Abstract
Purpose
Distal humeral fractures are rare, but severe injuries, the treatment of which is often accompanied by serious complications and its outcome strongly depends on the quality of surgical therapy. Non-union is a common entity, compromising clinical results and requiring revision surgery. Osteonecrosis is an underestimated etiologic factor in the development of non-union. The present study aims to display the distribution patterns of the arterial vessels at the distal humerus, to correlate the displayed vessels with local nutrient foramina and to disclose an endangerment of these structures by common osteosynthetic implants.
Methods
Eight plastinated fresh frozen upper extremities were digitally analyzed regarding the vascular density of the cancellous bone, by calculating the ratio of area comprised by arterial vessels and the area comprised by cancellous bone on sagittal cuts of the distal humerus. Possible differences in the vascular density of the medial epicondylar region, the lateral epicondylar region and a watershed area between the epicondyles and distal to the supracondylar region were investigated. On the basis of 200 macerated humeri, the distribution pattern of cortical nutrient foramina and their anatomic relation to properly applied common distal humerus plates were documented.
Results
The data show a significantly higher density of vessels per cancellous bone in the epicondylar regions than in the watershed region (p < 0.000, median 0.148 vs. 0.103). The analysis of the nutrient foramina showed distinct distribution patterns with a single foramen over the medial epicondyle (55 specimens, 27.5 %) and an area of several foramina at the posterior part of the lateral epicondyle (200 of the specimens, 100 %). In almost every specimen, the application of the osteosynthetic implants led to an overlay over the investigated nutrient foramina.
Discussion
Osteonecrosis and non-union are severe complications in the surgical treatment of distal humeral fractures. The biology of the bone, especially the blood supply, has to be respected as much as possible during open procedures, to optimize bony healing. This has to be considered when performing periosteal strip** or applying osteosynthetic plates over the postero-lateral and medial epicondyle. The watershed area of the distal humerus has to be considered as being prone to minor arterial blood supply and thereby non-union is possible, if the arterial vessels coming from the epicondyles are destroyed.
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Conflict of interest
The biomechanical laboratory of the Department of Trauma Surgery is supported by a yearly grant by the “Medartis” Company, but not specifically for this study. K.J.B. and L.P.M. did not and will not receive any financial benefit in any form. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.
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Prof Koebke tragically deceased in February 2012.
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Wegmann, K., Burkhart, K.J., Koslowsky, T. . et al. Arterial supply of the distal humerus. Surg Radiol Anat 36, 705–711 (2014). https://doi.org/10.1007/s00276-013-1240-z
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DOI: https://doi.org/10.1007/s00276-013-1240-z