distal humerus fractures

Distal Humerus FracturesDistal Humerus Fractures

Outline

Distal Humerus– Preop Planning– Surgical Technique

Olecranon

Demographics

Distal humerus Fx’s– 2-3% of all fx’s

2 groups– High energy in young– Low energy in elderly

Anatomy

Hinged joint with single axis of rotation

4 deg (males) to 8 deg (females) valgus, 3-8 deg ER

Skeletal Trauma, 3rd edition

Anatomy

Medial and lateral columns form triangle with trochlea

Medial column diverges 45 deg

Lat column 20 deg

Skeletal Trauma, 3rd edition

Anatomy

The distal humerus angles forward

Lateral or prone positioning during ORIF facilitates reconstruction of this angle

Slide courtesy of Stephany & Schmeling; OTA Resident Library

Fracture Pattern

Fracture pattern determined by load direction and position of elbow

Skeletal Trauma, 3rd edition

Classification

Extraarticular (A)

Partial Articular (B)

Complete Articular (C)

Müller ME, Nazareon S, Koch P, Schaftsker J: Comprehensive Classificationof Fractures of Long Bones. Berlin, Germany: Springer-Verlag, 1990, p 330.)

Treatment Principles

Anatomic articular reduction

Stable internal fixation

Preservation of blood supply

Early ROM

Avoidance of complications

Pre-op Planning

Intraarticular vs Extraarticular– Triceps splitting or

sparing– Olecranon osteotomy

Age and function of patient– ORIF– TEA– “Bag of Bones”

Triceps Splitting

Best for extraarticular fx’s

No worse than olecranon osteotomy for strength or outcome

McKee et al JBJS-Am 2000; 82: 1701-1707

Triceps Sparing

Bryan-Morrey– Approach started

medially, reflecting triceps off olecranon

– Anconeus reflected with flap as it is brought lateral

Triceps-Reflecting Anconeus Pedicle (TRAP)

O’Driscoll– Modified Kocher and

Bryan-Morrey– Anconeus preserved– Reflect Anconeus and

Triceps proximally as you would osteotomy

– Extreme flexion needed to see anterior articular surface

Anconeus

FCU

Extraarticular osteotomy

Good for low extraarticular fx’s or “simple” intraarticular fx’s

Still has complications associated with hardware (up to 30%)

Anglen JAAOS 2005; 13, 291-7

Intraarticular Osteotomy

Chevron osteotomy

Apex distal

Pre-drill for fixation of osteotomy (if using screw)

Jupiter Master Techniques

Intraarticular Osteotomy

Place Joker or gauze in joint

Bare spot, just proximal to coronoid

Complete osteotomy with osteotome

Jupiter Master Techniques

Intraarticular Osteotomy

Triceps reflected

Place olecranon and muscle in moist gauze

Don’t forget the radial nerve!

Jupiter Master Techniques

Steps to fixation

Articular reduction first

Don’t lag trochlea if comminution present

Fix articular surface to columns, columns to shaft

Jupiter Master Techniques

Fixation

90-90

180 or med/lat

2 plates dorsal

Locked vs. non-locked

Korner 2004– Locked or not, dorsal

plates failed vs. 90-90

– Plate configuration more important than locking technology

Korner J Orthop Trauma 2004;18:286–293

90-90 vs 180

Jacobsen et al., 1997 – Tested five constructs (direct lateral,

posterolateral, medial combo’s)

– All were stiffer in the coronal plane than compared to the sagittal plane

– Strongest construct medial reconstruction plate with posterolateral dynamic compression plate

Repair osteotomy

K-wires and tension band

6.5 screw w/ washer and tension band

Parallel small frag screws (lag techique)

Jupiter Master Techniques

Complications of Repair Osteotomy

Coles 2006– 70 pts– IM screw and tension

band– 30% HWR, 8% due

to SxRing 2004

– 45 pts– K-wires and tension

band– 27% HWR, 13%

due to Sx

Ulnar Nerve Transposition?

Routine transposition– Plenty of level 5

evidence– Don’t have to worry

about it if you go back– Strip blood supply– May do worse?

Post-op

Soft dressing vs. splint at 90 vs splint in extension

Early ROM (AROM/AAROM)

Consider NSAIDs for thermal and head injuries (4% HO), but risking nonunion

Outcomes

Most daily activities can be accomplished:– 30 –130 degrees extension-flexion– 50 – 50 degrees pronation-supination

Good functional outcome– 15-140 degrees of motion

75% strength to contralateral arm, regardless of approach (osteotomy vs triceps-splitting)

Slide courtesy of Stephany & Schmeling; OTA Resident Library

McKee et al JBJS-Am 2000; 82: 1701-1707

Complications

Non-union of olecranon osteotomy– 5% or more– Chevron osteotomy

has a lower rate– Bone graft and

revision tension band technique

– Excision of proximal fragment is salvage• 50% of olecranon must

remain for joint stability

Slide courtesy of Stephany & Schmeling; OTA Resident Library

Complications

Infection– Range 0-6% – Highest for open

fractures– No style of fixation has

a higher rate than any other

Slide courtesy of Stephany & Schmeling; OTA Resident Library

Complications

Ulnar nerve palsy– 8-20% incidence– Reasons: operative manipulation, hardware

prominence, inadequate release– Results of neurolysis (McKee, et al)

• 1 excellent result• 17 good results• 2 poor results (secondary to failure of

reconstruction)– Prevention best treatment

Slide courtesy of Stephany & Schmeling; OTA Resident Library

Pearls

Learn one extraarticular approach and one intraarticular approach well before trying new ones

90-90 or 180 plating more important than locked plates, but locked plates may be helpful with comminution

TEA may be better choice for osteopenic patient than locking plates

Case DM

34 yo M fell 15 feet from roof

Open wound posterior distal L arm

NVI