Distal Humerus Kırıkları
Özet
Yetişkinlerde tüm kırıkların %2'sini oluşturan distal humerus interkondiler kırıkları (DHK), karmaşık anatomileri ve düşük kemik kalitesi nedeniyle tedavisi zor yaralanmalardır. Konservatif yaklaşımların ciddi fonksiyonel kayıplara yol açması sebebiyle, dirsek ekleminin erken mobilizasyonunu hedefleyen stabil anatomik cerrahi fiksasyon güncel bakım standardı haline gelmiştir. Cerrahide intraartiküler parçalanmanın durumuna göre olekranon osteotomisi, triceps-refleks (Bryan-Morrey), TRAP, triceps koruyucu ve triceps split gibi çeşitli posterior yaklaşımlar tercih edilmektedir. Cerrahi tespitte ikili plak uygulamasının (paralel veya ortogonal) K-tellerine göre üstünlüğü kanıtlanmış olup ideal konfigürasyon tartışmalıdır. Ulnar sinirin cerrahi sırasındaki yönetimine yönelik yapılan meta-analizler, anterior transpozisyonun in situ korumaya kıyasla postoperatif nöropati insidansını düşürmediğini göstermektedir. Kırık sonrası gelişebilecek derin enfeksiyon, kaynamama, heterotopik ossifikasyon (HO) ve ulnar nöropati gibi komplikasyonların profilaksisinde indometasin veya selekoksib kullanımı incelenmektedir. İleri yaşlı ve osteoporotik hastalarda total dirsek artroplastisi (TDA), açık redüksiyon internal fiksasyona (ARİF) göre daha iyi fonksiyonel sonuçlar sunarken; postoperatif rehabilitasyonda 2-5 gün içinde başlanan hafif aktif hareket egzersizleri nihai fonksiyonel başarı için kritik önem taşır.
Distal humerus intercondylar fractures (DHF), which constitute 2% of all adult fractures, are challenging injuries to treat due to their complex anatomy and poor bone quality. Since conservative approaches lead to severe functional loss, stable anatomical surgical fixation aiming at early mobilization of the elbow joint has become the current standard of care. Depending on intra-articular comminution, various posterior surgical approaches such as olecranon osteotomy, triceps-reflecting (Bryan-Morrey), TRAP, triceps-sparing, and triceps-split are preferred. Regarding fixation, double plating (parallel or orthogonal) is proven superior to K-wires, though the ideal configuration remains controversial. Meta-analyses on perioperative ulnar nerve management demonstrate that anterior transposition does not decrease the incidence of postoperative neuropathy compared to in situ protection. The usage of indomethacin or celecoxib is evaluated for preventing complications like deep infection, nonunion, heterotopic ossification (HO), and ulnar neuropathy. Total elbow arthroplasty (TEA) provides superior functional outcomes compared to open reduction and internal fixation (ORIF) in elderly and osteoporotic patients, while early rehabilitation starting with gentle active exercises within 2 to 5 days post-surgery remains critical for final functional success.
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