Demographics Distal humerus Fxs 2-3% of all fxs 2 groups High
energy in young Low energy in elderly
Slide 4
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
Slide 5
Anatomy Medial and lateral columns form triangle with trochlea
Medial column diverges 45 deg Lat column 20 deg Skeletal Trauma, 3
rd edition
Slide 6
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
Slide 7
Fracture Pattern Fracture pattern determined by load direction
and position of elbow Skeletal Trauma, 3 rd edition
Slide 8
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.)
Slide 9
Treatment Principles Anatomic articular reduction Stable
internal fixation Preservation of blood supply Early ROM Avoidance
of complications
Slide 10
Pre-op Planning Intraarticular vs Extraarticular Triceps
splitting or sparing Olecranon osteotomy Age and function of
patient ORIF TEA Bag of Bones
Slide 11
Triceps Splitting Best for extraarticular fxs No worse than
olecranon osteotomy for strength or outcome McKee et al JBJS-Am
2000; 82: 1701-1707
Slide 12
Triceps Sparing Bryan-Morrey Approach started medially,
reflecting triceps off olecranon Anconeus reflected with flap as it
is brought lateral
Slide 13
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
Slide 14
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
Slide 15
Intraarticular Osteotomy Chevron osteotomy Apex distal
Pre-drill for fixation of osteotomy (if using screw) Jupiter Master
Techniques
Slide 16
Intraarticular Osteotomy Place Joker or gauze in joint Bare
spot, just proximal to coronoid Complete osteotomy with osteotome
Jupiter Master Techniques
Slide 17
Intraarticular Osteotomy Triceps reflected Place olecranon and
muscle in moist gauze Dont forget the radial nerve! Jupiter Master
Techniques
Slide 18
Steps to fixation Articular reduction first Dont lag trochlea
if comminution present Fix articular surface to columns, columns to
shaft Jupiter Master Techniques
Slide 19
Fixation 90-90 180 or med/lat 2 plates dorsal
Slide 20
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
Slide 21
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
Slide 22
Repair osteotomy K-wires and tension band 6.5 screw w/ washer
and tension band Parallel small frag screws (lag techique) Jupiter
Master Techniques
Slide 23
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
Slide 24
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?
Slide 25
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
Slide 26
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
Slide 27
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
Slide 28
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
Slide 29
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
Slide 30
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
Slide 31
Case DM 34 yo M fell 15 feet from roof Open wound posterior
distal L arm NVI