DISTAL HUMERUS FRACTURE-TREATMENT

PRESENTOR - DR. REJUL K RAJMODERATOR – DR. RITESH PANDEYDEPT OF ORTHOPAEDICS, CMCH LUDHIANA

OBJECTIVES

• Patho anatomy – Revision.

• Surgical approaches – Discuss

• Surgical techniques - Discuss

• Total Elbow Arthropasty - Introduce

• Complications - Enumerate

• Controversies – Enumerate

• Evidence - Review

REFERENCES

1. Rockwood and Green’s- Fractures in adults – 8th

Edition

2. Campbell’s Operative orthopaedics – 12 edition.

3. AO Principles of Fractures- 2000.

4. Schatzker · Tile The Rationale of Operative Fracture Care – 3rd edition

5. AO surgery reference

DEFINITON

PATHO ANATOMY

1. Trocho- ginglymoid joint – rotatory + hinge

2. Triangular cross section

3. Apex is directed anteriorly

4. Shaft diverges in to 2 cortical columns

5. Medial column – 45 degrees- coronal plane

6. Lateral column - 20 degrees- coronal plane

7. 35 TO 40 DEGREES ANTERIOR ANGULATION- SAGITTAL PLANE. -The medial epicondyle remains on the axis of the shaft - The lateral epicondyle follows the capitellum into flexion.

8. 4-8 DEGREES VALGUS TO THE SHAFT OF HUMERUS

9. 3 TO 8 DEGREES- INTERNAL ROTATION

10.Posterior aspect of lateral column is flat

– Well suited for plate application

12. LATERAL COLLATERAL LIGAMENT COMPLEX

• Restraint to Varus and PLRI

• 3 components1. RCL – isometric point

to AL

2. LUCL – isometeric point to proximal ulna

3. AL – anterior and posterior margins of the lesser sigmoid

13. MEDIAL COLLATERAL LIGAMENT

• Restraint to valgus and PMRI

• 3 components

1. Anterior bundle • Prime importance

• Medial epicondyle to coronoid.

2. Posterior bundle

3. Transverse ligament

14. PERIPHERAL NERVES1. ULNAR

– Medial head of triceps– Behind the medial condyle– Travels between the 2 heads of FCU

2. RADIAL – 20 cm – 74 % length – Enter– 14 cm – 51 % length - Exits– 10 cm – 36 % length – Lateral Inter muscular septum

3. MEDIAN – With brachial artery between biceps and brachialis– Anteromedial aspect of the arm– Under the bicipital aponeurosis

14. VASCULAR SUPPLY

TREATMENT OPTIONS

1. Non operative

2. Open reduction internal fixation

3. Total elbow arthroplasty

4. Hemi arthroplasty

1. NON OPERATIVE

• Rarely recommended in young

• Medically unfit patients

• Weekly radiographs fore 3-4 weeks.

• Above elbow casting

• Olecranon traction – Historical

• Collar and cuff method – ”Bag of bones”

Collar and cuff method

• Closed reduction

• Followed by elbow in 90-120 degrees of flexion.

• Elbow is hung freely

• To allow gravity assisted reduction.

• ROM exercises at 2 weeks.

2. OPEN REDUCTION + FIXATION

• Gold standard– Enhances the stability

– Immediate ROM

• Relative contraindications/ cant be attained.– Osteopenia

– Comminution

– Articular fragmentation

– Pre existing diseases .eg : RA

TIMING OF SURGERY

• 48 – 72 hours.

• If in case its being delayed for weeks– Well padded splints– Static external fixator

• With in 2- 3 weeks.– Increased surgical time– Difficult reduction– Increased bleeding– Increased HO

POSITIONING

APPROACHES1. POSTERIOR2. ANTERIOR3. LATERAL4. MEDIAL

• Sufficient exposure to allow anatomic reduction.

• Application of required internal fixation

• Minimal soft tissue or bony disruption

• Early mobilization

I. POSTERIOR APPROACH

• 3 types

1. Olecranon osteotomy

2. Triceps on / Paratricipital

3. Triceps off – Triceps splitting– Triceps reflecting/TRAP– Triceps tongue

1. OLECRANON OSTEOTOMY

LONGITUDINAL POSTERIOR SKIN INCISIONS ULNAR NERVE IS EXPOSED

APEX DISTAL CHEVRON OSTEOTOMYSAW IS USED FOR 2/3 rd

OSTEOTOMES- CONTROLLED LEVERAGE

FRACTURE IS EXPOSED PROVISIONAL FIXATION – CROSSED K WIRES

OLECRANON OSTEOTOMY

• Best visualization of the distal humerus articular surface

• Indications - Type C fractures

• Relative contra indications

– Very anterior articular fractures- B 3

– TEA

• Disadvantages

– Non union

– Mal union

– Hardware irritation

(a-c) Intrarticular chevron olecranon osteotomy, (d-f) Extraarticular olecranon osteotomy

2. TRICEPS ON / PARA TRICIPITAL APPROACH

• With out disrupting the triceps insertion.

• Windows along the medial and lateral side of the triceps

• Extensile posterior incision and ulnar nerve mobilization.

TRICEPS -ON / PARA TRICIPITAL APPROACH

• Advantages

– No osteotomy

– Triceps tendon insertion is not disrupted

• Early ROM

– Preserves the blood supply to Anconeus

• Dynamic Posterolateral stability

– Can be converted to Olecranon Osteotomy, Gerwinapproach etc

– Can proceed directly to TEA

3. TRICEPS SPLITTING APPROACH

• Campbell

• Mid line split through the triceps tendon.

CONCLUSION -TRICEPS TENDON IS REPAIRED TO THE OLECRANON – TRANS OSSEUOS SUTURES

TRICEPS SPITTING APPROACH

• Advantages

– Technical ease

– Ability to convert ORIF to TEA

• Disadvantages

– Limited visibility

– Post operative protection of triceps

4. TRICEPS REFLECTING ANCONEUS PEDICLE (TRAP) APPROACH

• O’Driscoll

• Completely detaching triceps with the anconeus muscle.

• Longitudinal posterior skin incision

• Identification of ulnar nerve

The interval between anconeus and extensor carpi ulnaris is used to elevate the anconeusmuscle and develop the distal lateral portion of the flap. The anconeus flap is then reflected proximally (A) to expose the triceps insertion which is a sharply released (B).

TRAP APPROACH

• The entire triceps–anconeus

flap

• is then reflected proximally releasing the triceps muscle

• from the posterior aspect of the distal humerus

4. TRAP APPROACH

• Advantages

– Good exposure to the posterior elbow joint

– Avoid complications of osteotomy

• Disadavntages

– Triceps is completely released

• Triceps dehiscence

• Extensor weakness

5. LATERAL / KOCHER’S APPROACH

• Direct lateral skin incision

• Interval between ECU and anconeus

• By the thin fat stripe or perforating branches of the recurrent posterior interosseous artery.

• Fore arm pronated– PIN – more anterior and distal

(A). The interval can be identified by a thin fat stripe (black arrow).The interval is developed by bluntly undermining the anconeusmuscle, identification of,

•the elbow joint capsule and •lateral ulnar collateral ligament (LUCL)

The posterior portion of the common extensor tendon origin will have to be elevated off the LUCL to allow an arthrotomy to be made anterior to the ligament (D).

TECHNIQUE

CHOICE OF IMPLANT

• Type A:

– 3.5 or 4.0 mm screws are more reliable than K-wires.

• Type B:

– For simple isolated lateral column injuries, single plate may be used or screws alone

• Type C:

– Two plates are needed for adequate strength.

– Increased by placing them at right angels to each other.

– For firm fixation, the lateral plate should reach down to the joint line.

– Plate bending and twisting equipment.

• A DCP 3.5 or reconstruction plate 3.5 must be used. – The medial plate - supracondylar crest.

• One-third - tubular plates- may be used but are not recommended

• Reconstruction plates 3.5 are preferable.

• For the capitellum, – fully threaded cancellous bone screws

– through the radial plate

A. Olecranon osteotomyB. K wire used as joy sticks to manipulate the fracture fragments

C. Stabilize the reductionD. K wires are drilled in to the opposite fragment

E. A small diametre screw is inserted from medial to lateral

F. The fixed articular segment is reduced to the shaft and provisionally stablized with k wires in each column

G. Screws are inserted through the plate in to the articular segment

H. The screws should be as long as possible should engage as many as fragments as possible.

1. K wire – provisional fixation

2,3. 3.5 mm cancellous screws

4,5. 3.5 mm DCP

6,7. first 2 screws forinterfragmental compression

8,9 Next 2 screws for interfragmentary compression

EADHP-Extra articlar distal humerus plate

A. 1/3 Semi tubular plates

B. 3.5 mm DCP

C. 3.5 mm Reconstruction plate

D. 1/3 Semi tubular +Reconsruction plate +Lag screws

•Type C 3 fracture

•Triple plating.

•1year follow up.

•Type C 1 fracture

•Olecranon osteotomy

•Parallel plating•Medial and lateral screws inthe articular surface.

•Distal humerus with ipsilateral humeral shaft fracture•Orthogonal 3.5 mm DCP – intra operatively countured•Lateral plate – Posterior as pect of the lateral column as distal as possible•Medial plate – Medial supra condylar ridge

TOTAL ELBOW ARTHROPLASTY

• Indications –– When ORIF is not attainable in elderly due to

osteopenia, comminution, articular fragmentation or pre existing conditions.

• Contraindications– Active infection

– Insufficient soft tissue coverage

– Younger active patient

79 year old with medial column fracture

BRYAN MORREY APPROACH

DETACHES TRICEPS TENDON IN CONTINUITY WITH ULNAR PERIOSTEUM AND ANCONEUS

HEMIARTHROPLASTY

• Indications.

• Advantages –

– Absence of Polyethylene wear debris / Osteolysis/ Aseptic loosening

• No literature evidence.

COMPLICATIONS

• Non union

• Elbow stiffness

• Heterotopic ossification.

• Wound complications

• Infections

• Ulnar neuropathy.

• Olecranon osteotomy

• TEA - Complications.

CONTROVERSIES

1. Surgical approach

2. Type of olecranon osteotomy

3. Method of stabilization of osteotomy

4. Orthogonal vs parallel plate fixation,

5. Need for transposition of ulnar nerve,

6. Place for primary total elbow replacement

7. Type of rehabilitation schedule

Controversies in the management of intra-articular fractures of distal humerus in adults

Sudhir Babhulkar, Sushrut Babhulkar1

Indian Journal of Orthopaedics | May 2011 | Vol. 45 | Issue 3

• The high rate of union - complex intra-articular fractures,

1. A posterior transolecranon approach .

2. Dual fixation of both columns.

3. Restoration of the continuity of articular surface.

4. Early intensive physiotherapy to restore elbow function.

THANK YOU