Distal Humeral Fractures - Basic Management Concepts. Dr. Jeffrey Kwee, PGY3 August 22, 2006
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1 Distal Humeral Fractures - Basic Management Concepts Dr. Jeffrey Kwee, PGY3 August 22, 2006
2 Incidence Elbow = 5% of fractures 0.5% Distal Humeral Adults Comminution ++ Kids Supracondylar/condylar minimal comminution
3 Anatomy Distal Humerus made up of 2 columns Medial and lateral Together have two articulations Ulna humeral Hinge joint Radio humeral Rotational joint Independent but related
4 Anatomy 2 Very thin sections of bone at olecranon fossa, radial fossa, coranoid fossa Provide room for ROM without impingment Weak area
5 Anatomy 3 Alignment 4-8 of valgus (carrying angle) 3-8 of external rotation 40 of forward flexion
6 Anatomy 4 Ligaments and muscles Medial and Lateral Ulnar collateral ligament Flexor and extensor origins
7 Classification Peri-articular - OTA Classification A Extra Articular B Partial Articular C Total articular No continuity shaft to articular surface
8 OTA/AO Classification Peri-articular
9 Diagnosis Standard X-rays Traction X-rays CT Scan with Recon Stress Views
10 Treatment Options - Type A Fractures As in Kids Brachial artery injury is sometimes associated with this type AKA transcolumnar fractures Also classified into high, low or oblique
11 Management Options Type A Fractures Closed Reduction and Casting Now recommended only for those who are medically unfit Closed Reduction and Traction Neither closed technique allows for early mobilization Percutaneous Pinning As in kids, crossed k-wires Must be immobilized in cast for 5-6 wks Open Reduction Internal Fixation The current standard of care
12 Management Options Type A Freactues Percutaneous Pinning As in kids, first obtain closed reduction Traction and flexion (if extension type) Traction and posterior pressure on the forearm (if flexion type) Then two crossed k-wires starting on the epicondyle and crossing the fracture site Under flouro Ulnar nerve a risk Not stable construct needs to be in cast/splint x 5-6 wks Possibility of stiff elbow
13 Management Options Type A Fractures Open Reduction and Internal Fixation Method of choice Allows for stable fixation and thus early ROM Minimizes chance of stiff elbow Can start ROM as soon as day 1 Technique Same as fixation for Type C Will go over this later
14 Treatment Options - Type B Fractures Milch Classification for medial or lateral column fractures Type I Lateral wall of trochlea attached to main mass of humerus Type II Lateral wall separated High/Low Classification OTA B1.1 or.2 OTA B2.1 or.2
15 Treatment Options - Type B Fractures Non-operative Non medically fit Low, undisplaced intraarticular fractures Operative Treatment of choice Muscle Pull significant force of displacement Cannulated screws / Lag screws
16 Management Options Type B Fractures Articular Fractures Capitellum With or without involvement of the trochlea If undisplaced closed treatment If displaced Open reduction and internal fixation Lateral or Anterior approach and Herbert type countersunk screws
17 Treatment Options - Type C Fractures Options Non-operative Classical teaching (1960s) At the time poor outcomes with ORIF Traction through olecranon pin 3 wks, then cast Collar and Cuff - Bag of Bones Treatment Maximal flexion initially, encouraging ROM of hands and fingers At 6 wks begin elbow ROM Operative Current Choice ORIF is now recommended because we have a better understanding of fractures, imaging and implants Can achieve reasonably functional outcomes because of early motion Total Elbow A few slides from now
18 Treatment Options Type C Fractures plating Posterior lateral plate Medial plate Distal end of medial plate can be bent so that it includes orthogonal screws Compression screw can be used across the condyle Biomechanically the strongest construct Helfet and Hotchkiss Pelvic reconstruction plates Pre-contoured plates Accumed - Locking Zimmer - Locking
19 Management Options - Type C Fracture Total Elbow Currently only recommended in the elderly and those with low demand Those with very poor bone quality Extremely comminuted fractures Cannot be used as a bailout if olecranon osteotomy used Must use either triceps split or osteotomy of epicondyles Generally should be done by experienced arthroplasty surgeon
20 Outcomes In Type C Fractures Outcomes proportional to energy type of fracture Stiffness Despite ORIF and optimal early ROM still can have flexion contracture Pain 25% can have exertional pain Strength 75% of normal side
21 Challenges Avoiding articular surfaces Avoiding impingement of fossae Capturing multiple small fragments Cancellous bone Achieving stable fixation to allow early ROM Osteoporotic bone ORIF Distal Humerus
22 Posterior Approach to the elbow Position lateral, or partial lateral Arm across body, or with sterile bolster Tourniquet applied high Incision: straight posterior, or slightly medial, curving around medial side of olecranon tip up midline of arm ORIF Distal Humerus
23 Posterior Approach Cont d Dissection consists of exposing the triceps fascia Identifying and the ulnar nerve on medial side +/- transposition depending on # To get to the joint a triceps split or an olecranon osteotomy Studies show no difference in muscle strength post-op ORIF Distal Humerus
24 ORIF Distal Humerus Posterior Approach Cont d Pre-drill and tap olecranon Create cevron apex distal Protect the articular surface by going through the last milimeter with an osteotome Aim for the bare patch at the apex of the trochlear notch
25 ORIF Distal Humerus Posterior Approach Cont d Pre-drill and tap olecranon Create cevron apex distal Protect the articular surface by going through the last milimeter with an osteotome Aim for the bare patch at the apex of the trochlear notch
26 ORIF Distal Humerus Postero-lateral Approach Used for isolated lateral column fractures Position Supine with arm across chest Incision: curved from lateral epicondylar ridge to lateral border of ulnar Internervous Plane: Anconeus and ECU supplied via radial and PIN respectively Superficial dissection: incise deep fascia in line with skin incision to find ECU and Anconeus. They share common origin
27 Deep dissection: pronate forearm to move PIN away. Find Supinator at the deep part of the incision and strip if off as necessary from epicondyle ORIF Distal Humerus
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