HISTORY OF HAND SURGERY

Treatment of Distal Humerus Fractures in Adults: A Historical Perspective Michal Kozánek, MD, Jan Bartonícek, MD, PhD, Samantha M. Chase, MD, Jesse B. Jupiter, MD

Nonsurgical treatment was the mainstay of management of distal humerus fractures for centuries and nonunions and malunions were common. The 19th century featured the recognition of distinct injury patterns. With advances in radiology, anesthesia, antisepsis, and hardware technology, surgical treatment is now generally preferred, yet loss of elbow joint mobility can still be a vexing problem. (J Hand Surg Am. 2014;39(12):2481e2485. Copyright Ó 2014 by the American Society for Surgery of the Hand. All rights reserved.) Key words Distal humerus fractures, elbow trauma, history.

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the treatment of distal humerus fractures for centuries, and complications, mainly stiffness and malunion, were prevalent. This began to change after the invention of x-ray detectors in 1895. Application of radiography led to the description of distinct injury patterns and to the appearance of classification systems such as those of Helferich1 and Cotton.2 Further, with the development of anesthesia and antisepsis, surgical treatment was feasible. Lambotte3 was among the first to surgically treat distal humerus fractures, although initial results were discouraging. Implementation of the Association for Osteosynthesis/ Association for the Study of Internal Fixation techniques in 1960s and 1970s resulted in improved outcomes. Nonetheless, loss of mobility of the elbow joint ONSURGICAL TECHNIQUES DOMINATED

From the Department of Orthopaedic Surgery, Massachusetts General Hospital and Harvard Combined Orthopaedic Residency Program, Boston, MA; the Department of Orthopaedic Trauma of 1st Faculty of Medicine of Charles University and Central Military Hospital, Prague, Czech Republic; and the Faculty of Medicine, Comenius University, Bratislava, Slovakia. Received for publication February 26, 2014; accepted in revised form August 5, 2014. The authors wish to thank Dr. Job Doornberg whose prior work was invaluable in tracing historical sources and the preparation of this manuscript. This work was aided by a grant from the Orthopaedic Research and Education Foundation. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Jesse B. Jupiter, MD, Massachusetts General Hospital, YAW 2, 55 Fruit St., Boston MA 02114, USA; e-mail: [email protected] 0363-5023/14/3912-0021$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.08.003

has remained a frustrating problem. Advances in arthroplasty and newer fixation techniques expand the options for management of comminuted fractures of physiologically sound but elderly patients. ANCIENT EGYPT (3000 BCE) Among the earliest known documents describing reduction and orthosis fabrication of an elbow injury was that of Imhotep between 3000 and 2500 BCE. Further examples of elbow trauma and posttraumatic deformities in ancient Egypt were identified in the excavations of Sir Grafton Elliot Smith (1871e1937) in the Nubian desert. Smith also uncovered a variety of orthoses constructed of bamboo or tree bark and padded with linen.4 ANCIENT GREECE AND ROME (450 BCE) Hippocrates recognized the complexity of elbow trauma and its adverse outcomes in 450 BCE.5 He recommended bandaging the injured elbow especially after a reduction at an angle slightly greater than 90 as this would be a more functional position should ankylosis develop. Although the exact nature of the elbow trauma described and treated by the ancient Egyptians or Greeks cannot be defined, it is very likely that some were fractures. MEDIEVAL AGES (1500e1800 CE) Nearly 2,000 years later, in order to attempt to correct posttraumatic ankylosis of the elbow, creative orthotic-type devices (akin to contemporary turnbuckle orthoses) were developed by Hans von Gersdorff

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FIGURE 1: Illustration of distal humerus lateral condyle fractures from Malgaigne’s book.15

(1455e1517)6 as well as Hieronymus Fabricius ab Aquapendente (1533e1619).7,8 During that same century, the French surgeon Ambroise Paré (1510e1590) recognized the potential benefit of early mobilization of the traumatized elbow.9e12 This was subsequently also supported by the German surgeon Lorenz Heister (1683e1758), who suggested the possible benefit of passive elbow motion to address posttraumatic stiffness.13 THE 19TH CENTURY: RECOGNITION OF THE DISTAL HUMERUS FRACTURE Prior to the development of x-ray detectors, the identification of a distal humerus fracture and fracture patterns was determined from both open fractures and from postmortem examinations. British surgeon Astley Cooper was among the first to clearly describe J Hand Surg Am.

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a distal humerus fracture pattern.14 Guillaime Dupuytren in Paris soon followed as he stated, “There is nothing so common as to see a fracture of the lower end of the humerus, immediately above the elbow joint, mistaken for a dislocation backward.”15 Not long after, Malgaigne in France published a detailed description of fractures of the distal humerus in his 1847 book, Traité des fractures et des luxations (Fig. 1).16 The descriptive term T fracture can be attributed to Gurtl, who defined several fracture patterns in 1864.17 Despite a better recognition of the injury, limited management and adverse outcomes continued. Bigelow, from Massachusetts General Hospital in Boston, stated in 1868, “There is no class of injuries so frequently productive of discontent, and perhaps so often the cause of litigation, as traumatic lesions of the elbow joint.”18 Vol. 39, December 2014

TREATMENT OF DISTAL HUMERUS FRACTURES IN ADULTS

FIGURE 2: First functional flexion x-rays of elbow published in Lambotte’s book.3

1907e1940: THE FOUNDATION OF SURGICAL TREATMENT The discovery of the x-ray by Roentgen (Germany) in 1885 along with the development of general anesthesia and antisepsis, ushered in the era of the surgical treatment of distal humerus fractures. Lambotte, a Belgian surgeon, began the surgical treatment of a wide range of fractures including those about the elbow in the 1890s. Against the opinions of colleagues, he developed his own implants and surgical approaches.3,19,20 Lambotte carefully illustrated his fracture cases and fixation techniques, many resembling methods used today. Although his surgical approach to the distal humerus was primarily lateral, he described an olecranon osteotomy for a neglected posterior elbow dislocation. In 1907, he published his own classification describing transverse, oblique, and complex distal humerus fractures.3 He included a functional lateral elbow x-ray in flexion in his 1907 textbook (Fig. 2). Lambotte also coined the term osteosynthesis and stimulated many surgeons to follow his approaches. William Arbuthnot Lane (1856e1943, England) equally contributed to the early experience in the surgical treatment of distal humerus fractures. In 1914, he published a report of a medial column fracture treated with open reduction and internal fixation through a medial approach using plate and screws.21 These two pioneers were soon followed by a number of innovative surgeons including HeyGroves22 and Leveuf,23 both of whom further developed implants specific to the anatomy of the distal humerus as well as bone reduction clamps (Fig. 3). J Hand Surg Am.

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Despite the innovative surgical procedures being documented, concern continued regarding unsatisfactory results, and many doctors still advocated nonsurgical treatment. Pre-eminent surgeons including Sir Reginald Watson-Jones believed open reduction and internal fixation of distal humerus fractures was seldom indicated and recommended immobilization in orthoses or casts.24 Riseborough and Radin suggested displaced intra-articular fractures would be better treated with skeletal traction.25 As late as 1980, in Canada, Horne documented poor results from open treatment of distal humerus fractures and recommended that, with the exception of simple articular fractures, nonsurgical management should be the accepted treatment.26 THE IMPACT OF THE SWISS AO The group of Swiss surgeons who founded the AO (Arbeitsgemeinschaft für Osteosynthesefragen) realized the need for better implants and surgical techniques. They collaborated with metallurgists and toolmakers to create a large array of implants for fracture treatment and carefully documented all their cases in order to define outcomes and complications. The first results of surgical treatment using the AO implants and techniques were published by Heim and Pfeiffer in 1972.27 Greater acceptance of the concepts and implants of these AO surgeons followed publication of the experience of Jupiter et al (United States) documenting the high proportion of good and excellent results in 34 patients.28 THE 21ST CENTURY Technological advances such as angular stable implants and the application of medially and laterally placed plates and screws have improved the outcome of surgical treatment, especially with the more complex articular fractures in older patients.29e33 Interest in the use of the total elbow arthroplasty for nonreconstructable fractures in the elderly has been stimulated by a number of more recent publications.34,35 Another recent technological advance has been the introduction of locking plates. Their successful use in periarticular fragility fractures of distal radius and femur have been shown to provide improved fixation and outcomes in osteoporotic bone.31e33 However, the use of locking plates for distal humeral fractures has not been well studied and therefore remains controversial. The indications for their use are unclear but small clinical case series reported promising results.29,30 Furthermore, advances in imaging technologies such as computed Vol. 39, December 2014

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FIGURE 3: Leveuf’s dorsal approach via J-shaped incision for fixation of bicolumnar fractures using plates A, C, lag screws, and cerclage B, D.22

tomography with 3-dimensional reconstructions have improved visualization of fracture patterns, which is helpful in presurgical planning. Custom implants have been introduced for fixation of acute fractures and correction of posttraumatic deformity.36e38 CONCLUSIONS Elbow injuries have likely occurred since our human ancestors first developed bipedal gait. Nonunions and malunions were predictable in the absence of surgical treatment. The 19th century featured the recognition of distinct injury patterns. With advances in radiology, anesthesia, antisepsis, and hardware technology, surgical treatment is now generally preferred, yet loss of elbow joint mobility can still be a vexing problem. We wait further improvements in care with anticipation. REFERENCES 1. Helferich H. Atlas und Grundriss der traumatischen Frakturen und Luxationen. 3rd ed. Munich, Germany: Lehmann; 1897. 2. Cotton FJ. Dislocations and Joint Fractures. Philadelphia, PA and London, UK: Saunders; 1911. 3. Lambotte A. L’intervention opératoire dans les fractures récentes et anciennes envisagée particulièrement au point de vue de l’ostéosynthèse avec la description de plusieurs techniques nouvelles. Bruxelles, Belgium: Henri Lamertin Libraire-Éditeur; 1907.

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4. Smith GE. The Most Ancient Splints. Br Med J. 1908;1(2465): 732e736. 5. Adams F. The Genuine Works of Hippocrates. London: Sydenham Society; 1849. 6. Von Gersdorff H. Feldtbuch der Wundartzney. Strassburg: Getruckt durch Joanne Schott; 1517. 7. Fabricius MR. Hieronymi Fabricii ab Aquapendente. Venice: Apud Robertum Megliettum; 1619. 8. Fabricius MR, Scultetus J. Wund-Artznei. Nürnberg: Druckts JohannPhilipp Miltenberger; 1673. 9. Andry de Bois-Regard N. De la generation des vers dans le corps de l’homme: de la nature et des especes de cette maladie : des moyens de s’en preserver & de la guerir. Paris: Lambert & Durant; 1741. 10. Andry de Bois-Regard N. Orthopedia: or, the art of correcting and preventing deformities in children : by such means, as may easily be put in practice by parents themselves, and all such as are employed in educating children. To which is added, a defence of the orthopaedia, by way of supplement/by the author. Vol 1&2. London: A. Millar; 1743. 11. Paré A. Les oevvres d’Ambroise Paré. Diuisses en vingt huict liures, auec les Figures & portraicts, tant de l’anatomie, que des instruments de chirurgie, & de plusieurs monsters. 4th ed. Paris: Ches Gabriel Buon; 1585. 12. Paré A, Johnson T. The Workes of that famous chirurgion Ambrose Parey, translated out of Latine and compared with the French. London: Th. Cotes and R. Young; 1634. 13. Heister L. Chirurgie, in welcher alles, was zur Wund- Artznei gehöret. Nürnberg: Aufl. ed. Nürnberg; 1718. 14. Cooper AP. A Treatise on Dislocations and on Fractures of the Joints. London: Longman, Hurst; 1822. 15. Dupuytren G. Lectures on Clinical Surgery. Paris: Hôtel-Dieu de Paris; 1835. 16. Malgaigne JF. Traité des fractures et des luxations. Paris, France: JB Bailliére; 1847.

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17. Gurtl E. Handbuch der Lehre von den Knochenbrüchen. Vol 2. Hamburg: Grote; 1864. 18. Bigelow HJ. Insensibility during surgical operations produced by inhalation. Boston Med Surg J. 1846;35(16):309e317. 19. Lambotte A. Chirurgie opératoire des fractures. Paris: Masson & Cie Èditeurs; 1913. 20. Lambotte A. The Beginnings of Internal Fixation of Fractures (ostheosynthesis) in Belgium. 2nd ed. Bruxelles: ASBL Acta Orthopaedica Belgica VZW; 1997. 21. Lane WA. The operative treatment of fractures. 2nd ed. London: Medical Publishing Co.; 1914. 22. Hey-Groves EW. On Modern Methods of Treating Fractures. New York: Wood and Co.; 1916. 23. Leveuf J. Traitment des fractures et luxations des membres. Paris: Masson; 1925. 24. Watson-Jones R. Fractures and Joint Injuries. Vol 2. 3rd ed. Baltimore, MD: Williams & Wilkins; 1944. 25. Riseborough EJ, Radin EL. Intercondylar T fractures of the humerus in the adult. A comparison of operative and non-operative treatment in twenty-nine cases. J Bone Joint Surg Am. 1969;51(1):130e141. 26. Horne G. Supracondylar fractures of the humerus in adults. J Trauma. 1980;20(1):71e74. 27. Heim U, Pfeiffer KM. Periphere Osteosynthesen. Berlin: Springer; 1972. 28. Jupiter JB, Neff U, Holzach P, Allgower M. Intercondylar fractures of the humerus. An operative approach. J Bone Joint Surg Am. Feb 1985;67(2):226e239. 29. Greiner S, Haas NP, Bail HJ. Outcome after open reduction and angular stable internal fixation for supra-intercondylar fractures of the distal humerus: preliminary results with the LCP distal humerus system. Arch Orthop Trauma Surg. 2008;128(7):723e729. 30. Reising K, Hauschild O, Strohm PC, Suedkamp NP. Stabilisation of articular fractures of the distal humerus: early experience with a novel perpendicular plate system. Injury. 2009;40(6):611e617.

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31. Markmiller M, Konrad G, Sudkamp N. Femur-LISS and distal femoral nail for fixation of distal femoral fractures: are there differences in outcome and complications? Clin Orthop Relat Res. 2004;(426):252e257. 32. Rozental TD, Blazar PE, Franko OI, Chacko AT, Earp BE, Day CS. Functional outcomes for unstable distal radial fractures treated with open reduction and internal fixation or closed reduction and percutaneous fixation. A prospective randomized trial. J Bone Joint Surg Am. 2009;91(8):1837e1846. 33. Wei DH, Raizman NM, Bottino CJ, Jobin CM, Strauch RJ, Rosenwasser MP. Unstable distal radial fractures treated with external fixation, a radial column plate, or a volar plate. A prospective randomized trial. J Bone Joint Surg Am. 2009;91(7):1568e1577. 34. Frankle MA, Herscovici D Jr, DiPasquale TG, Vasey MB, Sanders RW. A comparison of open reduction and internal fixation and primary total elbow arthroplasty in the treatment of intraarticular distal humerus fractures in women older than age 65. J Orthop Trauma. 2003;17(7):473e480. 35. McKee MD, Veillette CJ, Hall JA, et al. A multicenter, prospective, randomized, controlled trial of open reduction—internal fixation versus total elbow arthroplasty for displaced intra-articular distal humeral fractures in elderly patients. J Shoulder Elbow Surg. 2009;18(1):3e12. 36. Imatani J, Ogura T, Morito Y, Hashizume H, Inoue H. Custom AO small T plate for transcondylar fractures of the distal humerus in the elderly. J Shoulder Elbow Surg. 2005;14(6):611e615. 37. Takeyasu Y, Oka K, Miyake J, Kataoka T, Moritomo H, Murase T. Preoperative, computer simulation-based, threedimensional corrective osteotomy for cubitus varus deformity with use of a custom-designed surgical device. J Bone Joint Surg Am. 2013;95(22):e173. 38. Tricot M, Duy KT, Docquier PL. 3D-corrective osteotomy using surgical guides for posttraumatic distal humeral deformity. Acta Orthop Belg. 2012;78(4):538e542.

Vol. 39, December 2014

Treatment of distal humerus fractures in adults: a historical perspective.

Nonsurgical treatment was the mainstay of management of distal humerus fractures for centuries and nonunions and malunions were common. The 19th centu...
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