgical exposure are utilized, however, identification and
mobilization of the radial nerve are critical to the avoidance of iatrogenic
nerve injury3,4.
The conclusions of this study are limited by differences in
associated injuries, nonuniform surgical interventions in the operatively
treated patients, group sample-size differences, and a lack of longer-term
functional outcomes. These limitations make definitive recommendation of one
treatment method over the other difficult. Larger randomized studies with
uniform surgical interventions are required to help answer many of the other
questions that arise when treating these fractures.
*The authors did not receive any outside funding or grants
in support of their research for or preparation of this work. Neither they nor
a member of their immediate families received payments or other benefits or a
commitment or agreement to provide such benefits from a commercial entity. No
commercial entity paid or directed, or agreed to pay or direct, any benefits to
any research fund, foundation, division, center, clinical practice, or other
charitable or nonprofit organization with which the authors, or a member of their
immediate families, are affiliated or associated.
References
1. Sarmiento A, Horowitch A, Aboulafia A, Vangsness CT Jr. Functional bracing for comminuted extra-articular fractures of the distal third of the humerus. J Bone Joint Surg Br. 1990;72:283-7.
2. O'Driscoll SW, Spinner RJ, McKee MD, Kibler WB, Hastings H 2nd, Morrey BF, Kato H, Takayama S, Imatani J, Toh S, Graham HK. Tardy posterolateral rotatory instability of the elbow due to cubitus varus. J Bone Joint Surg Am. 2001;83:1358-69.
3. Gerwin M, Hotchkiss RN, Weiland AJ. Alternative
operative exposures of the posterior aspect of the humeral diaphysis with reference to the radial nerve. J Bone Joint Surg Am. 1996;78:1690-5.
4. Mills WJ, Hanel DP, Smith DG. Lateral approach to the humeral shaft: an alternative approach for fracture treatment. J Orthop Trauma. 1996;10:81-6.
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