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Distal Humerus Fractures

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Outline Distal Humerus Preop Planning Surgical Technique Olecranon

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Demographics Distal humerus Fxs 2-3% of all fxs 2 groups High energy in young Low energy in elderly

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Anatomy Hinged joint with single axis of rotation 4 deg (males) to 8 deg (females) valgus, 3-8 deg ER Skeletal Trauma, 3 rd edition

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Anatomy Medial and lateral columns form triangle with trochlea Medial column diverges 45 deg Lat column 20 deg Skeletal Trauma, 3 rd edition

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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

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Fracture Pattern Fracture pattern determined by load direction and position of elbow Skeletal Trauma, 3 rd edition

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Classification Extraarticular (A) Partial Articular (B) Complete Articular (C) Mller ME, Nazareon S, Koch P, Schaftsker J: Comprehensive Classification of Fractures of Long Bones. Berlin, Germany: Springer-Verlag, 1990, p 330.)

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Treatment Principles Anatomic articular reduction Stable internal fixation Preservation of blood supply Early ROM Avoidance of complications

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Pre-op Planning Intraarticular vs Extraarticular Triceps splitting or sparing Olecranon osteotomy Age and function of patient ORIF TEA Bag of Bones

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Triceps Splitting Best for extraarticular fxs No worse than olecranon osteotomy for strength or outcome McKee et al JBJS-Am 2000; 82: 1701-1707

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Triceps Sparing Bryan-Morrey Approach started medially, reflecting triceps off olecranon Anconeus reflected with flap as it is brought lateral

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Triceps-Reflecting Anconeus Pedicle (TRAP) ODriscoll 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

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Extraarticular osteotomy Good for low extraarticular fxs or simple intraarticular fxs Still has complications associated with hardware (up to 30%) Anglen JAAOS 2005; 13, 291-7

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Intraarticular Osteotomy Chevron osteotomy Apex distal Pre-drill for fixation of osteotomy (if using screw) Jupiter Master Techniques

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Intraarticular Osteotomy Place Joker or gauze in joint Bare spot, just proximal to coronoid Complete osteotomy with osteotome Jupiter Master Techniques

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Intraarticular Osteotomy Triceps reflected Place olecranon and muscle in moist gauze Dont forget the radial nerve! Jupiter Master Techniques

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Steps to fixation Articular reduction first Dont lag trochlea if comminution present Fix articular surface to columns, columns to shaft Jupiter Master Techniques

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Fixation 90-90 180 or med/lat 2 plates dorsal

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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;18:286293

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90-90 vs 180 Jacobsen et al., 1997 Tested five constructs (direct lateral, posterolateral, medial combos) All were stiffer in the coronal plane than compared to the sagittal plane Strongest construct medial reconstruction plate with posterolateral dynamic compression plate

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Repair osteotomy K-wires and tension band 6.5 screw w/ washer and tension band Parallel small frag screws (lag techique) Jupiter Master Techniques

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Complications of Repair Osteotomy Coles 2006 70 pts IM screw and tension band 30% HWR, 8% due to Sx Ring 2004 45 pts K-wires and tension band 27% HWR, 13% due to Sx

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Ulnar Nerve Transposition? Routine transposition Plenty of level 5 evidence Dont have to worry about it if you go back Strip blood supply May do worse?

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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

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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

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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

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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

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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

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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

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Case DM 34 yo M fell 15 feet from roof Open wound posterior distal L arm NVI

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