Distal Humerus Fractures

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Distal 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 - PowerPoint PPT Presentation

Text of Distal Humerus Fractures

Distal Humerus ORIF

Distal Humerus FracturesOutlineDistal HumerusPreop PlanningSurgical Technique

Olecranon

DemographicsDistal humerus Fxs2-3% of all fxs

2 groupsHigh energy in youngLow energy in elderly

AnatomyHinged joint with single axis of rotation

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

Skeletal Trauma, 3rd editionAnatomyMedial and lateral columns form triangle with trochlea

Medial column diverges 45 deg

Lat column 20 deg

Skeletal Trauma, 3rd editionAnatomyThe distal humerus angles forward

Lateral or prone positioning during ORIF facilitates reconstruction of this angle

Slide courtesy of Stephany & Schmeling; OTA Resident LibraryFracture PatternFracture pattern determined by load direction and position of elbow

Skeletal Trauma, 3rd editionClassificationExtraarticular (A)

Partial Articular (B)

Complete Articular (C)

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

Stable internal fixation

Preservation of blood supply

Early ROM

Avoidance of complicationsPre-op PlanningIntraarticular vs ExtraarticularTriceps splitting or sparingOlecranon osteotomy

Age and function of patientORIFTEABag of BonesTriceps SplittingBest for extraarticular fxs

No worse than olecranon osteotomy for strength or outcome

McKee et al JBJS-Am 2000; 82: 1701-1707Triceps SparingBryan-MorreyApproach started medially, reflecting triceps off olecranon

Anconeus reflected with flap as it is brought lateral

Triceps-Reflecting Anconeus Pedicle (TRAP)ODriscollModified Kocher and Bryan-MorreyAnconeus preservedReflect Anconeus and Triceps proximally as you would osteotomyExtreme flexion needed to see anterior articular surface

AnconeusFCUExtraarticular osteotomyGood for low extraarticular fxs or simple intraarticular fxs

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

Anglen JAAOS 2005; 13, 291-7Intraarticular OsteotomyChevron osteotomy

Apex distal

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

Jupiter Master TechniquesIntraarticular OsteotomyPlace Joker or gauze in joint

Bare spot, just proximal to coronoid

Complete osteotomy with osteotome

Jupiter Master TechniquesIntraarticular OsteotomyTriceps reflected

Place olecranon and muscle in moist gauze

Dont forget the radial nerve!

Jupiter Master TechniquesSteps to fixationArticular reduction first

Dont lag trochlea if comminution present

Fix articular surface to columns, columns to shaft

Jupiter Master TechniquesFixation90-90

180 or med/lat2 plates dorsalLocked vs. non-lockedKorner 2004Locked or not, dorsal plates failed vs. 90-90

Plate configuration more important than locking technology

Korner J Orthop Trauma 2004;18:28629390-90 vs 180Jacobsen 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 plateRepair osteotomyK-wires and tension band

6.5 screw w/ washer and tension band

Parallel small frag screws (lag techique)

Jupiter Master TechniquesComplications of Repair OsteotomyColes 200670 ptsIM screw and tension band30% HWR, 8% due to SxRing 200445 ptsK-wires and tension band27% HWR, 13% due to Sx

Ulnar Nerve Transposition?Routine transpositionPlenty of level 5 evidenceDont have to worry about it if you go backStrip blood supplyMay do worse?Post-opSoft dressing vs. splint at 90 vs splint in extension

Early ROM (AROM/AAROM)

Consider NSAIDs for thermal and head injuries (4% HO), but risking nonunionOutcomesMost daily activities can be accomplished:30 130 degrees extension-flexion50 50 degrees pronation-supination

Good functional outcome15-140 degrees of motion

75% strength to contralateral arm, regardless of approach (osteotomy vs triceps-splitting)Slide courtesy of Stephany & Schmeling; OTA Resident LibraryMcKee et al JBJS-Am 2000; 82: 1701-1707ComplicationsNon-union of olecranon osteotomy5% or moreChevron osteotomy has a lower rateBone graft and revision tension band techniqueExcision of proximal fragment is salvage50% of olecranon must remain for joint stabilitySlide courtesy of Stephany & Schmeling; OTA Resident LibraryComplicationsInfectionRange 0-6% Highest for open fracturesNo style of fixation has a higher rate than any otherSlide courtesy of Stephany & Schmeling; OTA Resident LibraryComplicationsUlnar nerve palsy8-20% incidenceReasons: operative manipulation, hardware prominence, inadequate releaseResults of neurolysis (McKee, et al)1 excellent result17 good results2 poor results (secondary to failure of reconstruction)Prevention best treatment

Slide courtesy of Stephany & Schmeling; OTA Resident LibraryPearlsLearn 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 platesCase DM34 yo M fell 15 feet from roof

Open wound posterior distal L arm

NVI