Distal humeral fractures: clinical guidelines

List of Abbreviations

EFS — external fixation system

AO — Association for Osteosynthesis

VTE - venous thromboembolism

DHF — distal humeral fracture

DH — diaphyseal humerus

MVA — motor vehicle accident

CT — computed tomography

HDL — high-density lipoproteins

LDL — low-density lipoproteins

PT — physical therapy

MoH Russia — Ministry of Health of the Russian Federation

INR — international normalized ratio

MRI — magnetic resonance imaging

LMWH — low-molecular-weight heparin from group B01AB Heparin group

NSAIDs — non-steroidal anti-inflammatory drugs from group M01A Non-steroidal anti-inflammatory and antirheumatic products

UFH — unfractionated heparin from group B01AB Heparin group

ATS — antitetanus serum

TIG — tetanus immunoglobulin

PWS — primary wound surgical debridement

SCT — spiral computed tomography

DVT — deep vein thrombosis

RF — risk factors

PRM — physical and rehabilitation medicine

FS — functional status

SAB — surgical antibiotic prophylaxis

TENS — transcutaneous electrical nerve stimulation

LCP — locking compression plate

MIPO — minimally invasive plate osteosynthesis

ORIF — open reduction internal fixation

Terms and Definitions

Absolute stability — absence of micromotion at the fracture site, provided there is anatomical reduction and interfragmentary bone compression after fixation with hardware.

Allograft — a bone tissue fragment from another human (donor), typically cadaveric, that has undergone preservation.

Apophyseolysis — injury to the growth plate located between the apophysis and its parent bone.

External fixation device (EFD) — an orthopedic device comprising an implant (a transosseous or extracortical element protruding through the skin, reaching or embedded in the bone) and an external (non-implantable) frame that connects bone fragments via transosseous elements in the treatment of fractures, pseudoarthrosis, or gradual lengthening (deformity correction) of a segment.

Autograft — a fragment of the patient's own bone harvested from a donor site for transplantation to cover a bone deficiency (bone defect).

Internal fixator — an orthopedic implant surgically implanted beneath the patient's skin to connect bone fragments in the treatment of fractures, deformities, or pseudoarthrosis.

Impression — the process of forming an articular surface fracture due to excessive pressure from the articulating bone exceeding the strength of cancellous bone, as well as the resulting compression fracture.

Fracture consolidation — the mutual union of fragments by living bone tissue resulting from the successful completion of reparative regeneration.

Contracture — restriction of the range of motion in a joint.

Bone fragment — a part of a bone separated as a result of injury, surgical intervention, or a destructive process.

Migration of fixation elements — the loss of the optimal position of fixation elements due to bone resorption around them, occurring when allowable cyclic loads or their frequency are exceeded, or due to improper surgical technique during insertion into the bone (in the context of this topic).

Load — mechanical force applied to a limb, bone, and fixation system during treatment, typically recurring at a constant periodicity (cyclically).

Delayed union / Nonunion — alterations in the reparative regeneration of bone tissue leading to a decrease in its rate, cessation, or the formation of a callus insufficient to perform mechanical function.

Osteoepiphyseolysis — disruption of the integrity of the growth cartilage of a tubular bone combined with a fracture of the metaphyseal region.

Post-traumatic deformity — fracture consolidation with disruption of spatial relationships, including axial and rotational alignment between fragments.

Fixation stability — the resistance of the system to external loads, allowing it to maintain the constancy of the mutual orientation of fragments and the optimal distance between them.

Fixation — a condition in which relative or complete immobilization of fragments is achieved.

Epiphyseolysis — disruption of the integrity of the growth cartilage of a tubular bone due to mechanical force, accompanied in some cases by displacement of the epiphysis.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Distal humerus fractures represent a non-classification concept combining extra-articular and intra-articular fractures of the lower third of the humerus. These fractures constitute a disruption of the integrity of the humerus in the distal metaepiphysis region due to trauma. According to the number of fragments, distal humerus fractures are divided into simple and comminuted.

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

Distal humerus fractures occur as a result of high-energy external traumatic agents. According to the mechanism of injury, direct and indirect impacts are distinguished. In a direct trauma mechanism, the force is applied directly to the fracture site. The indirect trauma mechanism is characterized by the application of force at a distance from the fracture site. High-energy and low-energy distal humerus fractures are distinguished. High-energy fractures are characterized by a large number of bone fragments in the fracture zone and concomitant soft tissue damage. Such injuries occur as a result of motor vehicle accidents, falls from a height, and sports activities. Low-energy fractures most often occur from a standing height fall, while the biology of local soft tissues is impaired to a lesser extent compared to high-energy injuries [1, 2].

1.3 Epidemiology of the Disease or Condition

Elbow region fractures account for 7% of all fractures in the adult population, with distal humerus fractures accounting for less than a third (30%) of these injuries. The incidence of distal humerus fractures is 5.7 per 100,000 population per year. However, some authors note a gradual increase in the incidence of distal humerus fractures [3]. The gender and age distribution of this injury shows a characteristic pattern with peaks among young males aged 12 to 19 years and elderly females over 80 years old. Young patients are characterized by a high-energy injury mechanism, whereas elderly patients typically present with low-energy injuries [1, 2].

1.4 Features of Coding the Disease or Condition

S42.4 — Fracture of lower end of humerus

1.5 Classification of the disease or condition

To accurately determine the anatomical location of a fracture, its center must be identified. For a simple fracture, the center is the midpoint of the oblique or spiral fracture line; for wedge fractures, it is the widest part of the wedge or the midpoint of the fragmented wedge after reduction; for complex fractures, the center is determined after reduction with restoration of bone length as the midpoint between the proximal and distal boundaries of the fracture.

All metaepiphyseal fractures are divided into extra-articular and intra-articular. Intra-articular fractures, in turn, are subdivided into partial, in which part of the articular surface remains intact and retains connection with the undamaged diaphysis, and complete, in which the entire cross-section of the metaphyseal bone is damaged.

According to a study by Jupiter et al. (1992), two bone columns can be identified in the distal humerus, connected to each other by the humeral trochlea [4]. Fixation of both columns in the event of their fracture is fundamental for successful surgical treatment. There is no universally accepted classification based on this division, but surgeons must consider this biomechanical feature when planning surgical intervention [4, 5].

Diagnosis coding begins with determining the anatomical localization of the fracture: the bone and the segment. According to the AO classification, the humerus is designated as number 1. The distal humerus is coded as 13. Next, the morphological characteristics of the fracture are determined, which consist of defining the type, group, and subgroup of the fracture. All fractures are subdivided into 3 types: A, B, and C.

13-A — extra-articular fracture of the distal humerus:

13-A1 — avulsion fracture of the humeral epicondyle;

13-A2 — simple extra-articular fracture of the distal humerus;

13-A3 — complex extra-articular fracture of the distal humerus;

13-B — partial intra-articular fracture of the distal humerus:

13-B1 — fracture of the lateral part of the humeral condyle;

13-B2 — fracture of the medial part of the humeral condyle;

13-B3 — condylar fracture with the fracture line in the frontal plane;

13-C — complete intra-articular fracture of the distal humerus:

13-C1 — simple intra-articular fracture combined with a simple metaepiphyseal fracture;

13-C2 — simple intra-articular fracture combined with a complex metaepiphyseal fracture;

13-C3 — complex intra-articular fracture combined with a complex metaepiphyseal fracture [6].

1.5.1. Classification features in children and adolescents

In the pediatric age group, distal humerus fractures include apophyseolysis of the medial or lateral humeral epicondyle, supracondylar humeral fracture (the fracture line crosses the olecranon and coronoid fossae), and fracture of the humeral condyle (epiphyseolysis and osteoepiphyseolysis).

Regarding extension supracondylar fractures, the Gartland classification (1959) is applied, where the determining criterion is the degree of displacement of humeral fragments on the lateral radiograph. Type I is defined as having no fragment displacement, Type II as displacement without complete separation of fragments, and Type III as complete transverse displacement with loss of contact between fragments. In 1996, Wilkins, based on the concept of posterior cortex integrity, modified the Gartland classification by dividing Type II into subtypes: A — posterior cortex intact, B — disruption of the posterior cortex.

1.6 Clinical presentation of the disease or condition

Complaints: pain in the shoulder and/or elbow region, impaired upper limb function, deformity in the lower third of the arm or elbow region, pain in wound areas (in open fractures).

Anamnesis: history of trauma; the patient describes a characteristic mechanism of injury. Most often, the mechanism of injury is indirect: a fall from standing height onto an abducted arm. High-energy traumas (such as road traffic accidents or falls from a height) are characterized by greater severity and may be combined with injuries to other body segments or regions; therefore, it is necessary to thoroughly take the patient's history and perform a physical examination.

Physical examination: edema of the elbow joint region, smoothed contours, limitation of active and passive movements due to severe pain, forced position of the limb; palpation reveals marked tenderness in the lower third of the arm, abnormal mobility in the fracture area, and possible crepitus of bone fragments during passive movements.

2. Diagnostics, medical indications and contraindications for diagnostic methods

Criteria for establishing the diagnosis/condition:

• anamnestic data: history of a characteristic upper extremity trauma mechanism (fall, traffic accident, etc.)

• physical examination findings: impaired function of the injured segment, local swelling and tenderness in the trauma region (pain exacerbated by axial loading), presence of abnormal mobility and/or fragment crepitus

• Instrumental examination data: radiographic signs of fracture based on radiography in 2 projections. Additional CT scanning may be performed as prescribed by the on-duty or attending trauma surgeon/orthopedic surgeon to clarify the nature of the fracture and determine the degree of fragment displacement.

2.1 Complaints and Anamnesis

In most cases, patients present with complaints described in Section 1.6 "Clinical Presentation"

• In patients with suspected distal humeral fracture, a thorough history taking and anamnesis are recommended for diagnostic purposes [6, 123].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

2.2 Physical Examination

Physical examination findings are described in Section 1.6 "Clinical Presentation"

• Assessment of the following parameters in patients with suspected distal humeral fracture is recommended to be performed no later than 1 hour after admission to the inpatient facility, with mandatory recording of the results in the medical documentation:

• assessment of somatic status;

• visual and palpation assessment of local status [7, 123].

LEL 5Grade of Recommendation C (Level of Evidence – 5).

• blood pressure measurement;

• body temperature measurement;

• assessment of the risk for venous thromboembolic complications [6, 7, 8, 123].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

• In patients with suspected distal radius fracture, it is recommended to assess peripheral innervation and circulation in the extremity to rule out neurovascular bundle injury at the fracture level [1, 2, 6, 124].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

• In patients with suspected distal humeral fracture, it is recommended to assess the condition of soft tissues and the severity of edema in order to rule out hematomas, developing compartment syndrome, and open fractures [1, 2, 6, 123, 124].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

• When deciding on surgical treatment for a distal humeral fracture in adult patients, it is recommended to take a medical history and perform a physical examination to identify risk factors and cardiovascular diseases [9, 10].

LE AQOE 3Level of Evidence A (reliability of evidence level – 3).

Comment: Cardiovascular disease risk factors include: arterial hypertension, smoking, dyslipidemia (elevated total cholesterol >4.9 mmol/L and/or LDL cholesterol >3 mmol/L and/or HDL cholesterol <1.0 mmol/L in men, <1.2 mmol/L in women, and/or triglycerides >1.7 mmol/L), diabetes mellitus, and a family history of premature cardiovascular disease (<55 years for men and <65 years for women) [9]. Established cardiovascular disease is defined as: coronary artery disease, cerebrovascular disease, peripheral artery disease, heart failure, pulmonary hypertension, valvular heart disease, and cardiomyopathies [10, 11].

• All adult patients scheduled for elective surgical treatment of a distal humeral fracture are recommended to undergo perioperative cardiovascular risk assessment, taking into account the type of planned surgical treatment regardless of comorbidities, in order to prevent life-threatening complications of surgical treatment [9, 12].

LE AQOE 3Level of Evidence A (reliability of evidence level – 3).

Comments: When surgical treatment is performed for emergency (<6 hours) and urgent (6–24 hours) indications, preoperative risk assessment is not performed.

Minor orthopedic procedures are associated with a low risk of cardiovascular complications (30-day risk of myocardial infarction or cardiovascular death after surgery is less than 1%). Major orthopedic procedures are associated with an intermediate (moderate) risk of cardiovascular complications (30-day risk of myocardial infarction or cardiovascular death after surgery is 1–5%) [13].

• To assess the risk of perioperative cardiovascular complications, it is recommended to use a special algorithm (Appendix B.2) [11, 14].

BMR BLEL 3Level of recommendation validity B (level of evidence – 3).

• Planned surgical treatment of a distal humeral fracture with the aim of creating conditions for bone healing is recommended without additional examination in adult patients in whom the risk of cardiovascular complications is determined to be low. In adult patients with intermediate or high perioperatice risk of cardiovascular complications, assessment of the patient's functional status is recommended [13, 15].

LE AQOE 3Level of Evidence A (reliability of evidence level – 3).

2.3 Laboratory Diagnostics

All patients diagnosed with a distal humeral fracture are recommended to undergo the following laboratory tests for diagnostic purposes:

• complete blood count;

• urinalysis;

• general clinical blood chemistry panel;

• blood grouping (ABO system) and Rh factor (RhD antigen) testing; hepatitis B surface antigen (HBsAg);

• antibodies to hepatitis C virus (Anti-HCV);

• determination of antibodies of classes M and G (IgM, IgG) to human immunodeficiency virus HIV-1/2 and p24 antigen (Human immunodeficiency virus HIV 1/2 + Agp24) in blood, and determination of antibodies to Treponema pallidum in blood;

• coagulogram (exploratory hemostasis screening);

• determination of the international normalized ratio (INR) [16, 17, 123].

LEL 5Grade of Recommendation C (Level of Evidence – 5).

• When deciding on surgical treatment in adult patients with distal humeral fractures, it is recommended to measure the NT-proBNP level for diagnostic purposes in cases of intermediate or high cardiovascular risk and low functional status (see Appendix G.2) [9, 13, 18, 19].

QOE 2Level of Evidence A (reliability of evidence level – 2).

2.4 Instrumental Diagnostics

• Patients with distal humeral fractures are recommended to undergo radiography of the humerus, shoulder joint, and elbow joint in two projections for diagnostic purposes [2, 6, 124].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

Comments: Performing radiography of the humerus capturing two joints is necessary to diagnose a distal humeral fracture, determine the fracture pattern and degree of fragment displacement, and rule out injury at other skeletal levels. As part of the radiological examination, oblique radiographs (e.g., in the projection for visualizing the humeral capitulum) may be performed for better visualization of bone fragments and fracture lines [2, 6]. After confirming a distal humeral fracture via imaging, the patient should be hospitalized in an inpatient facility if indicated; in the absence of indications for hospitalization, the patient may be discharged for outpatient treatment at their place of residence.

If a patient refuses inpatient treatment, the reason for refusal must be documented in the medical record and signed personally by the patient or their legal guardians (in cases of legally established incapacity).

• Patients with distal humeral fractures are recommended to undergo computed tomography of the upper extremity and/or joint if an intra-articular fracture is present or suspected, in order to refine the diagnosis [2, 6, 124].

Level of Evidence 4Grade of Recommendation C (Level of Evidence – 4).

2.4.1. Features of instrumental diagnostics in children and adolescents

• When diagnosing distal humeral fractures in children is difficult and without obvious fragment displacement, it is recommended to perform comparative radiography—that is, radiography of the elbow joints of both upper extremities using the radiographs of the healthy limb as reference—to clarify the radiographic picture [107].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

• Adolescent patients with complex types of distal humeral fractures are recommended to undergo computed tomography of the upper extremity [2, 6].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

Comments: Spiral CT provides the traumatologist with additional information about the fracture pattern, the degree of fragment displacement, and the severity of articular surface damage, thereby significantly improving the quality of preoperative planning.

2.5 Other Procedures

• When treating patients with proximal humeral fractures, it is recommended to consider the following indications for consultations with relevant specialists in clinical practice in order to rule out conditions threatening the patient's life or health:

• neurosurgical consultation: in case of nerve injury or suspected nerve injury and concomitant head injury;

• surgical consultation, pediatric surgery consultation: in case of suspected or objectively diagnosed concomitant abdominal trauma;

• vascular surgery consultation: in case of concomitant vascular injury or suspected vascular injury;

• physician consultation: in the presence of comorbid conditions of a therapeutic profile (according to medical history) [25].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

• If acute or unstable clinical conditions are identified in patients with distal humeral fractures, it is recommended to postpone elective surgical treatment, and transfer of the patient to a regional vascular center or a specialized cardiological department is indicated in order to improve cardiac status and stabilize the patient's condition [13].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1 Conservative Treatment

• For patients with distal humeral fractures upon admission to the hospital, it is recommended to provide the following minimum scope of care in the emergency department to stabilize the general condition:

• ensuring thermal comfort for the patient;

• adequate pain management;

• immobilization of the injured upper extremity;

• correction of fluid and electrolyte imbalances [7, 17].

Level of Evidence BLevel of Confidence 2Level of recommendation B (level of evidence – 2).

Comments: At the current stage of traumatology development, conservative treatment of distal humeral fractures is used relatively infrequently. Its use is justified in cases of stable distal humeral fractures without fragment displacement, provided that early functional loading is applied. However, scientific publications report that surgical treatment of fractures at this location helps increase fragment stability, allows immediate passive and active movements in the elbow joint, and reduces the risk of secondary fragment displacements [2]. This approach is partly due to the development of surgical techniques and the emergence of new hardware for plate osteosynthesis with angular screw stability. At the same time, studies published at the turn of the 21st century report a high proportion (96% of all observed cases) of successfully consolidated fractures with good functional results, some (15%) of which were open, and 18% of patients experienced post-traumatic neuropathy [27]. Nevertheless, most researchers agree that surgical treatment provides better functional results compared to conservative treatment [2, 28-30].

• In patients with distal humeral fractures, if a conservative treatment method is chosen, it is recommended to perform functional immobilization of the injured upper extremity with early functional movements in the elbow joint to create conditions for bone union [2].

GPP BLOE 3Grade of Recommendation B (Level of Evidence – 3).

Comments: In modern scientific literature, authors emphasize the importance of early functional movements in the joints of the injured extremity, while it is necessary to monitor the absence of secondary fragment displacements [2].

• For patients with distal humeral fractures, as part of conservative treatment, it is recommended to perform regular follow-up radiography of the upper extremity of the injured segment in two projections to monitor the fracture consolidation process and the position of bone fragments [7].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

3.1.1. Specifics of conservative treatment in children and adolescents

• It is recommended to use splint immobilization in children to achieve bone union in distal humeral epiphysiolysis and apophysolysis (DHEA) fractures in the following cases:

• in apophysiolysis of the humeral epicondyles with fragment displacement of no more than 2 mm;

• supracondylar humeral fractures of type I;

• osteometaepiphysiolysis of the humeral condyle head without displacement and with displacement up to 2 mm [103, 108, 109].

Level of Evidence BLevel of Confidence 2Level of recommendation B (level of evidence – 2).

Comments: Splint immobilization of the extremity from the metacarpophalangeal joints to the upper third of the arm in the mid-physiological position is prescribed for a period of three to five weeks.

3.1.2. Pain management

• To ensure adequate pain relief in patients with distal humeral fractures, it is recommended to use multimodal analgesia, which may include nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol**, gabapentinoids, and immediate-release opioids, or monomodal analgesia if multimodal administration is not feasible [31-38].

GOM ALOE 1Grade of Recommendation A (Level of Evidence – 1).

Comments: Multimodal analgesia (MMA) involves the use of several analgesic drugs (opioid and non-opioid) with different mechanisms of action and non-pharmacological interventions aimed at targeting peripheral and/or central parts of the nervous system [28]. This combination allows for more effective pain management by enhancing the effects of various drugs, which in most cases leads to a reduction in the frequency of prescriptions and/or doses of opioid analgesics. Thus, MMA reduces the risk profile of each drug while providing synergistic pain control using different classes of medications. Postoperative MMA may include psychotherapy, physical therapy, NSAIDs, paracetamol, gabapentinoids, regional anesthesia (single injection or peripheral nerve catheter placement), local injections, and opioids [33, 34].

In modern scientific literature, authors emphasize the use of the lowest effective doses of opioids for the shortest possible time, avoiding extended-release opioids. As an adjuvant during MMA, a single perioperative administration of #dexamethasone** can be used, which provides a significant reduction in pain syndrome [36].

It must be kept in mind that parenteral administration of most NSAIDs (ketorolac**, diclofenac**) is limited to a maximum of two days, which requires timely switching the patient to oral administration, changing the drug, or approving further use with a medical committee. The specific choice of local anesthesia technique and medications is made by the attending physician individually, in accordance with the patient's characteristics, local protocols, and the medical organization's equipment.

When prescribing analgesic therapy for children, a single dose should be chosen taking into account the child's weight and age. Preference should be given to analgesics with oral or rectal administration routes, avoiding intramuscular injections.

• In children with distal humeral fractures, the use of paracetamol** and ibuprofen** is recommended for analgesia [129].

GCR BLOE 2Grade of Recommendation B (Level of Evidence – 2).

• In cases of severe pain and ineffectiveness of paracetamol** and ibuprofen** in children, the use of other nonsteroidal and narcotic analgesics is recommended if there are appropriate indications and no contraindications [129].

GCR BLOE 2Grade of Recommendation B (Level of Evidence – 2).

• Patients with distal humeral fractures are recommended to undergo local blockade or regional anesthesia as part of a postoperative multimodal regimen for pain relief [33, 40].

GPP ALOE 1Grade of Recommendation A (Level of Evidence – 1).

Comments: Recommended analgesic medications are listed in Appendices A3.1–A3.3.

3.1.3. Surgical antibiotic prophylaxis

• During surgical treatment of patients with closed distal humeral fractures, it is recommended to perform surgical antibiotic prophylaxis (SAP) of surgical site infection by a single preoperative administration of an antibacterial drug to reduce the risk of infectious complications [51].

GRC ALOE 1Grade of Recommendation A (Level of Evidence – 1).

Comments. In accordance with international clinical guidelines for the prevention of surgical site infections [52, 53], the objective of SAP is to establish bactericidal concentrations of the antibacterial drug in tissues exposed to microbial contamination during surgery to prevent surgical site infections. The need for SAP is determined by the surgical wound class of the upcoming operation: SAP is not required for "clean" surgical wounds not associated with the placement of orthopedic implants and metal hardware. SAP should be administered: for clean-contaminated and contaminated surgical wounds; for "clean" surgical wounds involving the placement of orthopedic implants and metal hardware. In infected ("dirty") wounds, SAP is not indicated; antibiotic therapy is performed instead.

• In patients with distal humeral fractures, it is recommended to use first- and second-generation cephalosporins (cefazolin**, cefuroxime**) as the primary drugs for surgical antibiotic prophylaxis during surgical interventions in traumatology and orthopedics, and glycopeptide antibiotics (vancomycin**), lincosamides (#clindamycin**) as alternatives in case of beta-lactam antibiotic intolerance [54].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comments. For patients with an unremarkable allergy history and no significant risk factors for methicillin-resistant staphylococcal carriage, first- and second-generation cephalosporins (cefazolin**, cefuroxime**) are used for surgical site infection prophylaxis, administered intravenously 30 to 60 minutes before skin incision. In case of beta-lactam antibiotic intolerance, a combination of vancomycin** with one of the fluoroquinolones (ciprofloxacin**, #levofloxacin**), administered over at least 60 min starting the IV infusion 2 hours before incision, or #clindamycin** should be prescribed. In the presence of significant risk factors for methicillin-resistant staphylococcal carriage (MRS), the surgical site infection prophylaxis regimen must include an antibiotic with anti-MRS activity (vancomycin**). In most cases, a single preoperative dose of the antibiotic is sufficient for effective prophylaxis. For prolonged procedures or massive blood loss, an additional intraoperative dose of the antibiotic should be administered (the estimated time for intraoperative administration is two half-lives after the preoperative dose). Administering an antibiotic after wound closure in the operating room is impractical, even if drains are in place.

Single doses of main antibacterial drugs for surgical site infection prophylaxis in adult traumatology and orthopedic surgeries: cefazolin** 2 g (for patients weighing ≥120 kg — 3 g), cefuroxime** 1.5 g, #clindamycin** 900 mg [53], vancomycin** 15 mg/kg as a slow IV infusion, ciprofloxacin** 400 mg, #levofloxacin** 500 mg [53].

Single doses for children should be calculated based on actual body weight: cefazolin** 30 mg/kg, cefuroxime** 50 mg/kg, #clindamycin 10 mg/kg [53], vancomycin** 15 mg/kg; the use of fluoroquinolones during the period of musculoskeletal system development is contraindicated due to the risk of arthropathy [53, 125, 126].

Comments. In open fractures, prophylactic antibiotic administration is effective for the prevention of early infection. Antibiotics should be administered as soon as possible after trauma; cefazolin** is the antibiotic of choice, however, in patients with high-energy open fractures with displacement and segmental bone loss, major vascular injury, or heavily contaminated wounds, it is advisable to expand the spectrum of prescribed antibiotics to include Gram-negative pathogens. In such cases, for adult patients, it is possible to consider adding #gentamicin** (at a dose of 6 mg/kg once daily) to cefazolin** [56, 57]. An alternative to this combination may be #ampicillin+sulbactam** (at a dose of 3.0 g every 8 hours for 3 days) [58]; the latter is particularly relevant in case of the risk of clostridial infection. According to the majority of researchers, in Gustilo-Anderson type III open fractures, antibiotics should not be continued for more than 72 hours after soft tissue wound closure [59].

3.1.4. Prophylaxis of venous thromboembolic complications

• VTEC prophylaxis is not recommended routinely for upper extremity surgeries performed under local or regional anesthesia [61, 62].

GCR BLOE 2Grade of Recommendation B (Level of Evidence – 2).

• In patients with distal humeral fractures, it is recommended to consider perioperative VTEC prophylaxis to reduce the risk of their development when general anesthesia or tourniquet time exceeds 90 minutes during upper extremity interventions, or if the surgery may significantly impair the patient's mobility, or in the presence of a history of VTEC episodes [63].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

Comments: Major and minor shoulder surgeries are characterized by a low risk of VTE [61-63]. However, given the growing prevalence of genetically determined thrombophilias in the population (antithrombin III, protein C, and protein S deficiency, Factor V Leiden mutation, prothrombin G20210A mutation, etc.), the widespread and often uncontrolled use of estrogens, population aging, and the rising incidence of diabetes and other metabolic disorders that increase VTE risk, pharmacological thromboprophylaxis may be advisable when treating patients with additional VTE risk factors for fractures of the humerus and forearm, as well as extensive soft tissue trauma of the upper extremities. The final decision is made by the attending physician, taking into account the extent of injury, the nature of the planned procedure, and additional patient-related VTE risk factors. Perioperative administration of LMWH to this category of patients may be prescribed according to the regimens and dosages provided in Appendix A3.4 for 7–10 days (until hospital discharge) or for several days until normal/expected motor activity is restored.

Recommended medications and thromboprophylaxis regimens are given in Appendix A3.4.

The issues of VTE prevention in trauma and orthopedic patients are discussed in detail in the 2022 guidelines [60] and the 2023 recommendations of Russian experts [64].

3.1.5. Specifics of thromboprophylaxis in pediatric patients

• Hospitalized patients older than 6 months are recommended to undergo bleeding and VTE risk assessment within 24 hours of admission [110] and periodically during their hospital stay [111–113].

Leveled Recommendation CLevel of Evidence 5Level of Evidence C (Level of Evidence – 5).

Comment. No validated VTE risk assessment scales have been developed for pediatric patients, nor have bleeding risk assessment scales for anticoagulant therapy. Therefore, when deciding on VTE prophylaxis, individual bleeding risk factors (Appendix A3.5), VTE risk factors (Appendix A3.6), and the risk-benefit ratio should be considered [114, 115].

For VTE prophylaxis in children, mechanical and pharmacological methods are used.

• Pediatric patients at high risk for VTE are recommended to consider the administration of prophylactic doses of UFH or LMWH from the B01AB group [112, 118, 119, 123].

GCP BLeE 3Level of recommendation confidence B (level of evidence reliability – 3).

Comment. For pediatric patients, the use of LMWHs from the B01AB group is preferred [118, 119] (preferably #Enoxaparin [116]), but currently in Russia, the use of all LMWHs is contraindicated in children; therefore, their prescription is possible only by decision of a medical commission (off-label use). Some foreign guidelines mention the use of direct oral anticoagulants (#rivaroxaban**) for VTE prophylaxis in children [116], but there is currently insufficient clinical evidence regarding their efficacy and safety in children [115, 117].

To decide on pharmacological VTE prophylaxis, a consultation with a pediatrician or hematologist experienced in treating thrombosis in children is recommended. When prescribing anticoagulants to children, it is advisable to monitor complete blood count parameters within 48 hours after starting treatment with enoxaparin or heparin [110]. If indicated, anti-Xa levels should be determined 4 to 6 hours after the administration of #enoxaparin sodium** (target anti-Xa level 0.1–0.3 IU/mL). Routine monitoring of anti-Xa levels is not recommended [120]. Re-evaluation of anti-Xa levels may be considered in the event of active bleeding or signs of renal dysfunction during #enoxaparin sodium** therapy [121]. The glomerular filtration rate when prescribing anticoagulants to children is calculated using the Schwartz formula (http://nephron.com/peds_nic.cgi)

3.1.6. Blood-conserving technologies

Comments. Tranexamic acid** effectively reduces blood loss and leads to a smaller decrease in postoperative hemoglobin levels in patients undergoing surgery for proximal humeral fractures. This effect is observed both in osteosynthesis and shoulder arthroplasty. Furthermore, randomized clinical trials demonstrate the efficacy of local subfascial administration of #tranexamic acid** (1.0 g in 10 mL) into the surgical wound area, which is comparable to intravenous administration of an equivalent dose of the drug [67].

Comments. Systemic reviews and meta-analyses demonstrate that perioperative administration of intravenous iron preparations, specifically ferric carboxymaltose**, in orthopedic trauma patients—especially in the postoperative period—is an effective alternative to blood transfusion, as it reduces the proportion of patients receiving blood transfusions, decreases the volume of transfused packed red blood cells, and leads to a lower incidence of infectious complications, though it does not affect mortality rates [68, 69].

Evidence in pediatric populations supports the efficacy of intravenous iron preparations for correcting preoperative iron deficiency anemia in elective orthopedic procedures [127, 128]. Data on the use of these drugs in children during the postoperative period following trauma surgery are lacking.

3.2 Surgical Treatment

• To create conditions for bone healing, it is recommended to perform surgical treatment for patients with distal humeral fractures in the case of:

- intra-articular fractures with fragment displacement;

- open fractures;

- fractures complicated by neurovascular deficits;

- distal humeral fractures as part of polytrauma [6, 26, 44].

GPP CLOE 4Grade of Recommendation C (Level of Evidence – 4).

Comments: Plate osteosynthesis is currently the standard surgical treatment for distal humeral fractures. Traditionally, a posterior surgical approach is used, which involves a skin incision along the posterior aspect of the distal third of the arm and the elbow joint, followed by splitting or retraction of the muscle fibers. Variations of this approach exist, in which the surgeon retracts the triceps brachii muscle laterally or medially (depending on the clinical situation), splits the fibers of the triceps brachii, or performs an olecranon osteotomy followed by its osteosynthesis. The first of these variations is widely used for AO/OTA type A fractures because, in the case of intra-articular fractures, it does not provide adequate visualization of the articular surface. The triceps-splitting approach also fails to provide sufficient visualization of the articular surface of the humeral condyle; however, partial resection of the tip of the olecranon slightly improves joint exposure. The most widely used variation of the posterior approach to the distal humerus—the olecranon osteotomy approach—provides the best visualization of the articular surface and allows visual control during the reduction of anterior articular surface fragments; nevertheless, some authors report nonunion of the olecranon following this approach in 30% of cases [2]. To minimize the impact of this approach on local tissue blood supply, Athwal et al. (2006) performed olecranon osteotomy combined with the creation of an anconeus muscle flap while preserving its attachment to the olecranon [41]. For AO/OTA type B fractures, lateral approaches to the distal humerus may be utilized. Fractures of the lateral column and isolated fractures of the humeral condylar head and trochlea can be fixed via a lateral approach to the distal humerus using Kaplan or Kocher modifications [42]. Fractures of the medial column and humeral trochlea, in addition to the aforementioned posterior approach options, can be fixed via a medial approach. When making the skin incision, it is essential to visualize the ulnar nerve to prevent iatrogenic injury [43].

Regardless of the chosen approach, osteosynthesis of distal humeral fractures involves the identification and protection of the ulnar nerve. The risk of nerve injury exists not only during the skin incision but also during fragment reduction and hardware placement. Therefore, anterior transposition of the ulnar nerve may be performed to ensure its preservation. Several authors report that this technique helps reduce the likelihood of postoperative ulnar neuropathy [2, 30].

3.2.1 Plate Osteosynthesis

• It is recommended to use plate osteosynthesis in patients with distal humeral fractures to create conditions for bone healing [1, 2, 6, 26, 30].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

Comments: When performing plate osteosynthesis for distal humeral fractures, the following implants are used: non-absorbable sterile bone-fixation plate with screws***, non-absorbable non-sterile bone-fixation plate with screws***, non-absorbable sterile orthopedic bone screw***, non-absorbable non-sterile orthopedic bone screw***.

Plate osteosynthesis of distal humeral fractures allows for the restoration of the metaphyseal-epiphyseal component of the fracture while providing the opportunity for anatomical reduction and interfragmentary compression of the articular surface fragments of the humeral condyle. When both columns of the distal humerus are injured, fracture fixation must be performed using two plates positioned on the lateral and medial sides. The relative positioning of the implants may vary. The plates can be placed in the same sagittal plane, or one plate may be positioned at a 90-degree angle to the plane of the other (typically, the lateral plate is placed in the frontal plane, whereas the medial plate is oriented in the sagittal plane) [26]. When selecting implants, attention should be paid to the plate lengths. A difference in plate lengths helps reduce the risk of peri-implant fractures. To enhance stability, fixation should be performed using the longest possible screws inserted into the metaphyseal-epiphyseal zone [2].

The main objective of osteosynthesis in complex distal humeral fractures is to achieve anatomical restoration of the articular surface. Temporary fixation of fragments with Kirschner wires placed outside the path of the plates to be subsequently installed facilitates the reduction of the metaphyseal-epiphyseal fracture component.

3.2.2 Arthroplasty

Comments: When performing total elbow arthroplasty in elderly patients with reduced physical activity and complex distal humeral fractures, the following implants are used: uncoated humeral component of elbow prosthesis***, coated humeral component of elbow prosthesis***, total linked elbow prosthesis***, polyethylene ulnar component of elbow prosthesis***, metal-coated ulnar component of elbow prosthesis***.

Scientific literature provides data regarding the functional outcomes of treatment in the aforementioned group of patients treated with total elbow arthroplasty. A definite advantage of this type of surgical treatment is the rapid relief of pain syndrome and the possibility of early limb function [44-47].

Data regarding elbow function scoring and complication rates in total elbow arthroplasty vary. Publications predominantly use the Mayo Elbow Performance Score (MEPS) to assess functional treatment outcomes. The range of mean values at follow-up periods from 3 to 10 years is 79.3 to 93 points. Excellent and good results are observed in approximately 85% of patients. However, significant variation is noted in the rates of complications and revision procedures in these patients. Complications (infection, prosthesis component loosening, periprosthetic fractures, neuropathy) occur in 21.5–52% of cases, and revision procedures are performed in 18–31% of patients [44, 45, 47–49].

In a 2020 systematic literature review, the authors analyzed 10 publications on the topic, compiling data from a total of 269 patients. The study reported the following values: the postoperative range of motion averaged 102.3° for flexion-extension and 145.8° for pronation-supination. The mean MEPS score was 89.5. Better functional outcomes were noted when total elbow arthroplasty was performed less than 7 days after the injury. According to the review, the complication rate for this intervention averages 21.5% [46].

3.2.3 External Fixation Device

• Patients with distal humerus fractures are recommended the use of an external fixation device for temporary fracture stabilization in cases of open distal humerus fractures with massive soft tissue injury or in patients with polytrauma [50].

GPP BLOE 3Grade of Recommendation B (Level of Evidence – 3).

Comments: For temporary fracture stabilization in open distal humerus fractures with massive soft tissue injury or in polytrauma patients, the following implants are used: Schanz pins, Steinmann pins, Kirschner wires, and placeholder (stop) wires.

3.2.4. Surgical treatment specifics in children and adolescents

• For apophyseolysis of the medial epicondyle of the humerus accompanied by displacement in children and adolescents, surgical treatment comprising open reduction of the apophysis and internal osteosynthesis is recommended [103].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: Osteosynthesis in children under 10–12 years of age is performed using two crossed wires inserted through the apophysis (within the thickness of the condyle and the medial metaphyseal column); in older children, osteosynthesis can be performed using a compression screw.

• For fractures of the humeral condylar head in children and adolescents accompanied by a displacement of 2–4 mm, closed reduction and transcutaneous stabilization of fragments with two wires is recommended [103].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

Comments: For epi- and osteoapophyseolysis of the humeral condylar head with displacement, open reduction and wire osteosynthesis are indicated.

• For supracondylar humeral fractures in children of Gartland type IIA, closed reduction is recommended; for types IIB and III, closed reduction of humeral fragments with transcutaneous wire fixation is performed [103].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

Comments: Surgical treatment of supracondylar humeral fractures in children involves a posterior approach without olecranon osteotomy. For complex fracture types in adolescents, an approach with olecranon osteotomy is used. For fractures with vascular complications, an anterior approach is performed [104, 105, 106].

No publications have been found proving the efficacy of skeletal traction compared to other methods (closed/open reduction and osteosynthesis) in supracondylar distal humerus fractures in children.

3.3 Other Treatment

Comments: In accordance with clauses 4156–4157 of the Sanitary Rules and Norms on the Prevention of Infectious Diseases (SanPiN 3.3686-21), emergency tetanus prophylaxis is carried out for any injuries involving a breach of the skin and mucous membranes. Emergency tetanus prophylaxis is performed up to the 20th calendar day from the moment of injury [70]. The prescription of medications for emergency tetanus immunoprophylaxis is carried out differentially depending on the presence of documentary confirmation of vaccination or data from immunological monitoring of anti-tetanus immunity levels, as well as taking into account the nature of the injuries.

Emergency tetanus immunoprophylaxis is carried out in the form of:

• passive immunization or seroprophylaxis with human tetanus immunoglobulin** (HTIG), or in its absence, tetanus antitoxin (tetanus antitoxin**) (TAT);

• active-passive prophylaxis consisting of the simultaneous administration into different body sites of human tetanus immunoglobulin** (or TAT in its absence) and tetanus toxoid** (TT);

• emergency revaccination with tetanus toxoid** (or diphtheria-tetanus toxoid** with reduced antigen content - Td-m) to stimulate immunity in previously vaccinated individuals [70, 71].

4. Medical Rehabilitation and Sanatorium-Resort Treatment

• Patients with distal humerus fractures are recommended outpatient rehabilitation according to immobilization and post-immobilization period programs in conservative treatment of distal humerus fractures to restore the range of motion in the joints of the injured limb [72–76].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comments: Distal humerus fractures are intra-articular fractures, and a potential complication is elbow joint contracture [74, 75]. Prevention of elbow joint contracture development and restoration of its mobility are primary rehabilitation goals. The main rehabilitation principle is the earliest possible use of special physical exercises in the elbow joint.

• Patients with distal humerus fractures are recommended an outpatient rehabilitation program during the immobilization period to restore the range of motion in the joints of the injured limb using: active movements in joints free from immobilization, isometric exercises for the shoulder and forearm muscles, reflex (imagined) movements in the elbow joint, and passive repositioning of the elbow joint in a functional orthosis [73, 76, 77].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comments: The program is formulated individually by a physical and rehabilitation medicine (PRM) physician / exercise therapy physician and performed independently at home. The plaster cast immobilization period is 7–14 days. After this period, or in some cases immediately after injury, the arm is fixed in a functional orthosis, which allows changing the flexion and extension positions of the elbow joint during the day, thereby reducing the severity of contracture. If pain or arm swelling increases, or paresthesias develop in the fingers, consulting the attending physician or PRM/exercise therapy physician is recommended.

• Patients with distal humerus fractures are recommended an outpatient rehabilitation program (day hospital) in the post-immobilization period of conservative treatment of distal humerus fractures to restore the range of motion in the joints of the injured limb using lightweight, free dynamic exercises, stretching exercises, static exercises, and with additional resistance: medical upper limb massage, hydrokinesitherapy for bone fractures, low-frequency pulsed electrostatic field therapy, mechanotherapy for bone fractures using motorized/hydraulic mechanotherapy devices, biofeedback training based on dynamometric and goniometric parameters, and robotic mechanotherapy for bone fractures [72–74, 76, 78].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comments: The goal of rehabilitation is to restore elbow joint function and the working capacity of the entire arm. The program is prescribed by the PRM/exercise therapy physician. In the first 7–14 days after plaster cast removal, light movements in the elbow joint, corrective positioning, isometric exercises for the shoulder and forearm muscles, and dynamic exercises for the hand and shoulder joints are performed. To improve elbow joint mobility, multiple repetitions of each exercise and the entire complex 4–5 times a day are necessary. The load during physical exercises is gradually increased, and soft tissues limiting joint mobility are carefully stretched. Monitoring of the rehabilitation program implementation, its correction, and outcome assessment are carried out by the PRM/exercise therapy physician every two weeks.

Over the next two weeks, the rehabilitation program becomes more complex through free exercises with objects and resistance, with additional resistance and stretching of the muscles fixing the elbow joint; exercises for the entire arm with objects, passive and active mechanotherapy, coordination training, manual and underwater massage, and therapeutic swimming. The execution of exercises should not increase pain, but should be performed within the amplitude up to the sensation of pain and with slight overcoming of it [72–75, 76, 78].

The use of manual massage and physical therapy procedures on the elbow joint area is not recommended due to increased reactive changes in the tissues, which provokes the development of heterotopic ossification of the joint [74, 75, 77].

Only the shoulder and forearm muscles are recommended to be massaged using superficial stroking and kneading techniques. Hanging on a horizontal bar, arm presses, and mechanotherapy with resistance are not permitted.

• Patients with distal humerus fractures are recommended early rehabilitation starting from the first day after surgical treatment (internal plate fixation) and until discharge from the hospital according to the postoperative period program under the supervision of a PRM/exercise therapy physician to restore the range of motion in the joints of the operated limb [75–81].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comments: The tasks of rehabilitation include: prevention and reduction of soft tissue edema and creation of optimal anatomical and physiological conditions for the healing of tissues injured during surgery, prevention of cardiovascular and respiratory complications, prevention of elbow joint contracture, patient activation, and training in self-care skills.

• For patients with distal humeral fractures, an early rehabilitation program after plate osteosynthesis of the distal humeral fracture is recommended to restore the range of motion in the joints of the operated limb, including: breathing exercises, exercises for unaffected joints, isometric exercises, positioning of the elbow joint, reflex exercises, local air cryotherapy / cold packs, and transcutaneous electrical nerve stimulation (TENS) [75, 77-80, 83].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comments: Following consultation with a physical and rehabilitation medicine (PRM) physician / exercise therapy doctor, movements in the healthy joints of the operated limb, isometric tension of the shoulder and forearm muscles, passive repositioning for the elbow joint, and reflex exercises are performed from the first postoperative day. Local air cryotherapy and transcutaneous electrical nerve stimulation (TENS) are prescribed to reduce pain and edema. Passive flexion-extension in the elbow joint and forearm supination/pronation, in facilitated conditions with a small amplitude, begin on days 2-3 after the surgical intervention. The rehabilitation program is determined by the stability of fracture fixation and, in cases of insufficiently reliable fixation, a delayed start of rehabilitation is possible [75, 77, 78].

• For patients with distal humeral fractures, outpatient (day hospital) rehabilitation is recommended (weeks 3–8) according to the postoperative period program to restore elbow mobility and upper limb function [73-75, 77, 78].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comments: Rehabilitation is carried out under the dynamic supervision of a PRM physician / exercise therapy doctor. Given the complexity of restoring joint function after intra-articular fractures, rehabilitation should preferably be carried out in a day hospital setting.

• For patients with distal humeral fractures, an outpatient rehabilitation program after osteosynthesis surgery is recommended to restore the range of motion in the joints of the operated limb, including: passive and active mechanotherapy, positioning therapy, passive and assisted movements, free dynamic and isometric exercises, hydrokinesiotherapy for bone fractures, therapeutic exercise in a pool, training with biofeedback based on dynamographic and goniographic indicators for bone fractures, and mastering activities of daily living and occupational skills [74-79].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comments: The individual rehabilitation program (up to 8 weeks) consists of passive mechanotherapy for the elbow joint, positioning therapy, passive and active-assisted movements in the elbow joint combined with movements of the healthy arm, breathing exercises, and exercises for the hand, fingers, and shoulder joint.

The number of exercises and repetitions of each movement is gradually increased as the pain syndrome decreases. The range of motion and functional household loads are gradually increased. Various combinations of exercises and mechanotherapy are performed 3-4 times a day. The use of additional weight resistance during exercises should be avoided for at least 6 weeks postoperatively [77].

Starting from the 8th week after surgery, the rehabilitation program consists of active exercises, active exercises with objects, exercises with stretching of periarticular tissues, mechanotherapy, and exercises in water. Manual massage of the shoulder and forearm muscles is prescribed, and self-care and daily living skills continue to be mastered.

The use of manual massage and physical therapy procedures on the elbow joint area is not recommended due to increased reactive changes in the tissues, which provokes the development of heterotopic ossification of the joint [74, 75, 77].

• Patients with distal humerus fractures following elbow arthroplasty are recommended early rehabilitation from the first postoperative day until discharge from the hospital under the supervision of a physical and rehabilitation medicine (PRM) physician / exercise therapy specialist to restore the range of motion in the joints of the operated limb [80, 82, 83].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comments: To protect the wound until healing occurs, the elbow joint is fixed with an anterior splint in a position of neutral rotation and 30° extension. Immobilization is discontinued after wound healing (about 10-14 days), and exercises aimed at restoring joint motion are initiated. Between sessions, the limb is fixed with a soft orthosis for rest. When using paratricipital and lateral para-elbow approaches, flexion and extension of the elbow joint are not restricted. When using approaches with mobilization of the triceps muscle, active extension should be avoided during the first six weeks, and flexion beyond 90° is restored gradually depending on the tissue quality and the triceps tendon suture.

• Patients with distal humerus fractures following elbow arthroplasty are recommended outpatient rehabilitation under the dynamic supervision of a PRM physician / exercise therapy specialist to increase the range of motion in the elbow prosthesis and normalize muscle tone and strength. Rehabilitation is carried out at home or in a day hospital [80-83].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comments: After surgery, the arm is fixed in a soft orthosis at a 90-degree angle. For the first 4 weeks postoperatively, the rehabilitation program includes: passive and assisted dynamic exercises for the elbow joint, isometric exercises, and active exercises for the fingers and wrist joint. Movements are performed jointly or alternately with the healthy arm.

After 3-4 weeks, the orthosis is removed, the load during shoulder and forearm muscle exercises is increased, and passive mechanotherapy and sessions on simple exercise machines are introduced.

Recovery after surgery should take approximately up to three months. At 5-8 weeks postoperatively, the rehabilitation program becomes more complex. It includes active dynamic exercises for flexion, extension, supination, and pronation in the elbow joint, active strengthening exercises for the muscles around the elbow joint, and exercises to increase the mobility of the shoulder and wrist joints.

Early movements in the elbow joint may cause wound healing problems, while prolonged immobilization can lead to contracture.

If mobility of the elbow joint recovers slowly or not at all after 8-12 weeks, the method of static splinting in extreme positions of flexion and extension is applied.

5. Prevention and Dispensary Observation

• Prevention of humeral fractures consists in citizens observing social safety rules when performing household chores, being in traffic zones, walking on poor-quality pavement, and during icy conditions.

• A significant share of responsibility in fracture prevention also belongs to state structures, which are obliged to ensure safety to prevent road traffic injuries, as well as ensure compliance with safety regulations in industries with increased risk of trauma.

Comments: Upon discharge from the hospital, the patient should be referred to a trauma center or outpatient traumatology department, indicating the treatment performed and providing detailed recommendations for the continuation of treatment and rehabilitation. This will ensure continuity between the inpatient and outpatient stages of treatment.

Follow-up examinations with radiography of the humerus and/or shoulder joint and assessment of functional recovery dynamics are performed at 4-6 weeks postoperatively (assessment of fracture consolidation degree and the possibility of increasing limb load), 12 weeks postoperatively (assessment of fracture consolidation degree and decision on the possibility of full limb load), 24 weeks postoperatively (assessment of functional recovery dynamics), and 1 year postoperatively (assessment of the functional outcome of treatment and decision on the necessity and timing of implant removal).

In children, if there is damage to the growth plates of the distal humerus, primarily the capitulum of the humerus, the patient is subject to orthopedic dispensary observation; an examination is recommended 6 months after the injury and then annually until growth completion.

6. Organization of Medical Care

Clinical application of recommendations: Traumatology and Orthopedics, Anesthesiology and Intensive Care, Medical Rehabilitation, Health Organization and Public Health.

The aim of the clinical guidelines: The clinical guidelines are developed to improve the quality of medical care, standardize algorithms for the diagnosis and treatment of patients with distal humeral fractures.

Indications for planned hospitalization:

• unsatisfactory result of conservative treatment: absence of signs of distal humeral fracture consolidation after conservative treatment or osteosynthesis surgery within 2.5 - 3.5 months after the injury or surgery [6, 84].

Indications for emergency hospitalization:

Patients with suspected or confirmed distal humeral fractures must be referred to a hospital to resolve the issue of emergency hospitalization. Indications for emergency hospitalization are:

• extra-articular distal humeral fracture with fragment displacement;

• intra-articular distal humeral fractures with fragment displacement;

• pathological distal humeral fracture;

• combination of a distal humeral fracture with vascular or neurological disorders;

• open distal humeral fracture;

• distal humeral fracture as part of polytrauma;

• ipsilateral fractures of the distal humerus and other segments of the upper extremity.

Pediatric patients are subject to hospitalization in a specialized department if any type of distal humeral fracture with fragment displacement is present.

Pediatric patients with isolated distal humeral fractures without displacement and without neurovascular disorders may continue outpatient treatment under the supervision of an orthopedic trauma surgeon.

Indications for patient discharge from the hospital:

1. Internal fixation of the fracture with hardware or elbow arthroplasty has been performed, or adequate plaster immobilization has been achieved during conservative treatment.

2. Fragment reduction has been achieved, and secondary displacement has been ruled out based on follow-up radiography before patient discharge.

3. The first stage of rehabilitation has been completed.

4. There is no acute infectious process.

5. Refusal of the patient or their guardians (legal representatives in the event of the patient's legally established incapacity) to continue inpatient treatment (the reason for refusal must be documented in the medical chart and signed personally by the patient or their guardians).

7. Additional Information

To assess treatment outcomes in patients with fractures at the shoulder girdle and arm level, questionnaires have been developed to evaluate the functional result of treatment.

1. Disabilities of the Arm, Shoulder, and Hand (Disabilities of the Arm, Shoulder, and Hand, DASH) was developed jointly by the American Academy of Orthopaedic Surgeons, the Council of Musculoskeletal Specialty Societies, and the Institute for Work and Health of Canada. It belongs to patient-reported outcome measures (patient-reported outcome measures) and was introduced in 1996 for the standardized assessment of the impact of various musculoskeletal injuries and diseases on upper extremity function [85]. DASH is a 30-item questionnaire with response options presented as a 5-point Likert scale. Scores range from 0 (no functional limitations) to 100 (most severe functional limitations). The questionnaire is intended for patients with any musculoskeletal disorders of the upper extremities [86]. DASH has two optional modules (four items each) intended for athletes, musicians, and workers whose activities require special physical training, and whose functional limitations may occur only under high loads that exceed the scope of the 30 DASH items. Approved translations of DASH in 56 languages and dialects, including Russian, are available on the website of the Institute for Work and Health of Canada, which holds the copyright to the questionnaire (https://dash.iwh.on.ca/available-translations).

2. Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) is an 11-question shortened version of the DASH questionnaire with the same response options [87, 88]. Like DASH, it is intended for patient self-assessment of the degree of upper extremity functional impairment in various diseases and injuries. QuickDASH also has two optional modules (four items each) intended for athletes, musicians, and workers whose activities require special physical training, and whose functional limitations may occur only under high loads that exceed the scope of the 11 QuickDASH items. The optional modules are scored separately. In a number of studies, comparison of the DASH and QuickDASH questionnaires showed that both instruments have approximately equal sensitivity, specificity [89–93], and minimal clinically important difference values (12–14 points for DASH and 12–15 points for QuickDASH) [94]. In a systematic review of 23 self-assessment instruments for patients with various upper extremity pathologies, the QuickDASH questionnaire demonstrated the highest content and construct validity, reliability, and responsiveness [95]. There are reports on the successful use of QuickDASH in children aged 8–18 years [96, 97]. Approved translations of QuickDASH in 56 languages and dialects, including Russian, are available on the website of the Institute for Work and Health of Canada, which holds the copyright (https://dash.iwh.on.ca/available-translations).

   The Russian translation of QuickDASH in the author's version is given in Appendix G.1.

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

1. Belenky I.G., MD, DSc, Associate Professor, Saint Petersburg I.I. Janelidze Research Institute of Emergency Medicine, Saint Petersburg, member of ATOR

2. Bozhkova S.A., Dr. Sci. (Med.), National Medical Research Center of Traumatology and Orthopedics named after R.R. Vreden of the Ministry of Health of the Russian Federation, St. Petersburg, member of ATOR.

3. Geroeva I.B., MD, Professor, Priorov National Medical Research Center of Traumatology and Orthopedics of the Ministry of Health of the Russian Federation, Moscow.

4. Zorin V.I., PhD, Associate Professor, Turner National Medical Research Center for Children's Orthopedics and Trauma of the Ministry of Health of Russia, St. Petersburg.

5. Kleymenova E.B., MD, Professor, Priorov National Medical Research Center of Traumatology and Orthopedics of the Ministry of Health of the Russian Federation, Moscow.

6. Lukyanov S.A., Cand. Sci. (Med.), National Medical Research Center for Pediatric Traumatology and Orthopedics named after G.I. Turner of the Russian Ministry of Health, St. Petersburg.

7. Mayorov B.A., Ph.D. in Medicine, Janelidze St. Petersburg Research Institute of Emergency Medicine, Pavlov First St. Petersburg State Medical University, St. Petersburg, member of ATOR

8. Nazarenko A.G., MD, Professor of the RAS, Director of the Priorov National Medical Research Center of Traumatology and Orthopedics of the Ministry of Health of the Russian Federation, Moscow, Vice President of ATOR.

9. Otdelenov V.A., PhD, Priorov National Medical Research Center of Traumatology and Orthopedics of the Ministry of Health of the Russian Federation, Moscow.

10. Sergeev G.D., PhD, Saint Petersburg Dzhanelidze Research Institute of Emergency Medicine, St. Petersburg, member of ATOR

Conflict of interest.

The working group for drafting clinical guidelines for the treatment of distal humeral fractures has no conflicts of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

1. Trauma and orthopedic surgeons

2. Surgeons

3. General practitioners

4. Medical rehabilitation physicians

5. Healthcare organization and public health specialists.

Stages of evaluating the levels of evidence and grades of recommendation:

1. Definition of search and selection criteria for publications on clinical trials (CT) regarding the efficacy and/or safety of the medical intervention described in the recommendation statement.

2. Systematic search and selection of CT publications in accordance with the previously defined criteria.

Systematic search and selection of clinical trial publications:

The evidence base for the recommendations consisted of publications retrieved via information retrieval in the following databases: Central Scientific Medical Library (CSML) "Russian Medicine", MEDLINE (US NLM), and COCHRANE Library; scientific electronic libraries eLibrary.ru and "CyberLeninka"; as well as on the Internet using Yandex, Google, and Google Scholar search engines, by reviewing leading specialized peer-reviewed domestic medical journals on the subject and treatment guidelines for fractures from the international Association for Osteosynthesis AO/ASIF.

Table 1. Levels of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)

Table 2. Scale for grading levels of evidence (LE) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)

Table 3. Scale for grading grades of recommendation (GR) for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)

Procedure for updating clinical guidelines.

The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

Appendix A3.1. Recommendations for pain management in major musculoskeletal trauma (surgical interventions for long bone fracture fixation or complex articular fracture, extensive soft tissue trauma, major surgery, etc.) in adults

Appendix A3.2. Recommendations for pain management in non-surgical musculoskeletal trauma (closed fractures, superficial wounds, etc.) in adults

Appendix A3.3. Recommendations for postoperative pain management in children

¹ In children under 12 years of age, morphine** is preferred when opioid analgesics need to be prescribed, as the use of tramadol** is associated with a higher risk of adverse reactions [8,9].

² Its use in children is not recommended, as its metabolite accumulates in the body and provokes seizures upon repeated use [10].

* In children under 12 years of age, morphine** is preferred when opioid analgesics need to be prescribed, as the use of tramadol** is associated with a higher risk of adverse reactions [130, 131].

** Its use in children is not recommended, as its metabolite accumulates in the body and provokes seizures upon repeated use [132].

Appendix A3.4 Recommended dosing regimen of low-molecular-weight heparins for the prevention of high-risk venous thromboembolism (VTE) in conservative treatment and orthopedic surgeries in adult patients at high risk of VTE

Appendix A3.5. Bleeding risk factors in children aged 6 months to 18 years

Notes:

1. If the patient meets at least one "NOT recommended" criterion, avoid pharmacoprophylaxis, as the risk outweighs the benefit.

2. If the patient has at least one relative contraindication criterion, consider withholding pharmacoprophylaxis.

3. Consider a hematology consultation if the patient is at high VTE risk with a high bleeding risk [112].

4. Uncontrolled hypertension is defined as systolic or diastolic blood pressure above the 95th percentile for age, height, and sex [113].

5. Coagulopathy is defined as INR > 1.5, aPTT > 44 s, fibrinogen < 100 g/dL, or platelets < 50,000/μL.

Appendix A3.6. VTE risk factors in children aged 6 months to 18 years

Notes:

• Decreased mobility compared to baseline or unable to participate in physical therapy.

• Central venous access device is defined as a non-tunneled catheter, tunneled catheter, or central venous catheter.

• A massive burn is defined as a burn involving more than 50% of the body surface area.

• Major surgical interventions include operations lasting more than 45 minutes.

• Critically ill patients are defined as those admitted to an intensive care unit or critical care unit (requiring inotropic support, mechanical ventilation).

• Thrombophilic conditions include antithrombin defects, protein C or S deficiency, Factor V Leiden, or prothrombin gene mutation.

• Active malignancy is defined as receiving chemotherapy/radiation therapy within the preceding 6 months.

• Active inflammatory disease includes Kawasaki disease, inflammatory bowel disease, systemic lupus erythematosus, or nephrotic syndrome.

• Estrogen therapy includes oral contraceptives, estrogen replacement therapy, or use within the past 2 weeks.

• Obesity is defined as a BMI above the 95th percentile for age.

Key:

Low VTE risk:

• No altered mobility and 0-1 risk factor

Moderate VTE risk:

• No mobility impairment and 2-3 risk factors

• Altered mobility and 0-1 other risk factors

High VTE risk:

• No mobility impairment and ≥4 risk factors

• Altered mobility and ≥2 other risk factors

Thromboprophylaxis recommendation

Appendix B. Physician Action Algorithms

Appendix B.1. Algorithm of physician actions in suspected distal humerus fracture

Appendix B.2. Assessment of cardiovascular risk of surgery

Notes and abbreviations:

CVRF – cardiovascular risk factors (arterial hypertension, smoking, dyslipidemia (elevated total cholesterol >4.9 mmol/L and/or LDL cholesterol >3 mmol/L and/or HDL cholesterol <1.0 mmol/L in men, <1.2 mmol/L in women, and/or triglycerides >1.7 mmol/L), diabetes mellitus, family history of premature cardiovascular disease (<55 years for men and <65 years for women);

CVD – cardiovascular disease (coronary artery disease, cerebrovascular disease, peripheral artery disease, chronic heart failure, pulmonary hypertension, valvular heart disease, cardiomyopathies);

rRCRI - reconstructed RCRI index (See Appendix G2);

FS – functional status (the patient's ability to climb 2 flights of stairs independently without stopping before the injury).

*- regional vascular center or specialized cardiological department.

Appendix C. Patient Information

Fractures of the lower third of the humerus are injuries requiring specialized treatment in a trauma center or traumatology department. Conservative treatment of such injuries is only possible for fractures without fragment displacement. This type of treatment involves immobilization with a plaster cast or its equivalents with early initiation of rehabilitation and active movements in the elbow joint. Without proper rehabilitation and with prolonged immobilization, elbow joint contracture may develop, leading to a significant decrease in quality of life. Surgical treatment is indicated for all fractures with fragment displacement. Plates of various configurations are used to treat fractures of the lower third of the humerus. Treatment can be single-stage (for isolated closed fractures and satisfactory soft tissue condition) and two-stage, where the fracture is first temporarily fixed with an external fixator followed by conversion to internal fixation (in multiple and polytrauma, severe open fractures, significant soft tissue injury). In all cases, the goal should be stable osteosynthesis that does not require additional external immobilization after surgery. This makes it possible to start early rehabilitation treatment.

Rehabilitation treatment should begin immediately after surgery. It consists of passive and active movements in the joints of the upper extremity, physiotherapeutic procedures, and exercises aimed at normalizing the trophism of damaged soft tissues and bone. The timing for allowing limb weight-bearing may vary depending on the nature of the fracture and the method of fixation. Following osteosynthesis of fractures with plates, the timing for initiating axial weight-bearing on the limb depends on the complexity of the fracture, whereas functional joint movements in the injured upper extremity are possible within the first days after surgery.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Appendix G1. Quick Disabilities of the Arm, Shoulder and Hand Questionnaire QuickDASH

Russian title: The shortened disabilities of the arm, shoulder and hand questionnaire.

Original title: The shortened disabilities of the arm, shoulder and hand questionnaire (Quick DASH)

Source: Quick DASH Outcome Measures: Russian translation. Institute for Work & Health, 2006. https: //dash.iwh.on.ca /available-translations

Type: questionnaire

Purpose: assessment of the impact of musculoskeletal injuries and diseases on upper extremity function.

Content:

INSTRUCTIONS: This questionnaire asks about your symptoms as well as your ability to perform certain activities. Please answer each question based on your condition over the past week by circling the appropriate number. If you did not have the opportunity to perform a specific activity last week, please choose the most appropriate response. It does not matter which hand you use to perform the action; please answer based on your ability, regardless of how you independently perform the task.

QuickDASH disability/symptom score =

where n is the number of completed responses.

The QuickDASH score cannot be calculated if more than 1 item is missed.

OPTIONAL MODULE SCALING. All 4 questions must be answered. Simply add the assigned values for each response and divide by 4 (number of items); subtract 1 and multiply by 25.

Appendix G2. Reconstructed Cardiac Risk Index rRCRI

Russian title: Reconstructed cardiac risk index for noncardiac surgical procedures

Original title: Reconstructed Revised Cardiac Risk Index (rRCRI)

Source: Davis C., Tait G., Carroll J. et al. The Revised Cardiac Risk Index in the new millennium: a single-centre prospective cohort re-evaluation of the original variables in 9,519 consecutive elective surgical patients. Can. J. Anaesth. 2013; 60(9): 855-863.

Type: scale

Purpose: prediction of the risk of perioperative cardiac complications in noncardiac surgery: myocardial infarction, pulmonary edema, ventricular fibrillation or cardiac arrest, complete AV block.

Content:

1. High-risk surgery (intrathoracic, intra-abdominal, or suprainguinal vascular surgery) – 1 point.

2. Ischemic heart disease (myocardial infarction, positive stress test, angina pectoris, nitroglycerin use, pathological Q wave on ECG) – 1 point.

3. Heart failure (history of heart failure, pulmonary edema, paroxysmal nocturnal dyspnea, bilateral pulmonary rales, gallop rhythm, pulmonary congestion on chest X-ray) – 1 point.

4. TIA/Stroke – 1 point.

5. Creatinine clearance <30 ml/min - 1 point

Scoring:

1. total score of 0 – low risk of cardiovascular complications;

2. a total score of 1 – moderate risk of cardiovascular complications;

3. a total score of 2 or more – high risk of cardiovascular complications.

Notes:

The RCRI index was developed in 1977 [100] to predict the risk of perioperative cardiac complications in noncardiac surgery. It was validated in the Lee study [101], revised in 2013 [102], and re-validated based on clinical risk factors (instead of the criterion "creatinine level >176.8 µmol/L", the scale uses the criterion "creatinine clearance <30 mL/min"; the clinical criterion "insulin-dependent diabetes mellitus" was removed), which is why it is called the reconstructed index. It includes 5 parameters, each assigned 1 point. This specific version of the index is recommended by the Russian Society of Cardiology [13].