DISTAL HUMERUS

FRACTURES WHEN TO DO

OLECRANON OSTEOTOMY

Steven A. Chandler D.O. FAOAO Associate Clinical Professor Midwestern University

South Chicago Orthopedic Specialists, S.C.

2315 E. 93rd St., Suite 200

Chicago, Illinois 60617

(872) 228-0235

Distal Humerus Fractures

Incidence and Distribution Overall incidence in adults is small,

Distal Humerus Fractures

Anatomy

The distal humerus is widest distally in the coronal dimension to a maximum between the medial and lateral epicondyle

The joint surface to shaft axis is 4 to 8 degrees of valgus, giving rise to the carrying angle

The articular segment projects anterior to the axis of the shaft at an angle of 400

(the capitellum slightly more forward then the trochlea)

Distal Humerus Fractures

Anatomy

Medial and lateral columns, roughly triangular composed of an epicondyle (non articulating) and condyle (articulating)

Displacement of condylar fragment is common due to absence of muscle attachment to oppose those attached to the epicondyles

The medial epicondyle is closely related to the ulnar nerve and is the site of attachment of the ulnar collateral ligaments. This being the strongest ligament of the elbow

Distal Humerus Fractures

AO Classification

AO Classification

Type A: Extraarticular Fx

A1: apophyseal avulsion

A2: metaphyseal simple

A3: metaphyseal multifragmentary

Type B: Partially articular, part

of the articular segment remains

in congruity with the shaft

B1: lateral sagittal

B2: medial sagittal

B3: frontal

Distal Humerus Fractures

AO Classification AO Classification

Type C: Complete articular, no articular fracture fragment

remains in congruity with the shaft

C1: articular simple, metaphyseal simple

C2: articular simple, metaphyseal multifragmented

C3: articular and metaphyseal multifragmented

Distal Humerus Fractures

Mechanism and Assessment Mechanism of Injury:

axial load through the elbow with the joint flexed beyond 90 degrees or direct trauma

Clinical Assessment: Careful physical and neurovascular exam is

imperative checking for open wounds, neurological and arterial injuries

Plain x-ray: A/P and Lateral while maintaining gentle longitudinal traction

Stress x-rays can help assess ligamentus stability

CT Scan to evaluate articular comminution

Distal Humerus Fractures

Treatment based on AO Classification

Nonoperative Treatment Nondisplaced distal humeral fractures

Patients who can’t tolerate anesthesia, advanced dementia

Traction with conversion to cast, functional brace, or hinged brace when fracture is “sticky” controlled motion is started

Outcomes of modern operative fixation is indicated in most cases

Other Methods: “Bag of bones” arm is placed in a collar and cuff with as much flexion as possible, elbow is left hanging free allowing gravity to exert a ligamentotaxis effect

Distal Humerus Fractures Operative

Treatment based on AO Classification

Evidence supports Operative Treatment in patients who can tolerate anesthesia with early ROM if appropriate

Displaced distal humerus fractures Exceptions:

Frail or debilitated individuals, Open wounds/degloving injury, Blast or open crush injury, Extreme osteoporosis

Intra-articular fractures

Distal Humerus Fractures Operative

Treatment based on AO Classification

Controversy in approach: Triceps splitting,

Triceps reflecting, Triceps reflecting with anconeus pedicle, Triceps sparing with and without olecranon osteotomy

Insufficient evidence to recommend or against ulnar nerve transposition

Speaker preference: Triceps sparing or

reflecting for extra-articular or simple intra-articular fractures

Olecranon osteotomy for comminuted/complex intra-articular fractures

No ulnar nerve transposition

Distal Humerus Fractures Operative

Treatment based on AO Classification

A. Triceps splitting,

B. Triceps reflecting with anconeus pedicle

C. Triceps reflecting

D. Triceps sparing with & w/o olecranon osteotomy

Distal Humerus Fractures Operative

Treatment based on AO Classification

Triceps sparing: Avoids extensor

violation

Utilizes medial and lateral windows on triceps

Good for extra-articular fractures and C-1, 2 types

Disadvantage poor visualization of articular surface Can be converted to

olecranon osteotomy or TEA

Distal Humerus Fractures Operative

Treatment based on AO Classification

Triceps splitting Midline incision

leaves triceps tendon intact with extensor/flexor fascia

Triceps repaired transosseous to olecranon; functional studies equivalent to osteotomy

Distal Humerus Fractures Operative

Treatment based on AO Classification

Olecranon osteotomy: Chervon osteotomy

2.5-3 cm from olecranon tip

Oscillating saw finished with osteotomy

Osteotomy fixated with either tension band, intermedullary screw, plate, or IM nail

Distal Humerus Fractures Operative

Treatment based on AO Classification

Olecranon

osteotomy:

Superior

visualization of

articular surface

Retrospective

Studies show no

functional difference

with triceps splitting

Distal Humerus Fractures Operative

Treatment based on AO Classification

Olecranon

osteotomy:

6-30% hardware

removal

0-9% nonunion

rates

Distal Humerus Fractures Operative

Treatment based on AO Classification

Plate fixation: Since 1970 AO introduction of dual column fixation substantial improvement in surgical outcomes Anatomic articular

reduction, Rigid fixation with 2 plates, 3.5 mm minimum

In cases of severe comminution of metaphysis or substantial bone loss Treat with

shortening but maintain alignment

Distal Humerus Fractures Operative

Treatment based on AO Classification

Debate on location of plate placement Perpendicular or

parallel to each other

Most studies show no significant difference in functional outcomes

Parallel plates had slight higher nonunion rate but stronger with metaphyseal comminution

Distal Humerus Fractures Operative

Treatment based on AO Classification

Use of locked

plating has been

controversial

proven superior in

osteoporotic bone

and comminuted

fractures

No data to go

against locked

plating

Distal Humerus Fractures Operative

Treatment based on AO Classification

Coronal Shear fracture OTA/AO type B3

Uncommon, involves capitellum , trochlea or both

Usually associated with elbow dislocation

Often missed on plain x-rays 66% sensitivity, CT recommended

Distal Humerus Fractures

Capitellum Fractures

Classification Type I: Hahn-Steinthal

Fragment. Large osseous component of capitellum, sometimes with trochlear involvement

Type II: Kocher-Lorenz Fragment. Articular cartilage with minimal subcondylar bone attachment “ uncapping of the condyle”

Type III: markedly comminuted

Distal Humerus Fractures

Capitellum Fractures, Treatment Nonoperative Treatment

Primarily for nondisplaced fx Posterior splint immobilization for 3 weeks

Operative Treatment Goal is anatomic reduction ORIF

Indicated for displaced type I fractures Screws placed via lateral approach or posterior with olecranon

osteotomy for trochlea component or medial comminution, headless screws may be placed anterior to posterior direction, plate added to lateral column for comminution

Fixation should be stable enough to allow early ROM Excision

Contraindicated in the presence of associated elbow fractures Allows for early mobilization and less morbidity but associated

with instability Recommended treatment in old missed fractures with limited

ROM

Distal Humerus Fractures

Capitellum Fractures, Complications

Complications Osteonecrosis; uncommon

Posttraumatic arthritis: increased with failure to restore articular congruity

Cubitus valgus: may result with excision of the articular fragment or with associated lateral condylar or radial head fx. It is associated with tardy ulnar palsy

Loss of motion (flexion): associated with retained chondral or osseous fragment that may become entrapped in the coronoid or radial fossae

Distal Humerus Fractures Operative

Treatment

Total Elbow Arthroplasty (TEA) Reserved for elderly

patients with poor bone quality, low physical demands not amenable to ORIF

Good/excellent results compared to ORIF in elderly as primary treatment

Distal Humerus Fractures Operative

Treatment

Total Elbow

Arthroplasty (TEA)

Higher rate of

infection, nerve

injury, implant

failure

Olecranon

Osteotomy

contraindicated

Distal Humerus Fractures,

Complications

Ulnar nerve injury Due to initial

trauma or operative treatment

Transposition not proven to beneficial even when nerve is out preoperatively

Decompression recommended when nerve is out preop

Heterotopic Ossification (HO)

After operative fixation

Limits ROM

Prophylactic treatment indications are controversial

Use of indomethacin didn’t significantly reduce HO

When prophylaxis used 0-21% clinically significant HO

Distal Humerus Fractures, Complications

Heterotopic

Ossification (HO)

1 dose post op

radiation and 2 weeks

indomethacin

treatment 3% rate

clinically significant

HO

Benefits weighted

against risks of union

with prophylactic

treatment

Heterotopic

Ossification (HO)

Risk factors: CNS

injury, delay in

operative treatment,

sx prior to definitive

treatment

Distal Humerus Fractures, Complications

Modern dual plate

fixation 89-100%

union rates

Failing to adhere to

these principles

increase nonunion

rates

Nonunion treated with

revision ORIF, bone

grafting, selective

releases

Mean flex-ext arc

ROM 99°-112°

Recommended start

ROM at 2 weeks

Functional outcomes

after ORIF 84-100%

good/excellent

Regain 70-75%

strength compared

to contra lateral side

DJ 2018 - OleON PPT

Tension Band w/ K-Wires

6.5 Cancellous Screw w/ Tension Band

Lag Screw w/ Tension Band

Plate Fixation

Current AO product options:

Distal Humerus Fractures Fixation

Options of Olecranon Osteotomies

DJ 2018 - OleON PPT

Clinical needs:

– Improved method to maintain reduction of olecranon osteotomy

– Intermedullary solution for fixation of an olecranon osteotomy

Indications: The Olecranon Osteotomy Nail is indicated to treat osteotomies of the

olecranon

and simple olecranon fractures.

The Olecranon Osteotomy Nail

Overview

DJ 2018 - OleON PPT

Main features and Benefits :

Pre-osteotomy fixation ensuring anatomic alignment

Simpler fixation of olecranon osteotomy than current

commonly used techniques after distal humerus

surgery

Simple instrumentation for easy insertion and locking

of nail

Low profile minimizing soft tissue irritation and re-

operation

More stable fixation than current methods*

Targeted locking to minimize size of incision

* Mechanical testing on file at Synthes

The Olecranon Osteotomy Nail

Overview

Overall

Decision making made on most recent literature

Best available treatment option

Surgeon preference and comfort

Informed decision with patient

Need for prospective, multicenter, large scale study

Use sound surgical

techinque and use

AO fixation

prinicles.

Distal Humerus Fractures

References

Fractures in Adults, Rockwood and Wilkins. Lippincott William & Wilkins, 2005. 6th Edition

Handbook of Fractures, Koval and Zuckerman, Lippincott William & Wilkins, 2002. 2nd Edition

Campbell’s Operative Orthopaedics, Mosby, tenth edition

Chapman's Orthopaedic Surgery, 3rd Edition, Lippincott Williams & Wilkins .

Distal Humerus Fractures

References Current Concepts Review: Distal humerus Fractures in

Adults, A. Nauth MD, M. Mckee MD, B. Ristevski MD; JBJS; 2011, vol. 93-A no. 7, 4-6-2011

The olecranon osteotomy: a six-year experience in the treatment of intraarticular fractures of the distal humerus. Coles CP, Barei DP, Nork SE, Taitsman LA, Hanel DP, Bradford Henley M. J Orthop Trauma. 2006 Mar;20(3):164-71.

A true triceps-splitting approach for treatment of distal humerus fractures: a preliminary report. Ziran BH, Smith WR, Balk ML, Manning CM, Agudelo JF. J Trauma. 2005 Jan;58(1):70-5.

Distal Humeral Hemiarthroplasty vs Total Elbow Arthroplasty for Acute Distal Humeral Fractures, R. Rangarajan MD, R. Papandrea MD, A. Cil MD, Orthopedics Jan/Feb vol.40, no. 1:13-23

http://www.ncbi.nlm.nih.gov/pubmed?term="Coles CP"[Author]http://www.ncbi.nlm.nih.gov/pubmed?term="Barei DP"[Author]http://www.ncbi.nlm.nih.gov/pubmed?term="Barei DP"[Author]http://www.ncbi.nlm.nih.gov/pubmed?term="Barei DP"[Author]http://www.ncbi.nlm.nih.gov/pubmed?term="Nork SE"[Author]http://www.ncbi.nlm.nih.gov/pubmed?term="Nork SE"[Author]http://www.ncbi.nlm.nih.gov/pubmed?term="Nork SE"[Author]http://www.ncbi.nlm.nih.gov/pubmed?term="Taitsman LA"[Author]http://www.ncbi.nlm.nih.gov/pubmed?term="Taitsman LA"[Author]http://www.ncbi.nlm.nih.gov/pubmed?term="Taitsman LA"[Author]http://www.ncbi.nlm.nih.gov/pubmed?term="Hanel DP"[Author]http://www.ncbi.nlm.nih.gov/pubmed?term="Hanel DP"[Author]http://www.ncbi.nlm.nih.gov/pubmed?term="Hanel DP"[Author]http://www.ncbi.nlm.nih.gov/pubmed?term="Bradford Henley M"[Author]http://www.ncbi.nlm.nih.gov/pubmed?term="Ziran BH"[Author]http://www.ncbi.nlm.nih.gov/pubmed?term="Ziran BH"[Author]http://www.ncbi.nlm.nih.gov/pubmed?term="Ziran BH"[Author]http://www.ncbi.nlm.nih.gov/pubmed?term="Smith WR"[Author]http://www.ncbi.nlm.nih.gov/pubmed?term="Smith WR"[Author]http://www.ncbi.nlm.nih.gov/pubmed?term="Balk ML"[Author]http://www.ncbi.nlm.nih.gov/pubmed?term="Manning CM"[Author]http://www.ncbi.nlm.nih.gov/pubmed?term="Agudelo JF"[Author]http://www.ncbi.nlm.nih.gov/pubmed?term="Agudelo JF"[Author]http://www.ncbi.nlm.nih.gov/pubmed?term="Agudelo JF"[Author]

Extra Articular fracture Distal Humerus fx

in 67 y.o. F after someone tried to steal her

purse.

S/P ORIF Extra Articular fracture with

triceps reflecting

24 y.o. male GSW

Under went ORIF triceps reflecting

approach

23 y.o. running from police for no

reason…?

S/P ORIF with 90-90 plating with

olecranon osteotomy

21 y.o. S/P GSW

S/P ORIF with Triceps sparing

approach

2 weeks post op

89 Y.O. S/P Mechanical fail

S/P ORIF triceps reflecting

approach

26 y.o. s/p GSW

S/P ORIF

47 y.o. MCC Polytrauma patient,

multiple visceral, CH injuries.

S/P ORIF with Triceps sparing

approach

77 y.o. obese F S/P mechanical fail

Same patient same arm

S/P ORIF with 90-90 plating and

olecranon osteotomy

S/P ORIF with 90-90 plating and

olecranon osteotomy

S/P ORIF Distal raduis

DJ 2018 - OleON PPT

Review 8/15/08

Comminuted distal humerus fx

The Olecranon Osteotomy Nail

DJ 2018 - OleON PPT

Case Review 8/15/08

S/P ORIF 90-90 plating, with olecranon osteotomy and

olecranon IMN

The Olecranon Osteotomy Nail