title: Surgical interventions for treating distal humeral fractures in adults.
abstract: BACKGROUND
  Distal humeral fractures in adults are relatively uncommon injuries that require surgical intervention in most cases. There is a lack of consensus regarding the best management of distal humeral fractures in adults, including the role of conservative treatment, appropriate surgical approach, fixation strategies, the role of total elbow arthroplasty and handling of nerves such as the ulnar nerve.
  
  
  OBJECTIVE
  To assess the effects (benefits and harms) of surgical interventions for distal humeral fractures in adults.
  
  
  METHODS
  We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (May 2012), the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2012 Issue 4), MEDLINE (1946 to April Week 4 2012), EMBASE (1980 to 2012 Week 17), Current Controlled Trials (1st May 2012), the WHO International Clinical Trials Registry Platform (1st May 2012) and the bibliographies of trial reports and relevant articles.
  
  
  METHODS
  All randomised and quasi-randomised controlled trials pertinent to the management of distal humeral fractures in adults were included.
  
  
  METHODS
  Two review authors independently performed study selection, assessed of risk of bias and extracted data. Pooling of data was impossible due to study heterogeneity.
  
  
  RESULTS
  Three small randomised controlled trials, with a total of 109 participants with Orthopaedic Trauma Association/Arbeitsgemeinschaft für Osteosynthesefragen (OTA/AO) type C distal humeral fractures, were included. Overall, the quality of the available evidence is limited. As well as the small sample sizes and detection bias from the lack of blinding of subjective outcomes, the methods and results of all three trials were incompletely reported.One trial, involving 42 participants, compared open reduction-internal fixation (ORIF) with total elbow arthroplasty (TEA) in patients aged over 65 years. Of the 40 participants followed up for two years, five allocated ORIF underwent intraoperative conversion to TEA. These participants were crossed-over to the TEA group in the analyses. The reported Mayo Elbow Performance Score (MEPS) results were consistently better in the TEA group at follow-up after 6, 12, and 24 months, whereas the Disability of the Arm, Shoulder, Hand (DASH) scores showed short term (after 6 months), but not longer term (after 12 and 24 months), superiority in the TEA group. The reoperation rate, complication rate and elbow range of motion results showed no statistically significant differences between the two groups. While an intention-to-treat analysis of treatment failure, where the five cross-over participants are placed in their original allocated group, is in favour of TEA, the result did not reach statistical significance (9/21 versus 3/21; RR 3.00, 95% CI 0.94 to 9.55).The second trial, involving 38 patients but reporting results for 35, compared perpendicular versus parallel double plate fixation strategies. There was a consistent finding of a lack of significant differences between the two treatment groups in terms of MEPS, re-operation for complications (3/17 versus 3/18; RR 1.06, 95% CI 0.25 to 4.54), complications and elbow joint range of motion.The third trial, which included 29 patients with preoperative ulnar nerve compression symptoms, compared anterior subfascial transposition with in situ decompression of the ulnar nerve. Although results for complete recovery of ulnar nerve function (12/15 versus 8/14; RR 1.4, 95% CI 0.83 to 2.35) and grades based on the Bishop rating system tended to favour the transposition group, none of the differences were statistically significant.
  
  
  CONCLUSIONS
  Overall, this review found there is either no or insufficient evidence from randomised or quasi-randomised controlled trials to determine whether surgery is, and which surgical interventions are, the most appropriate for the management of different types of distal humerus fractures. Well designed and reported large and multi-centre randomised controlled trials testing current interventions, such as pre-contoured and locking plating systems, are needed.
authors: Department of Orthopaedic Surgery, Chinese PLA General Hospital, Beijing, China.
authors: Yan
authors: Y
authors: Wang
authors: Qi
authors: Q
authors: Zhuo
authors: Peifu
authors: P
authors: Tang
authors: Wei
authors: W
authors: Yang
mesh_terms: D000328:Adult; D000368:Aged; D057929:Arthroplasty, Replacement, Elbow / Q000379:methods; D001860:Bone Plates; D061887:Conversion to Open Surgery / Q000379:methods; D005592:Fracture Fixation / Q000379:methods*; D006801:Humans; D006810:Humeral Fractures / Q000601:surgery*; D008875:Middle Aged; D016032:Randomized Controlled Trials as Topic; D017769:Ulnar Nerve Compression Syndromes / Q000601:surgery*