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Distal humerus frakturer Eythór Jónsson Ortoped Övre extremitetsteamet, Sahlgrenska

Distal humerus frakturer

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Ortopedidagen 2018 Distal humerus frakturer_EJ• 1/3 är C-frakturer enligt AO (många bitar!)
• Sverige: 300-400 C-frakturer/år
Fall
54 årig man Vurpade på cykeln Öppen fraktur på distala humerus
Innan ”brukbar” operativ behandling -(halv-användbara tekniker börjar komma på 80/90-talet)
Icke-operativ behandling • Långa gipstider, mer än 6 veckor! Risk för dålig funktion • Stelhet • Non-union • Smärta
”Further trauma [operative treatment] can only be justified if stable fixation/early motion can be obtained” 80 talets slutsats!
ETT RÖRBEN HAR 3 DELAR
DIAPHYS
METAPHYS
EPIPHYS
DIAPHYS -3 MÅNADER+
METAPHYS -6 VECKOR
EPIPHYS – MOTSVARAR INTRAARTKIULÄRT FRAKTURLÄGE SOM ÄR ETT BEGREPP SOM ANVÄNDS I KLINISK VARDAG. BENVÄVNADEN HAR SAMMA EGENSKAPER SOM METAPHYSEN
VARFÖR FINNS SKILLNAD I LÄKNINGSTID?
BIOLOGISK AKTIVITET
Non-union (icke-läkning)
DIAPHYSÄRA FRAKTURER HAR STÖRRE RISK ATT GÅ TILL ICKE-LÄKNING ÄN METAPHYSÄRA!
DEFINITION: A. INTE LÄKT INOM 6
MÅNADER B. INTE LÄKT INOM
FÖRVÄNTAT TID
Fracture forces
Gips behandling inte bra Dåligt intern fixation inte bra
O’Driscoll 2000 Acumed precontoured ”antomical plates” Parallell plating
Operativ behandling – första val 1. Plattfixation enligt O’Driscoll • Vanligaste behandlingen • Ibland med osteotomi
4. Capitellum frakturer (”coronal shear”) • Ledbanden kan vara instabila (skada/kirurg)
3. Icke-operativ behandling • Äldre patienter med väldigt låga funktionskrav
2. Väldigt komminuta (mosade) frakturer • Plattfixation: ”Yngre patienter” 60 år? • Halvprotes: ”High demand” äldre patienter • Totalprotes: ”Low demand” äldre patienter
Plattfixation
traction injuries to the nerve. If the lateral border needs to be extended proximally the radial nerve can be identified and protected. The nerve is typi- cally located approximately at the level of the prox- imal end of the tendinous portion of the triceps.
The distal exposure achieved with this approach is limited, so it is not suitable for complex intra- articular distal humerus fractures.
Posterior triceps-splitting approaches The triceps tendon and muscle are incised at its midline exposing the humerus and dissecting each half of the triceps toeither side (Fig.7).8,9 Ulnar nerve identification and protection is advised. Distally, the incision runs over the olecranon and separates the anconeus laterally and the FCU medially. Access to the posterior and posterolateral aspect of the hu- merus is readily available but positioning of true lateral plates can be cumbersome. Meticulous closure of the triceps with side-to-side sutures and additional transosseous sutures at the level of the olecranon is recommended.
Olecranon osteotomy This is probably the most used approach to treat distal humerus fractures because it provides great access to the articular surface and the
supracondylar columns (Fig. 8). The chevron os- teotomy is favored over transverse osteotomy because of added intrinsic stability.
After the olecranon is identified, the ulnar nerve should be located and protected. The ulnohumeral joint is opened laterally to the olecranon and protected with a sponge when performing the osteotomy.
A distal chevron is made at the level of the bare spot of the greater sigmoid notch of the ulna. The cut is started with a saw and finished with an os- teotome. The proximal olecranon and tendon are retracted proximally and separated from capsular attachments and collateral ligaments. The dissec- tion can be carried out proximally as in a bilatero- tricipital approach. At the end of the procedure the olecranon is reduced and fixed with a cerclage and K-wires, a lag screw, an intramedullary nail, or a plate.
To avoid denervation of the anconeus, some au- thors favor dissecting the anconeus distally, re- flecting it from the ulna without detaching it from the triceps to preserve its innervation.10
Bryan-Morrey approach A posterior skin incision is performed just slightly lateral to the tip of the olecranon. After elevating
Fig. 6. The Alonso-Llames approach allows access to the posterior part of the elbow joint without triceps detachment.
Anatomy and Exposures in Elbow Trauma 513
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Immobilisering - rehabilitering
Plattfixation
traction injuries to the nerve. If the lateral border needs to be extended proximally the radial nerve can be identified and protected. The nerve is typi- cally located approximately at the level of the prox- imal end of the tendinous portion of the triceps.
The distal exposure achieved with this approach is limited, so it is not suitable for complex intra- articular distal humerus fractures.
Posterior triceps-splitting approaches The triceps tendon and muscle are incised at its midline exposing the humerus and dissecting each half of the triceps toeither side (Fig.7).8,9 Ulnar nerve identification and protection is advised. Distally, the incision runs over the olecranon and separates the anconeus laterally and the FCU medially. Access to the posterior and posterolateral aspect of the hu- merus is readily available but positioning of true lateral plates can be cumbersome. Meticulous closure of the triceps with side-to-side sutures and additional transosseous sutures at the level of the olecranon is recommended.
Olecranon osteotomy This is probably the most used approach to treat distal humerus fractures because it provides great access to the articular surface and the
supracondylar columns (Fig. 8). The chevron os- teotomy is favored over transverse osteotomy because of added intrinsic stability.
After the olecranon is identified, the ulnar nerve should be located and protected. The ulnohumeral joint is opened laterally to the olecranon and protected with a sponge when performing the osteotomy.
A distal chevron is made at the level of the bare spot of the greater sigmoid notch of the ulna. The cut is started with a saw and finished with an os- teotome. The proximal olecranon and tendon are retracted proximally and separated from capsular attachments and collateral ligaments. The dissec- tion can be carried out proximally as in a bilatero- tricipital approach. At the end of the procedure the olecranon is reduced and fixed with a cerclage and K-wires, a lag screw, an intramedullary nail, or a plate.
To avoid denervation of the anconeus, some au- thors favor dissecting the anconeus distally, re- flecting it from the ulna without detaching it from the triceps to preserve its innervation.10
Bryan-Morrey approach A posterior skin incision is performed just slightly lateral to the tip of the olecranon. After elevating
Fig. 6. The Alonso-Llames approach allows access to the posterior part of the elbow joint without triceps detachment.
Anatomy and Exposures in Elbow Trauma 513
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Armbågsproteser för fraktur
Advantages of HEA* • No restriction max weight (5kg for TEA) • No polyethylene or ulna
Disadvantage of HEA • Technically demanding • Erosion of the ulna?
Totalprotes
Halvprotes
Komminuta frakturer - helprotes
Röra fritt. Får inte lyfta mer än 5 kg. Inga andra begränsningar.
Komminuta frakturer - halvprotes
Outcome data
The mean follow-up of the 121 reported cases was 37.5 months (range 6 months to 127 years). The mean age of the patients was 72.6 years (range 29 years to 92 years).
Functional outcome scores
All studies report using the MEPS, whereas some also used the Quick Disabilities of Arm, Shoulder and Hand (qDASH) score,18,20–24 American Shoulder and Elbow Score 18,21 and Oxford Elbow Score.23
The mean reported MEPS was 87.6 (SD 14.5) (107 patients). According to the MEPS, the outcome was classified as excellent in 65 patients (61%), good in 27 (25%), fair in nine (8%) and poor in six (6%). The characteristics of the 15 patients with fair or poor MEPS are shown in Table 5. Patients who had an olec- ranon osteotomy had significantly lower MEPS than patients with all other approaches (mean: 75.1, SD: 14.8 versus mean: 90.7, SD: 9.5) (p! 0.001, independent Student’s t-test). There was a nonsignificant trend that younger patients also had a lower MEPS score.
Most studies report using the DASH or quick DASH score to assess their patient measured functional outcomes.18,20–24 The mean quick DASH score (94 patients) was 18.3 (SD 21.2). Overall, there was good
correlation between the MEPS and DASH scores (Pearson’s correlation co-efficient 0.77, p! 0.01).
These functional results are comparable to the good results reported for TEA performed for fracture.6,7,26,32,33
Range of motion
All studies reported the postoperative range of motion (ROM). The mean flexion arc and pronosupination arcs achieved were 108" (SD 19.6") and 176" (SD 15.3"), respectively (excludes one patient with a radio- ulnar synostosis from an associated forearm fracture). This range of motion is similar to following TEA33
or ORIF.34–36 The difficulty in restoring pre-operative motion emphasizes that any intervention should permit early range of motion. TEA and EHA have an advan- tage over ORIF in this respect.
Radiographic outcomes
Loosening
A theoretical benefit of EHA is that there should be less torque on the implant–cement and cement–bone inter- face than a linked device. There is also no potential for polyethylene-induced osteolysis.
Figure 2. Reconstruction of fractured condyles. (a) Drill holes made in medial and lateral condylar fragments. (b, c) 2-0 Fibre wire passed through cannulation in spool and pre-made drill holes, then whip-stitched into collateral ligaments. (d) Condyles reduced to implant and humeral columns and tied firmly to each other through the cannulated spool. (e, f) Condyles further secured with tension band sutures via drill holes and cerclage sutures to the implant.
E Phadnis et al. 179
Ledbandsursprungen måste sättas på plats. Ortos i några veckor efteråt med successivt ökande extension. Inga restriktioner efter att ledbanden är läkta.
Own data
• MEPS 90 • Excellent (>90) in 29pts • Fair/poor (<75) in 5pts
• ROM 23.5 – 126.8 • >100 in 70%
• DASH 20 (0-63)
Icke-operativ behandling 82 årig kvinna. Fallit
• Parkinson • Alzheimer 2 månader6 veckor gips
Capitellum frakturer – obs ledband!