Intraartikularni kominutivni prelomi distalnog humerusa. rezime ...
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1 /STRU^NI RAD UDK 616/ DOI: /ACI C Kominutivni intraartikularni prelomi distalnog humerusa le~eni minimalnom fiksacijom- jedna od opcija za le~enje... V. R. Cvetkovi} 1, A. R. Le{i} 2, M. Bumba{irevi} 2 1 Traumatolo{ka slu ba KBC Zemun 2 Institut za ortopedsku hirurgiju i traumatologiju, KCS, Beograd Prelomi distalnog humerusa predstavljaju retke prelome na ljudskom skeletu a intraartikularni prelomi distalnog dela humerusa su jo{ redji entitet i ~ine oko 3% preloma na humerusu. Medjutim mogu da ostave trajni funkcionalni deficit zgloba lakta sa ograni~enjem i trajnim invaliditetom. Cilj rada je bio da se prika e jedna od mogu}nosti operativnog le~enja ove vrste preloma, minimalnom koli~inom fiksacionog materijala. Rezultat le~enja ocenjivan je Broberg-Morrey-evim (BM) skor sistemom. Rad, pilot studija je obuhvatio 8 bolesnika sa kominutivnim prelomom distalnog humerusa (tip IV) le~enih u periodu godine. Kominutivni prelom je fiksiran minimalnom koli~inom fiksacionog materijala-kirner iglama i zavrtnjima. Bolesnici su pra}eni inicijalno kao i nakon 4, 9, 24 meseci, B-M skorom. Rezultati po B-M skoru nakon 4 meseca su bili slede}i: odli~ni kod 0 bolesnika, dobri kod 2 bolesnika, zadovoljavaju}i kod 4 bolesnika i lo{i kod 2 bolesnika, da bi nakon sprovedenih fizikalnih terapija na kontroli posle 9 meseci rezultati bili slede}i: odli~ni kod 3 bolesnika, dobri kod 3 bolesnika, zadovoljavaju}i kod 2 bolesnika, nije bilo lo{ih rezultata. Ovaj rezultat B- M skora je bio indenti~an i na kraju ispitivanja nakon 24 meseca uz manja odstupanja obima pokreta u laktu {to nije uticalo na krajnji rezultat B-M skora. Klju~ne re~i: distalni humerus, intraartikularni, prelomi, Broberg-Morrey skor rezime UVOD Intraartikularni kominutivni prelomi distalnog humerusa predstavljaju najve}i izazov {to se ti~e preloma u distalnom delu humerusa. Po podeli Riseborough-Radina ovi prelomi su klasifikovani u IV grupu preloma distalnog humerusa i nazivaju se "vre}a kostiju" i ne postoji jedinstveno preporu~en na~in le~enja ove vrste preloma 1. Ovi prelomi uglavnom se vidjaju kod osoba starijih od 50 godina i nastaju naj~e{}e direktnom silom u predelu olekranona tako da ovaj biva utisnut na artikularnu povr{- inu humerusa prouzrokuju}i kominuciju u distalnom delu humerusa (2) a po polo aju lakta mehanizam sile mo e biti fleksioni ili ekstenzioni 2. Pod dejstvom mi{i}a koji se pripajaju na distalnom delu humerusa dolazi do znatne dislokacije i rotacije fragmenata. Dijagnozu ovih preloma postavljamo na osnovu klini~kog pregleda bolesnika, radiografskim ispitivanjem (AP i profilnim snimkom lakta), a po mogu}stvu treba uraditi i kompjuterizovanu tomografiju (CT). Za ocenu rezultata le~enja postoje skor sistemi. Mi smo koristili Broberg-Morey skor sistem pomo}u koga se mo- e procenjivati uspe{nost kako operativnih tako i neoperativnih tretmana preloma distalnog dela humerusa 3. Striktni na~in le~enja preloma nije preporu~en od strane niti jednog autora kao tehnika izbora jer su vrlo specifi~ni i predstavljaju izazov za ortopedske hirurge. Na osnovu svakog pojedina~nog slu~aja treba odrediti najoptimalniji vid le~enja, a koji se kre}e od neoperativnog, pa do procedura aloartoplastike. Neoperativno le~enje se sastoji od gipsane imobilizacije sa laktom u fleksiji od 90 i polo ajem podlaktice u neutralnom polo aju izmedju pronacije i supinacije. Kao vid neoperatvnog le~enja navodi se trakcija kroz olecranon, nakon koje sledi rana rehabilitacija. Operativno le~enje se naj~e{}e sastoji iz rigidne fiksacije, jednom ili dve plo~e sa {rafovima, a Kir{ner igle slu e kao privremena fiksacija. Kod te{kih o{te}enja zgloba i velike kominucije primenjuje se artroplastika zgloba ili proteza lakta. Kod pojedinih slu~ajeva mogu}e je primeniti takozvanu mioplastiku zgloba lakta koja omo-gu}ava pokrete u laktu, kao i spolja{nju fiksaciju po metodi Ilizarova (sa tzv. zglobnim spolja{njim fiksatorima). Kod dece se primenjuje fiksacija Kir{nerovim iglama.
2 62 V.R. Cvetkovi} i sar. ACI Vol. LV TABELA 1 BODOVANJE BROBERG-MORREY SKORA POSLE 4 MESECA OD POVREDE Bolesnici I II III IV V VI VII VIII Fleksija Pronacija Supinacija Snaga Stabilnost u laktu Bol Rezultati TABELA 2 BODOVANJE BROBERG-MORREY SKORA POSLE 9 MESECI OD POVREDE Bolesnik I II III IV V VI VII VIII Fleksija Pronacija Supinacija Snaga Stabilnost u laktu Bol Bodovi Komplikacije koje nastaju nakon ovih preloma su brojne, mogu se podeliti na rane i kasne a mogu se javiti u svim fazama le~enja (preoperatvnoj, operativnoj i postoperativnoj). U literaturi se navode kao te{ke komplikacije povrede krvnih sudova i nerava. Nakon unutra{nje fiksacije mogu}e su infekcije ili migracija osteofiksacionog materijala 4. S obzirom da je nekada nemogu}e izvr{iti stabilnu-rigidnu unutra{nju fiksaciju preloma (stariji bolesnik sa ostepororti~nom kosti), ili je nemogu}a primarna ugradnja proteze lakta, mi prikazujemo, kao mogu}nost uspe{nog re{avanja ovih preloma, postupak otvorene repozicije i fiksacije sa minimalnom koli~inom osteofiksacionog materijala. Metod se uglavnom primenjuje kod dece 1, 5, 6, ali i kod odraslih 7. MATERIJAL I METODE U radu je obradjeno 8 bolesnika sa isto toliko multifragmentarnih intraartikularnih preloma distalnog dela humerusa u periodu godine, po tipu IV po Riseborough-Radinu. Uzrast bolesnika iznosio je prose~no 67,87. godina, a raspon je bio od 28 godina do 84 godine. Od ukupno 8 bolesnika a 7 su bile ene. Pad niz stepenice je bio uzrok preloma kod 3 bolesnika, pad sa bicikla kod 2 bolesnika, pad na ravnom kod 3 bolesnika. Leva ruka je bila povredjena kod 6 bolesnika a desna kod 2 bolesnika. Povrede su nastale u leto kod 4 bolesnika, u zimu kod po 2 bolesnika. Svi bolesnici su tretirani operativno posteriorim pristupom po Kembelu i otvorenom repozicijom i fiksacijom Kir{nerovim iglama i ev. zavrtnjima (slika 1a,b,c). Bolesnici su hospitalizovani od dan. Gipsana imobiliizacija longetom stavljana je neposredno nakon operacije i no{ena je 4-5 nedelja ili dana (prose~no 33,25 dana). Nakon ~ega su vadjenje Kir{nerove igle i zapo~injana fizikalna terapija koja je trajala prose~no 2 meseca. Bolesnici su pra}eni u tri vremenska intervala - posle 4 meseca, posle 9 i nakon 24 meseca od povrede, klini~kim i radiolo{kim nalazom, kao i subjektivnom procenom samih bolesnika.
3 Br. 4 Kominutivni intraartikularni prelomi distalnog himerusa 63 le~eni minimalnom fiksacijom TABELA 3 KRETANJA OBIMA POKRETA UNUTAR B-M SKORA U TOKU PRA]ENJA BOLESNIKA NA 4, 9 I 24 MESECA Bolesnik I II III IV V VI VII VIII Fleksija 135 Posle 4 meseca Posle 9 meseci Posle 16 meseci Pronacija 60 Posle 4 meseca Posle 9 meseci Posle 16 meseci Supinacija 70 Posle 4 meseca Posle 9 meseci Posle 16 meseci Kori{}ena ja klasifikacija preloma je po Riseborough- Radinu, koji prelome distalnog dela humerusa svrstava u IV grupe. Svi bolesnici u radu su imali IV stepen preloma po R-R. Procena rezultata le~enja vr{ena je numeri~kim skor sistemom Broberg Morrey. Ovaj skor sistem ima maksimalno 100 bodova, a tezultat je lo{ sa 0-60 bodova, zadovoljavaju}i sa bodova, dobar od bodova i odli~an sa bodova. Dobri i odli~ni rezultati smatrani su prihvatljivim, a samo zadovoljavaju}i i lo{i kao neprihvatljivi. Broberg Morrey skor obuhvata procenu pokreta (max. 40 bodova), procenu stabilnosti zgloba lakta (5 bodova), mi{i}nu snagu (20 bodova), i bol u laktu (35 bodova). REZULTATI Za prikaz je obradjeno 8 bolesnika le~enih u periodu sa periodom pra}enja od meseci. Rezultati Broberg-Morrey skora posle 4 meseca pokazuju veliki broj bolesnika sa neprihvatljivim rezultatima 6(75%) u odnosu na 2(25%) sa prihvatljivim rezultatima B-M skora. (tabela 1). Posle 9 meseci do{lo je do zna~ajnog pomeranja rezultata B-M skora ka prihvatljivim u odnosu na rezultate koji su bili nakon 4 meseca odn. broj bolesnika sa neprihvatljivim rezultatima bio je 4(50%) u odnosu na one koji imaju prihvatljiv rezultat 4 (50%) (tabela 2). Nakon 24 meseca nije bilo ve}ih odstupanja osim u obimu pokreta u lakatnom zglobu, te na tabeli 3 dajemo prikaz kretanja obima pokreta u toku sva tri merenja (posle 4, 9 i 24 meseci od povrede). Konstatovano je da je do{lo do zna~ajnog pobolj{anja obima pokreta na kraju ispitivanja u odnosu na prvo merenje B-M skora nakon 4 meseca jer su bolesnici u medjuvremenu sprovodili vi{e puta fizikalnu terapiju kako u domovima zdravlja tako i u banjskim uslovima. To je dovelo do pove}anja obima pokreta u laktu kod prikazanih bolesnika te samim tim i prihvatljivih rezultata B-M skora (Tabela 2 i 3). Posle 9 meseci rezultati su bili slede}i: odli~ni kod 3 bolesnika, dobri kod 3 bolesnika, zadovoljavaju}i kod 2 bolesnika, nije bilo lo{ih rezultata. Ovaj rezultat B- M skora je bio indenti~an i na kraju ispitivanja nakon 24 meseca uz manja odstupanja obima pokreta u laktu to nije uticalo na krajnji rezultat B-M skora. Normalna mi{i}na snaga, stabilnost u laktu i nepostojanje bola, je bilo prisutno u po~etku kod 5 bolesnika, a kod 3 bolesnika umerena i jaka slabost, dok je na kraju ispitivanja 1 bolesnik imao normalnu mi{i}nu snagu, 5 malo smanjenje i 2 bolesnika umerenu slabost. Stabilnost u zglobu lakta u po~etku je kod 5 bolesnika bila normalna i malo smanjena, a kod 3 bolesnika umereno ili jako smanjena dok je na kraju ispitivanja njih 3 imalo normalnu stabilnost, 3 bolesnika malo smajenu stabilnost i 2 bolesnika umerenu nestabilnost. 6 bolesnika je na po~etku imalo mali bol, 2 umereni dok je na kraju ispitivanja taj odnos bio 3 bolesnika bez bola, 2 bolesnika sa malo bola i 3 bolesnika sa umerenim bolom (tabela 4). KOMPLIKACIJE. Infekcija oko igala je bila prisutna kod 2(25%) bolesnika kao i prolazna pareza n.ulnarisa kod 1. (12,25%) bolesnika.
4 64 V.R. Cvetkovi} i sar. ACI Vol. LV TABELA 4 PRIKAZ MI[I]NE SNAGE, STABILNOSTI U LAKTU I BOLA TOKOM PRA]ENJA BOLESNIKA NA 4, 9 I 24 MESECA NAKON POVREDE Period Posle 4 meseca Posle 9 meseci Posle 24 meseca Snaga Normalna Malo smanjena Umereno smanjena Jako smanjena Stabilnost u laktu Normalna Malo smanjena Umereno smanjena Jako smanjena Bol Bez bola Mali bol Srednji bol Jak bol DISKUSIJA Le~enje kominutivnih preloma distalnog humerusa se bazira primarno na individualnoj proceni ortopeda. Klasi- ~na unutra{nja fiksacja ne mo e da re{i problem postojanja mnogo fragmenata posebno kod osteoporoti~ne kosti, te se primenjuje i zglobni Ilizarov aparat, a navodi se i primarna ugradnja proteze lakta. Kod dece se primenjuje fiksacija Kir{nerovim iglama da bi se sa~uvale zone rasta. Kod odraslih se Kir{nerove igle primenjuju kao faza interne fiksacije, za kanulirane rafove i do postavljanja plo~a. Medjutim, ako se uzme u obzir stepen komplikacija kod rigidne fiksacije kod starih osoba, i kominucija, mogu}- nost nastanka infekcije i ektopi~nih osifikacija (miositis osifikans), mislimo da je u odredjenim slu~ajevima mogu- }e dobiti prihvatljive rezultate fiksacijom samo sa K- iglama i 1-2 zavrtnja. Autori su prikazali razli~ite rezultate unutra{nje fiksacije (tabela 5) koji se kre}u od lo{ih do odli~nih za ovaj tip preloma te su rezultati u na{oj pilot studiji najpribli - niji radovima Kinga, Doornberga, Alvareza, Sotela gde se procenat prihvatljivih (odli~nih i dobrih) rezultata kre}e u rasponu od 64,28% do 86,66% {to je sli~no na{im reziltatima od 75% prihvatljivih rezultata 8,9,10,11. U na{em radu je dat prikaz primene skor sistema po Bromberg-Morrey koji se zasniva i na subjektivnim ali i na objektivnim parametrima ocene rezultata nakon operativnog i neoperatvnog le~enja preloma u predelu lakatnog zgloba. Takodje je prikazana i jedna od hirur{kih tehnika za re- {avanje vrlo komplikovanih intraartikularnih preloma distalnog dela humerusa sa ve}im brojem fragmenata. Razni autori prikazuju razli~it stepen uspeha, kao i razli~it procenat komplikacija kod primene razli~itih metoda fiksacije ovih preloma. Tako, King i saradnici 8 prikazuju rezultate operativnog tretmana preloma distalnog humerusa otvorenom repozicijom i fiksacijom pomo}u plo~ice i rafova i navode da od ukupno 21. bolesnika, njih 4(19,04%) je imalo odli~an rezultat, 12(57,14%) dobar rezultat a 5 (23,8%) bolesnika je imalo zadovoljavaju}i rezultat Mayo- skora. Ovi rezultati su u delu neprihvatljivih sli~ni kao i u na{em radu gde je taj procenat 25%, a ukupan broj prihvatljivih rezultata u na{em radu je 75%, i pribli an je rezultatima Kinga (76,18%). Doornberg i saradnici u svom radu navode da su ovu vrstu preloma re{avali plo~icama sa kortikalnim {rafovima, samo {rafovima ili Kir{nerovim iglama, uz posteriorni pristup po Campbellu i osteotomiju olecranona. Doornberg navodi da je od 30 bolesnika 19(63,33%) imalo odli~ne rezultate,7(23,33%) dobre rezultate, 1(3,33%) bolesnik zadovoljavaju}i rezultat i 3 (10%) bolesnika lo{e rezultate, tj. 86.6% je imalo prihvatljive rezultate 9.
5 Br. 4 Kominutivni intraartikularni prelomi distalnog himerusa 65 le~eni minimalnom fiksacijom TABELA 5 Autor Tip fiksacije Br bolesnika Rezultati Komplikacije O D Z L Alvarez, 1975 ekstenzija 14 64,28% 35,72% lak bol Mc Kee, 2000 plo~ica sa {rafovima 25 reoperacija Skaggs, 2001 Kir{nerove igle kod dece % 0% povrede nerava King, 2003 plo~ica sa {rafovima 21 19,04 57,14 23,8 0 bez komplikacija Kamineni, 2004 proteze lakta heterotrofna osifikacija Revizije Skaggs, 2004 Kir{nerove igle kod dece pomeranje fragmenata Doornberg, 2007 plo~ica sa {rafovima 30 63,33 23,33 3,22 10 bez komplikacija Dubberley, 2006 plo~ica sa {rafovima 28 reintervencija ugradnje proteze lakta Sotelo, 2007 Cvetkovi}, Le{i}, 2007 dve plo~ice u dve ravni Kir{neropve igle sa {rafovima 34 55,99 29,41 5,88 8,82 duboke infekcije, bol 6 37,5 37, povr{na infekcija prolazna pareza narava Kamineni 12 je pratio 49 bolesnika tokom 7 godina od kojih je 48 tretirao primarno protezom lakta. I on navodi da su svi imali 95 bodova od mogu}ih 100 u skor sistemu (Mayo skor). Medjutim, navodi i komplikacije koje su bile prisutne u obliku heterotropi~nih osifikacija kod 7(14,58%) bolesnika, te revizija kojih je uradjeno kod 5(10,41%) bolesnika, {to je ukupno 25% komplikacija 12. Mc Kee i saradnici u svom radu iz 2000 godine prikazuju 25 bolesnika sa prelomom distalnog humerusa koji su tretirani otvorenom repozicijom i plo~icom sa {rafovima. Rezultati koje navodi autor su uspe{ni 74% u odnosu na zdravu ruku, ali navodi komplikacije u 9 bolesnika ( od toga 6 reoperacija u kojih su 3 posledica osteotomije olecranona) 13. Dubberley i saradnici su pratili 28 bolesnika sa intraartikularnim prelomom humerusa koji su tretirani otvorenom repozicijom i internom fiksacijom i njihovi rezultati pokazuju da je obim fleksije-extenzije bio od , Mayo skor 91+ 1, a 2 bolesnika su ponovno operisana i ugradjena im je proteza lakta 14. Riseborough navodi zanimljiv podatak da je kod te{kih kominucija uspeh kod onih koji nisu operisani zna~ajno bolji u odnosu na one tretirane operativno i po njemu indikacije za otvorenu repoziciju i internu fiksaciju su vrlo retke 15. Za razliku od Riseborougha, Sotelo u svom radu daje prednost maksimalnoj fiksaciji artikularnih povr{ina i stabilnosti u suprakondilarnom nivou na osnovu analize 34 bolesnika tretiranih plo~icama na medijalnoj i lateralnoj strani sa pra}enjem od 2 godine. Rezulatati skor sistema u radu Sotela su bili slede}i: odli~ni kod 19(55,88) bolesnika, dobri kod 10(29.41%) bolesnika, zadovoljavaju}i kod 2(5,88%) bolesnika, lo{i kod 3(8,82%) bolesnika 11. Alvarez 10 daje prikaz 14 bolesnika sa prelomom kapituluma humerusa i od tog broja njih 10 (71,42%) je le~eno ekscizijom a prikazani rezultati su slede}i: prihvatljive rezultate (odli~ne i dobre) imalo je 9 (64,28) bolesnika {to se uklapa u rezultate drugih autora kao i na{eg rada. Skaggs i saradnici su obradili 345 bolesnika (dece) u periodu koji su tretirani Kir{nerovim iglama medijalnim ili medio-lateralnim pristupom bez otvaranja i nihovi rezultati su svi u grupi odli~nih. Navode povrede n.ulnarisa u 6 slu~ajeva kod medio-lateralnog pristupa 5. Skaggs navodi u svom drugom radu takodje primenu fiksacije Kir{nerovim iglama kod dece u periodu od godine kod 124 deteta gde navodi da je plasirao ili 2 ili 3 ukr{tene igle te da nije imao ozbiljnijih komplikacija. Navodi da je samo kod 1. bolesnika postojala povr{na infekcija i gubitak pozicije, ali kao posledica tehni~ke gre{ke odn. nepravilne aplikacije Kir{nerovih igala 6. ZAKLJU^AK Kominutivni intraartikularni prelomi distalnog humerusa po tipu IV po Radinu predstavljaju dilemu za izbor na- ~ina le~enja jer pred ortopedskog hirurga postavljaju ponekad te{ko re{iv problem. Da li ove prelome tretirati operativno i kojom tehnikom ili ih le~iti neopartivno. Na osnovu dobijenih rezultata u na{em radu i rezultata stranih autora mi{ljenja smo da je neoperativni tretman vrlo nekomforan za bolesnika i da je ishod le~enja najneizvesniji.
6 66 V.R. Cvetkovi} i sar. ACI Vol. LV Otvorena repozicija i posteriorni pristup po Campbellu, sa i bez osteotomije olekranona uz repoziciju fragmenata i internu fiksaciju Kir{nerovim iglama smatramo predno{}u zbog manje invazivnosti, te malog broja kako operativnih tako i postoperativnih komplikacija kao i mogu}- nosti fiksiranja malih fragmenata sa artikularnom povr{inom humerusa (u slu~aju kada se ne mogu fiksirati plo- ~om i zavrtnjima). Po na{oj oceni skor po Broberg Morrey predstavlja uspe{an na~in vrednovanja rezultata neoperativnog i operativnog na~ina le~enja preloma distalnog humerusa i na jednostavan na~in odvaja one sa prihvatljivim (odli~nim i dobrim) od onih sa neprihvatljivim (dovoljni i lo{) rezultatima, te pru a uvid u uspe{nost pojedinog primenjenog na~ina le~enja. SUMMARY COMMINUTED INTRA-ARTICULAR FRACTURES OF DISTAL HUMERUS TREATED WITH MINIMAL FIXA- TION, one of treatment options Fractures of distal humerus on humen skeleton are rare and intraarticular fractions of distal part of humerus occur even less freqvently, they comprise abouth 3% of fractures of humerus. However,these fractures can result in a functional deficiency of elbow joint and permanent disability. The main goal if our work was to present one of the surgical treatment options of this kind of fracture with minimal amount of fixation material. Treatment result were evaluated by Broberg-Morrey score system. Pilot study consisted of eight patient with comminuted type IV fracture of distal humerus during time period. Comminuted fracture was fixed with minimal amount of material: a Kirchner needle and a screw. Patient treatment progress was evaluated initially and followed up after four, nine and twenty four months by B-M score after removal of cast and bone fixing material. The results of the B-M score after four months were: excellent in 0 patient, good in 2 patients, fair in 4 patients and poor in 2 patients. After physical therapy and follow up check- up at the end of nine months the result were: excellent in 3 patients, good in 3 patients, fair in 2 patients and no patients had shown poor result. This B-M score result was identical after 24 months follow up with minor deviations in range of motions of elbow, which did not influence the final result of B-M score. Key words: distal humerus, intra-articular fractures, Broberg-Morrey score. SLIKA 1A. BOLESNICA S.D (73 GODINE) INICIJALNI AP RA- DIOGRAFIJA SLIKA 1B POSTOPERATIVNA RADIOGRAFIJA ISTE BOLESNICE, U GIPSANOJ [INI. BIBLIOGRAFIJA 1. Crenshaw AH. Fractures of shoulder girdle,arm and forearm. In Campbells operative orthoapedics (ed.canale TS), A.H Crenshaw. Mosby year book.1992: Baji} D. Prelomi i i{~{aenja zgloba lakta u Traumatologija ko{tano-zglobnog sistema. (urednik D. Banovi}) De~je novine, Gornji Milanovac 1989: SLIKA 1C. RADIOGRAFIJA NAKON SANACIJE PRELOMA (POSLE 24 MESECA), SA IZVADJENIM K IGLAMA IZ HUMERUSA.
7 Br. 4 Kominutivni intraartikularni prelomi distalnog himerusa 67 le~eni minimalnom fiksacijom 3. Broberg MA, Morrey SF. Reqet of delayed excision of the radial head after the fracture. J Bone Joint Surg. 1986, 68A: Levy RN, Weiner LS, Lisser SP. Complication in treatment of fractures and dislocations of elbow. In Complication in orthopaedic surgery (Ed. Epps CH). J.B.Lippincot Company, Philadelphia, 1994: Skaggs DL,Hale JM,Basset J at al. Operative treatment of supracondilar fractures of the humerus in children.the conseqvences of pin placement.j Bone Joint Surg, 2001;83-A: Skaggs DL, Cluck M,Mostofi A at al. Lateraly entry pin fixation in management of supracondilar fractures in children. J Bone Joint Surg, 2004;86-A: Helfet P, Kloen, Avand N. Open reduction and internal fixation of delayed unions and nonunions of fractures of the distal part of the humerus. J Bone Joint Surg. 2003; 85A: King D, Jupiter J,Gulotta L.Articular fractures of the distal part of the humerus.j Bone Joint Surg; A: Doornberg J, Doijn P, Linzel D at al.surgical treatment of intrarticular fractures of the distal part of the humerus-functional outcome after twelve to thirty years. J Bone Joint Surg; A: Alvarez E, Patel MR, Nimberg G.Fractures of the capitulum humeri.j Bone Joint Surg; A: Sotelo J, Torchia M,O Discol S.Complex distal humeral fractures internal fixation with a principle-based parallel plate technique. J Bone Joint Surg2007; 89A: Kamineni S, Morrey B. Distal humeral fractures treated with noncustom total elbow replacement.j Bone Joint Surg. 2004; 86A: Mc Kee M, Wilson T,Winesborn L at al. Functional outcome following surgical treatment of intra-articular distal humeral fractures trough a posterior approach. J Bone Joint Surg; : Dubberley J, Faber K,Mac Dermid J at al. Outcome after open reduction and internal fixation of capitellar and trochlear fractures. J Bone Joint Surg; A: Riseborough E, Radin E. Intraarticular T fractures of humerus in adult- a comparasion of operative andv nonoperative treatment in twenty nine cases. J Bone Joint Surg; :
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