Distal Humerus Fractures

EpidemiologyDistal Humeral Fracture

 

2 groups

- young patient with high velocity injury

- older patient with comminuted, osteoporotic fracture

 

In the second group fixation can be very difficult

 

Anatomy

 

Hinged Joint

- trochlea axis is centre of rotation

- 40o anterior angulation in sagittal plane

- trochlea 3-8o externally rotated

- 4 - 8o valgus

- medial and lateral columns

 

Elbow Lateral NormalElbow Lateral Normal 40 degree anterior angulation

 

Elbow AP NormalElbow Normal AP 4 degrees valgus

 

CT scan

 

Aids preoperative planning

- identify capitellar fracture

- identify if trochlea deficiencies which might need bone grafting

- aid diagnosis / reconstruction intr-articular extension

 

Muller's Classification

 

Type A: Extra-articular fracture

 

Distal Humerus Fracture

 

Type B: Uni-condylar fracture

- lateral /  medial

 

Elbow Medial Condyle FractureElbow Lateral Condyle Fracture

 

Type C: Bi-condylar fracture

 

Distal Humeral Fracture APDistal Humeral Fracture BicondylarDistal Humeral Fracture

 

Operative Management

 

Timing

 

Within 24 hours or at 5 - 7 days

- minimises inflammation

- minimises risk HO

 

Options

 

1.  ORIF

 

2.  Distal humeral replacement / osteoporotic and highly comminuted fractures

 

Kalogrianitis et al J Should Elbow Surg 2008

- 9 patients mean age 37

- highly comminuted, osteoporotic, non reconstructable fractures

- no deep infections

- ROM 15 - 120o

 

McKee et al JSES 2009

- RCT 42 patients > 65 years of age

- ORIF vTEA

- 5 ORIF patients converted to TEA intraop

- better outcomes and decreased reoperation rate with TEA

 

Impression

- good treatment if unable to ORIF

- high level of skills required

- can replace distal humerus only if ligaments and proximal ulna preserved

- otherwise must replace ulna +/- linked prosthesis

 

3.  "Bag of bones" treatment

- patient elderly and not operative candidate

- intial rest in plaster

- then mobilisation

- surprisingly good ROM and function

 

Distal Humerus Non Operative

 

Approach

 

Extra-articular fracture

 

Distal Humerus Extraarticular ORIF

 

1.  Mobilise triceps either side of humerus 

- reduce distal fragment and hold with K wires

- application 2 x perpendicular plates

 

2.  Bryan - Morrey Triceps sparing posteromedial approach

- find and protect ulna nerve

- elevate triceps aponeurosis medial to lateral off ulna

- leave one side of periosteum intact

 

3.  Split triceps

- feather with osteotome off ulna medial and laterally

 

Intra-articular fracture

 

Need to visualise distal humerus to get anatomical reduction

- olecraonon blocks visualisation

- Chevron Osteotomy

 

Technique for Intra-articular fracture

 

Distal Humerus ORIF APDistal Humerus ORIF Lateral

 

Position

- lateral decubitus with bolsters

- arm over bolster

- tourniquet

- may need to prep and drape iliac crest for bone graft

 

Elbow Lateral Decubitus

 

Posterior approach

- midline posterior incision is used

- deviate radial side of olecranon (prevents painful incision)

- ulnar nerve identified / mobilised / vessiloops / protected

 

Chevron Olecranon Osteotomy

 

Chevron Osteotomy

 

Technique

- predrill proximal ulna with 3.2 mm bit 

- partially tapped for 6.5 mm cancellous screw

- cut with oscillating saw, apex distal

- homan retractors each side to protect structures

- attempt to make in bare area of central olecranon

- 3 cm from tip olecranon

- complete with osteotome so can interdigitate fracture and not saw away segment of articular cartilage

- take fragment and retract proximally, taking triceps with it to expose distal humerus

- radial nerve 14 cm proximal to lateral epicondyle

- wrap in wet sponge, clip with artery to drapes

 

Restoration of Articular Anatomy

- Anatomic reduction of the condyles / distal articular surface

- ORIF with cannulated 4.0 mm partially threaded screws

- reduce fragment onto distal humerus

- fix with K wires in medial and lateral columns

- check with II

 

Pre-contoured locking plates

- posterolateral and medial

- ensure not of equal length to decrease stress risers proximally

- can get variants of posteriorlateral plate to fix coronal plane fracture of capitellum (AP screws in PL plate)

- fix with locking screws

- ensure not in olecranon or coronoid fossa  

 

Assess ROM

- no block to motion

- good stability

 

Check II

 

Assess ulna nerve 

- ensure not impinging on medial plate   

- may need to consider anterior transposition  

 

ORIF olecranon

- 6.5 mm screw + washer, then wire tension band

- may need plate if screw does not get good bite

- can use K wires and TBW

 

Post op 

 

POP backslab 2/52 for wound healing

Range if stable with physio / active assist

- avoid PROM (HO)

 

Results

 

G/E 75%

 

Complications

 

ROM

- loss of 10 - 20o extension common

 

Humeral non union

 

Olecranon osteotomy non union

- 5%

- bone graft and plate

 

Ulna nerve palsy

- keep in mind the need to perform anterior transposition in original OT

- treat with neurolysis + transposition

 

Painful Hardware

- most common

- re-fracture risk if remove both plates

 

Adult Lateral Condyle Fracture

 

Elbow Lateral Condyle FractureElbow Lateral Condyle Fracture 2

 

Definition

 

Fracture of lateral condyle

- involve capitulum alone

- may extend medially to involve the lateral portion of trochlea

 

Management Options

 

These fractures are typically displaced and require surgical treatment

- Kocher approach and ORIF with compression screws

- Posterior approach and posterolateral plate

 

Adult Medial Condyle Fracture

 

Elbow Medial Condyle Fracture

 

Anatomy

 

Medial epicondyle is common origin of several flexor muscles of hand and wrist

When medial epicondyle is fractured, flexor muscles pull fragment distally

 

Management

 

1.  Medial approach

- find and protect ulna nerve

- ORIF with screws

 

2.  Posterior approach

- find and protect ulna nerve

- application of medial plate / ORIF with screws

- ensure at end no encroachment of  plate on nerve or might need anterior transposition

 

Transcondylar Fracture

 

Definition

 

Type of supracondylar fractures that occurs within joint capsule

- very distal / often very comminuted

- most commonly occurs with osteoporotic bone

 

Treatment

 

Non-displaced fractures are treated with splinting or percutaneous pinning

 

Displaced fracture

- consider ORIF

- may need to consider primary hemiarthroplasty / elbow replacement

 

Capitellar Fracture

 

Uncommon fracture which is difficult to diagnose if fracture fragment is small

 

Elbow Capitellar FractureCapitellar Fracture CT SagittalCapitellar Fracture CT Axial

 

Type I

- Hans Steinthal fracture

- fracture of the capitellum in the coronal plane

- involves large part of the osseous portion of capitulum

- fracture hinges anteriorly between radial head and radial fossa producing a block to flexion

 

Management

 

If closed reduction is obtained, then reduction is usually stable with elbow flexion

 

Open reduction

- Kocher approach

- one or two headless compression screws

- front to back

- buried

 

Capitellar Fracture ORIF0001Capitellar Fracture ORIF0002

 

Type II

- Kocher Lorenz fracture               

- affects primarily articular cartilage and very little underlying bone

- these usually cause few subsequent joint problems

 

Management

- healing potential is minimal & excision is recommended