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Fractures of the Distal Humerus
Gregory J. Della Rocca, MD, PhD
Original authors: Jeffrey J. Stephany, MD and Gregory J.
Schmeling, MD; March 2004Second author: Laura S. Phieffer, MD;
Revised January 2006Curent author: Gregory J. Della Rocca, MD, PhD;
Revised October 2010
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Functional AnatomyHinged joint with single axis of rotation
(trochlear axis)Trochlea is center point with a lateral and medial
column
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Functional AnatomyThe distal humerus angles forwardLateral
positioning during ORIF facilitates reconstruction of this
angle
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Surgical AnatomyThe trochlear axis compared to longitudinal axis
is 94-98 degrees in valgusThe trochlear axis is 3-8 degrees
externally rotatedThe intramedullary canal ends 2-3 cm above the
olecranon fossa
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Surgical AnatomyMedial and lateral columns diverge from humeral
shaft at 45 degree angleThe columns are the important structures
for support of the distal humeral triangle
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Mechanism of InjuryThe fracture pattern may be related to the
position of elbow flexion when the load is applied
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EvaluationPhysical examSoft tissue envelopeVascular statusRadial
and ulnar pulsesNeurologic statusRadial nerve - most commonly
injured14 cm proximal to the lateral epicondyle20 cm proximal to
the medial epicondyle Median nerve - rarely injuredUlnar nerve
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EvaluationRadiographic examAnterior-posterior and lateral
radiographsTraction views may be helpful to evaluate
intra-articular extension and for pre-operative planning (creates a
partial reduction via ligamentotaxis)Traction removes overlapCT
scan helpful in selected casesComminuted capitellum or
trochleaOrientation of CT cut planes can be confusing
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OTA ClassificationFollows AO Long Bone SystemHumerus (#1X-XX),
distal segment (#X3-XX) = 13-XX3 Main TypesExtra-articular fracture
(13-AX)Partial articular fracture (13-BX)Complete articular
fracture (13-CX)Each broad category further subdivided into 9
specific fracture types
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OTA ClassificationHumerus, distal segment
(13)TypesExtra-articular fracture (13-A)Partial articular fracture
(13-B)Complete articular fracture (13-C)
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OTA ClassificationHumerus, distal segment
(13)TypesExtra-articular fracture (13-A)Partial articular fracture
(13-B)Complete articular fracture (13-C)
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OTA ClassificationHumerus, distal segment
(13)TypesExtra-articular fracture (13-A)Partial articular fracture
(13-B)Complete articular fracture (13-C)
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Summary - ClassificationsA good classification should do the
following:Describe injuryDirect treatmentDescribe prognosisBe
useful for researchHave good inter-observer reliabilityHave good
intra-observer reliabilityMost classification schemes fail in some
of these categories
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Treatment PrinciplesAnatomic articular reductionStable internal
fixation of the articular surfaceRestoration of articular axial
alignmentStable internal fixation of the articular segment to the
metaphysis and diaphysisEarly range of motion of the elbow
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Treatment: Open FractureUrgent I&DDefinitive reduction and
internal fixationPrimary closure acceptable in some
circumstancesTemporary external fixation across elbow if definitive
fixation not possibleDefinitive fixation at repeat
evaluationAntibiotic therapyRepeat evaluation in OR as necessary
until soft tissue closure
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FixationImplants determined by fracture patternExtra-articular
fractures may be stabilized by one or two contoured platesLocked
vs. nonlocked based upon bone quality, working length for fixation,
surgeon preferenceIntra-articular fracturesDual plates most often
used in 1 of 2 configurations90-90: medial and posterolateralMedial
and lateral plating
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Dual plating configurationsSchemitsch et al (1994) J Orthop
Trauma 8:468Tested 2 different plate designs in 5 different
configurationsDistal humeral osteotomy with and without bone
contactConclusions:For stable fixation the plates should be placed
on the separate columns but not necessarily at 90 degrees to each
other
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Dual plating configurationsJacobson et al (1997) J South Orthop
Assoc 6:241.Biomechanical testing of five constructsAll were
stiffer in the coronal plane than the sagittal planeStrongest
constructmedial reconstruction plate with posterolateral dynamic
compression plate
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Dual plating configurationsKorner et al (2004) J Orthop Trauma
18:286Biomechanically compared double-plate osteosynthesis using
conventional reconstruction plates and locking compression
platesConclusionsBiomechanical behavior depends more on plate
configuration than plate type. Advantages of locking plates were
only significant if compared with dorsal plate application
techniques (not 90/90)
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Other Potential Surgical OptionsTotal elbow
arthroplastyComminuted intra-articular fracture in the
elderlyPromotes immediate ROMUsually limited by poor remaining bone
stockBag of bones techniqueRarely indicated if at allCast or cast /
braceIndicated for completely non-displaced, stable fractures
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Fixation in elderly patientsJohn et al (1993) Helv Chir Acta
60:21949 patients (75-90 yrs)41/49 Type CConclusionsNo increase in
failure of fixation, nonunion, nor ulnar nerve palsyAge not a
contra-indication for ORIF
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Total elbow arthroplastyCobb and Morrey (1997) JBJS-A 79:82620
patients avg age 72 yrsTEA for distal humeral fractureConclusionTEA
is viable treatment option in elderly patient with distal humeral
fracture
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ORIF vs. elbow arthroplastyFrankle et al (2003) J Orthop Trauma
17:473Comparision of ORIF vs. TEA for intra-articular distal
humerus fxs (type C2 or C3) in women >65yoRetrospective review
of 24 patientsOutcomesORIF: 4 excellent, 4 good, 1 fair, 3 poorTEA:
11 excellent, 1 goodConclusions: TEA is a viable treatment option
for distal intra-articular humerus fxs in women >65yo,
particularly true for women with assoc comorbidities such as
osteoporosis, RA, and conditions requiring the use of systemic
steriods
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Surgical TreatmentLateral decubitus positionProne positioning
possibleSupine position difficultArm hanging over a postSterile
tourniquet if desiredMidline posterior incisionExposure ?
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ExposuresReduction influences outcome in articular
fracturesExposure affects ability to achieve reductionExposure
influences outcome!Choose the exposure that fits the fracture
pattern
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Surgical exposuresTriceps splittingAllows exposure of shaft to
olecranon fossaExtra-articular olecranon osteotomyAllows adequate
exposure of the distal humerus but inadequate exposure of the
articular surface
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Surgical exposuresIntra-articular olecranon
osteotomyTypesTransverseIndicated for intra-articular Group II
fracturesTechnically easier to do30% incidence of nonunion (Gainor
et al, (1995) J South Orthop Assoc 4:263)Olecranon implant removal
may be necessary due to irritation
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Surgical exposuresIntra-articular olecranon
osteotomyTypesChevronIndicated for intra-articular Group II
fracturesTechnically more difficultMore stableOlecranon implant
removal may be necessary due to irritation
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Osteotomy Fixation OptionsTension band techniqueDorsal
platingSingle screw
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Osteotomy FixationSingle screw techniqueLarge screw +/-
washerBeware of the bow of the proximal ulna, which may cause a
malreduction of the tip of the olecranon if a long screw is
used.Eccentric placement of screw may be helpfulHak and Golladay,
JAAOS, 8:266-75, 2000
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Osteotomy FixationSingle screw techniqueLarge screw +/-
washerBEWARE: large-diameter screw threads may engage ulnar
diaphysis (small medullary canal) prior to full seating of screw
headBite of screw may be strong without full compressionCareful
scrutiny of lateral radiograph important to assure full seating of
screw headHak and Golladay, JAAOS, 8:266-75, 2000
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Osteotomy FixationSingle screw techniqueLong screw may be
beneficial for adequate fixationShort screw may loosen or toggle
with contraction of triceps against olecranon segmentHak and
Golladay, JAAOS, 8:266-75, 2000
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Osteotomy FixationTension band techniqueK-wires or screw with
figure-of-8 wireEasy to place (?)May be less stable than
independent lag screw or plateImplant irritationK-wires try to
engage anterior ulnar cortex near coronoid baseMullett et al (2000)
Injury 31:427,Prayson et al (1997) J Orthop Trauma 11:565
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Tension band screwTension band wireEngage anterior ulnar cortex
here with wires to improve fixation stability/strengthLength of
screw may be important to resist toggling and loss of reduction
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Osteotomy FixationDorsal platingLow profile periarticular
implants now availableAxial screw through plateGood results after
plate fixationHewin et al (2007) J Orthop Trauma 21:58Tejwani et al
(2002) Bull Hosp Jt Dis 61:27
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Chevron OsteotomyExpose olecranon and mobilize ulnar nerveIf
using screw/TBW fixation, pre-drill and tap for screw placement
down the ulna canalSmall, thin oscillating saw used to cut 95% of
the osteotomyOsteotome used to crack and complete it
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Chevron osteotomyColes et al (2006) J Orthop Trauma 20:16470
chevron osteotomiesAll fixed with screw plus tension band or with
plate-and-screw construct67 with adequate follow-up: all healed2
required revision fixation prior to healing18 of 61 with sufficient
follow-up required implant removal
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Surgical exposureTriceps-sparing postero-medial approach
(Byran-Morrey Approach)Midline incisionUlnar nerve identified and
mobilizedMedial edge of triceps and distal forearm fascia elevated
as single unit off olecranon and reflected laterallyResection of
extra-articular tip of olecranon
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Bryan-Morrey Approach
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Surgical exposureMedial and lateral exposures triceps
sparingTriceps-sparingGood for extra-articular fractures and some
simple intra-articular fractures (OTA type 13-C1 or 13-C2)Can split
triceps tendon for further visualization of articular surfaceCan
resect tip of olecranon to improve visualization without detaching
triceps
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Surgical TreatmentLateral decubitus position (or prone)Arm
hanging over a postSterile tourniquet if desiredMidline posterior
incisionExposure dependent upon fracture patternReduction and
provisional K-wire fixationLag screws inserted and K-wires
removedBEWARE: Do not compress a comminuted articular
fractureBi-columnar platingReconstruction of triceps insertion per
exposure chosen
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To transpose or not to transpose?Identification and mobilization
of the ulnar nerve is often requiredUlnar nerve palsy may be
related to injury, surgical exposure/mobilization/stripping,
compression by implant, or scar formation
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To transpose or not to transpose?Wang et al (1994) J Trauma
36:770consecutive series of distal humeral fractures treated with
ORIF and anterior ulnar nerve transposition had no post-operative
ulnar nerve compression syndrome. overall results: Excellent/Good
75%, Fair 10%, and Poor 15%. conclusion: routine anterior
transposition indicated.
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To transpose or not to transpose?Chen et al (2010) J Orthop
Trauma 24:391Retrospective cohort comparison89 patients underwent
transposition, 48 patients did not4x greater incidence of ulnar
neuritis in patients receiving transpositionConclusion: routine
ulnar nerve transposition not recommended during ORIF of distal
humerus fractures
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To transpose or not to transpose?Vazquez et al (2010) J Orthop
Trauma 24:395Retrospective series69 distal humerus fracture
patients without preoperative ulnar nerve dysfunction10% with
immediate postoperative nerve dysfunction,16% with late nerve
dysfunctionTransposition not effective at protecting nerveLarge
prospective cohort series are likely needed to answer this question
definitively
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To transpose or not to transpose?If transposing,
methods:Anterior sub-cutaneous technique fascial sling (off of
flexor mass) attached to skin to prevent loss of
transpositionIntramuscularSubmuscular
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Post-operative careBulky splint applied intra-opElbow position90
degrees of flexion or extension?Authors support either and
proponents strongly argue that their position is the bestExtension
is harder to recover than flexionFinal arc of motion recovered is
more functional if centered on 90 degrees of flexionUse what works
in your hands and rehab protocol
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Post-operative careRange-of-motion begun 1-3 daysTailored to the
fixation and soft tissue envelopeAROM / AAROM (PROM may be used but
may promote heterotopic ossification)Anti-inflammatory for 6 weeks
or single-dose radiation therapy used occasionally if at high risk
for heterotopic ossificationRecent report documents
dramatically-increased complication risk of olecranon osteotomy
after radiation therapy (Hamid et al (2010) JBJS-A 92:2232
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OutcomesMost daily activities can be accomplished with the
following final motion arcs:30 130 degrees extension-flexion50 50
degrees pronation-supinationOutcomes based on pain and
functionPatients not necessarily satisfied with above motion
arcs
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OutcomesGood elbow flexion is often the first to returnExtension
seems to progress more slowlySupination/pronation usually
unaffectedPain- 25 % of patients describe exertional pain
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OutcomesWhat patients may expect, for example:Lose 10-25 degs of
flexion and extensionMaintain full supination and pronationDecrease
in muscle strengthOverall:Good/excellent75%Factors most likely to
affect outcomeSeverity of injuryOccurrence of a complication
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ComplicationsFailure of fixationAssociated with stability of
operative fixationK-wire fixation alone is inadequateAdult distal
humerus is much different from pediatric distal humerusIf diagnosed
early, revision fixation indicatedLate fixation failure must be
tailored to radiographic healing and patient symptoms
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ComplicationsNonunion of distal humerusUncommonUsually a failure
of fixationSymptomatic treatmentBone graft with revision
plating
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ComplicationsNon-union of olecranon osteotomyRates as high as 5%
or moreChevron osteotomy has a lower rateTreated with bone graft
occasionally and revision fixationExcision of proximal fragment is
salvage50% of olecranon must remain for joint stability
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ComplicationsInfectionRange 0-6% Highest for open fracturesNo
style of fixation has a higher rate than any other
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ComplicationsUlnar nerve palsy8-20% incidenceReasons: operative
manipulation, hardware prominence, inadequate releaseResults of
neurolysis (McKee, et al)1 excellent result17 good results2 poor
results (secondary to failure of reconstruction)Prevention best
treatment (although routine transposition is of unknown
importance)
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ComplicationsPainful implantsThe most common complaintCommon
locationOlecranon Medial implants (over medial epicondyle)Lateral
implants (some plates prominent over posterior-lateral aspect of
lateral condyle)Implant removalAfter fracture unionPatient may need
to restrict activity for 6-12 weeks
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SummaryORIF indicated for most displaced patternsTotal elbow
arthroplasty excellent alternative in patient with poor bone
quality and low functional demandsChevron osteotomy is preferred
type of olecranon osteotomy when neededRoutine transposition of
ulnar nerve has not been demonstrated to be beneficial
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Case ExamplesLateral column fractureMedial column
fractureIntra-articular distal humeral fractureExtra-articular
distal humeral fractureFixation failure olecranon osteotomyFixation
failure distal humeral fracture
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Case 1: 18 y/o s/p fallLateral epicondyle and capitellum Fxs
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Lateral approachCapitellum: Post to Ant lag screwsEpicondyle:
Screw + buttress plateHealedLoss of 20 degs ext
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Case 2:43 y/o female fell from horse
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Chevron intra-articular approachTension band screwORIF medial
column FxExtensile exposure required intra-op
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Antegrade IM nail for humeral FxHealedLacks 10 degs elbow
extensionFull shoulder motionOlecranon implants tender
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Case 3: 20 y/o male MCCDistal, two column FxNV intact
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Transverse intra-articular approachLag screw and bi-column
platingTension band wire (medullary placement of K-wires)
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HealedLacks 20 degs flex & ext.Osteotomy healed without
complications
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ReferencesHamid et al. Radiation therapy for heterotopic
ossification prophylaxis acutely after elbow trauma. JBJS-A (2010)
92:2032.Vazquez et al. Fate of the ulnar nerve after operative
fixation of distal humerus fractures. J Orthop Trauma (2010)
24:395.Chen et al. Is ulnar nerve transposition beneficial during
open reduction internal fixation of distal humerus fractures? J
Orthop Trauma (2010) 24:391.
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ReferencesColes et al. The olecranon osteotomy: a six-year
experience in the treatment of intraarticular fractures of the
distal humerus. J Orthop Trauma (2006) 20:164.Tejwani et al.
Posterior olecranon plating: biomechanical and clinical evaluation
of a new operative technique. Bull Hosp Jt Dis (2002) 61:27.Gainor
et al. Healing rate of transverse osteotomies of the olecranon used
in reconstruction of distal humerus fractures J South Orthop Assoc
(1995) 4:263.
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ReferencesJohn, H, Rosso R, Neff U, Bodoky A, Regazzoni P,
Harder F: Operative treatment of distal humeral fractures in the
elderly. JBJS 76B: 793-796, 1994.Pereles TR, Koval KJ, Gallagher M,
Rosen H: Open reduction and internal fixation of the distal
humerus: Functional outcome in the elderly. J Trauma 43: 578-584,
1997Hewins et al. Plate fixation of olecranon osteotomies. J Orthop
Trauma (2007) 21:58.
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ReferencesCobb TK, Morrey BF: Total elbow arthroplasty as
primary treatment for distal humeral fractures in elderly patients.
JBJS 79A: 826-832, 1997Frankle MA, Herscovici D, DiPasuale TG et
al: A comparison of ORIF and Primary TEA in the treatment of
intraarticular distal humerus fractures in women older than age 65.
J Orthop Trauma 17(7):473-480, 2003.Mullett et al. K-wire position
in tension band wiring of the olecranon: a comparison of two
techniques. Injury (2000) 31:427.
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ReferencesSchemitsch EH, Tencer AF, Henley MB: Biomechanical
evaluation of methods of internal fixation of the distal humerus. J
Orthop Trauma 8: 468-475, 1994Korner J, Diederichs G, Arzdorf M, et
al: A Biomechanical evaluation of methods of distal humerus
fracture fixation using locking compression versus conventional
reconstruction plates. J Orthop Trauma 18(5):286-293, 2004.Prayson
et al. Biomechanical comparison of fixation methods in transverse
olecranon fractures: a cadaveric study. J Orthop Trauma (1997)
11:565.
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ReferencesJacobson SR, Gilsson RR, Urbaniak JR: Comparison of
distal humerus fracture fixation: A biomechanical study. J South
Orthop Assoc 6: 241-249, 1997Voor, MJ, Sugita, S, Seligson, D:
Traditional versus alternative olecranon osteotomy. Historical
review and biomechanical analysis of several techniques. Am J
Orthop 24: Suppl, 17-26, 1995
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ReferencesWang KC, Shih, HN, Hsu KY, Shih CH: Intercondylar
fractures of the distal humerus: Routine anterior subcutaneous
transposition of the ulnar nerve in a posterior operative approach.
J Trauma 36: 770-773, 1994McKee MD, Jupiter JB, Bosse G, Hines L:
The results of ulnar neurolysis for ulnar neuropathy during
post-traumatic elbow reconstruction. Orthopaedic Proceedings JBJS-B
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