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Fractures of the Distal Humerus Gregory J. Della Rocca, MD, PhD Original authors: Jeffrey J. Stephany, MD and Gregory J. Schmeling, MD; March 2004 Second author: Laura S. Phieffer, MD; Revised January 2006 Curent author: Gregory J. Della Rocca, MD, PhD; Revised October 2010

Distal humerus revised

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  • 1.Fractures of the Distal HumerusGregory J. Della Rocca, MD, PhDOriginal authors: Jeffrey J. Stephany, MD and Gregory J. Schmeling, MD; March 2004Second author: Laura S. Phieffer, MD; Revised January 2006Curent author: Gregory J. Della Rocca, MD, PhD; Revised October 2010

2. Functional Anatomy Hinged joint withdistal humeralsingle axis of rotationtriangle(trochlear axis) Trochlea is centerpoint with a lateral andmedial column 3. Functional Anatomy The distal humerusangles forward Lateral positioningduring ORIFfacilitatesreconstruction of thisangle 4. Surgical Anatomy The trochlear axis compared to longitudinalaxis is 94-98 degrees in valgus The trochlear axis is 3-8 degrees externallyrotated The intramedullary canal ends 2-3 cmabove the olecranon fossa 5. Surgical Anatomy Medial and lateralcolumns diverge fromhumeral shaft at 45degree angle The columns are theimportant structuresfor support of thedistal humeraltriangle 6. Mechanism of Injury The fracture patternmay be related to theposition of elbowflexion when the loadis applied 7. Evaluation Physical exam Soft tissue envelope Vascular status Radial and ulnar pulses Neurologic status Radial nerve - most commonly injured 14 cm proximal to the lateral epicondyle 20 cm proximal to the medial epicondyle Median nerve - rarely injured Ulnar nerve 8. Evaluation Radiographic exam Anterior-posterior and lateral radiographs Traction views may be helpful to evaluate intra-articular extension and for pre-operativeplanning (creates a partial reduction vialigamentotaxis) Traction removes overlap CT scan helpful in selected cases Comminuted capitellum or trochlea Orientation of CT cut planes can be confusing 9. OTA Classification Follows AO Long Bone System Humerus (#1X-XX), distal segment (#X3-XX) = 13-XX 3 Main Types Extra-articular fracture (13-AX) Partial articular fracture (13-BX) Complete articular fracture (13-CX) Each broad category further subdivided into9 specific fracture types 10. OTA Classification Humerus, distal segment (13) Types Extra-articular fracture (13-A) Partial articular fracture (13-B) Complete articular fracture (13-C) 11. OTA Classification Humerus, distal segment (13) Types Extra-articular fracture (13-A) Partial articular fracture (13-B) Complete articular fracture (13-C) 12. OTA Classification Humerus, distal segment (13) Types Extra-articular fracture (13-A) Partial articular fracture (13-B) Complete articular fracture (13-C) 13. Summary - Classifications A good classification should do the following: Describe injury Direct treatment Describe prognosis Be useful for research Have good inter-observer reliability Have good intra-observer reliability Most classification schemes fail in some ofthese categories 14. Treatment Principles1. Anatomic articular reduction2. Stable internal fixation of the articular surface3. Restoration of articular axial alignment4. Stable internal fixation of the articular segment to the metaphysis and diaphysis5. Early range of motion of the elbow 15. Treatment: Open Fracture Urgent I&D Definitive reduction and internal fixation Primary closure acceptable in somecircumstances Temporary external fixation across elbow ifdefinitive fixation not possible Definitive fixation at repeat evaluation Antibiotic therapy Repeat evaluation in OR as necessary untilsoft tissue closure 16. Fixation Implants determined by fracture pattern Extra-articular fractures may be stabilized byone or two contoured plates Locked vs. nonlocked based upon bone quality, working length for fixation, surgeon preference Intra-articular fractures Dual plates most often used in 1 of 2 configurations 90-90: medial and posterolateral Medial and lateral plating 17. Dual plating configurations Schemitsch et al (1994) J Orthop Trauma8:468 Tested 2 different plate designs in 5 differentconfigurations Distal humeral osteotomy with and withoutbone contact Conclusions: For stable fixation the plates should be placed on the separate columns but not necessarily at 90 degrees to each other 18. Dual plating configurations Jacobson et al (1997) J South Orthop Assoc6:241. Biomechanical testing of five constructs All were stiffer in the coronal plane than thesagittal plane Strongest construct medial reconstruction plate with posterolateraldynamic compression plate 19. Dual plating configurations Korner et al (2004) J Orthop Trauma 18:286 Biomechanically compared double-plateosteosynthesis using conventional reconstructionplates and locking compression plates Conclusions Biomechanical behavior depends more on plate configuration than plate type. Advantages of locking plates were only significant if compared with dorsal plate application techniques (not 90/90) 20. Other Potential Surgical Options Total elbow arthroplasty Comminuted intra-articular fracture in the elderly Promotes immediate ROM Usually limited by poor remaining bone stock Bag of bones technique Rarely indicated if at all Cast or cast / brace Indicated for completely non-displaced, stable fractures 21. Fixation in elderly patients John et al (1993) Helv100% 90%Chir Acta 60:219 80% 70% 49 patients (75-90 yrs)60% 41/49 Type C 50% 40% Conclusions30% 20% No increase in failure10% of fixation, nonunion, 0% nor ulnar nerve palsy Result Age not a contra- very good good fair/poor indication for ORIF 22. Total elbow arthroplasty Cobb and Morrey100%(1997) JBJS-A 79:82690%80% 20 patients 70% avg age 72 yrs 60%50% TEA for distal humeral40%fracture30%20% Conclusion10% TEA is viable treatment 0% option in elderly patientResult with distal humeralExcellent Good Fair/poor fracture 23. ORIF vs. elbow arthroplasty Frankle et al (2003) J Orthop Trauma 17:473 Comparision of ORIF vs. TEA for intra-articular distalhumerus fxs (type C2 or C3) in women >65yo Retrospective review of 24 patients Outcomes ORIF: 4 excellent, 4 good, 1 fair, 3 poor TEA: 11 excellent, 1 good Conclusions: TEA is a viable treatment option for distalintra-articular humerus fxs in women >65yo, particularlytrue for women with assoc comorbidities such asosteoporosis, RA, and conditions requiring the use ofsystemic steriods 24. Surgical Treatment Lateral decubitus position Prone positioning possible Supine position difficult Arm hanging over a post Sterile tourniquet ifdesired Midline posterior incision Exposure ? 25. Exposures Reduction influences outcome in articularfractures Exposure affects ability to achievereduction Exposure influences outcome! Choose the exposure that fits the fracturepattern 26. Surgical exposures Triceps splitting Allows exposure of shaft to olecranon fossa Extra-articular olecranon osteotomy Allows adequate exposure of the distal humerusbut inadequate exposure of the articular surface 27. Surgical exposures Intra-articular olecranon osteotomy Types Transverse Indicated for intra-articular Group IIfractures Technically easier to do 30% incidence of nonunion (Gainor et al,(1995) J South Orthop Assoc 4:263) Olecranon implant removal may be necessary due to irritation 28. Surgical exposures Intra-articular olecranon osteotomy Types Chevron Indicated for intra-articular Group IIfractures Technically more difficult More stable Olecranon implant removal may be necessary due to irritation 29. Osteotomy Fixation Options Tension band technique Dorsal plating Single screw 30. Osteotomy Fixation Single screw technique Large screw +/- washer Beware of the bow of the proximal ulna, which may cause a malreduction of the tip of the olecranon if a long screw is used. Eccentric placement ofscrew may be helpful Hak and Golladay, JAAOS, 8:266-75, 2000 31. Osteotomy Fixation Single screw technique Large screw +/- washer BEWARE: large-diameter screw threads may engage ulnar diaphysis (small medullary canal) prior to full seating of screw head Bite of screw may be strongwithout full compression Careful scrutiny of lateralradiograph important to assurefull seating of screw head Hak and Golladay, JAAOS, 8:266-75, 2000 32. Osteotomy Fixation Single screwtechnique Long screw may bebeneficial for adequatefixation Short screw may loosen or toggle with contraction of triceps against olecranon segmentHak and Golladay, JAAOS, 8:266-75, 2000 33. Osteotomy Fixation Tension band technique K-wires or screw with figure-of-8 wire Easy to place (?) May be less stable than independent lag screwor plate Implant irritation K-wires try to engage anterior ulnarcortex near coronoid base Mullett et al (2000) Injury 31:427, Prayson et al (1997) J Orthop Trauma 11:565 34. Engage anterior ulnarcortex here with wires toimprove fixationstability/strengthTension band wire Length of screw may be important to resist toggling and loss of reductionTension band screw 35. Osteotomy Fixation Dorsal plating Low profile periarticularimplants now available Axial screw through plate Good results after platefixation Hewin et al (2007) J Orthop Trauma 21:58 Tejwani et al (2002) Bull Hosp Jt Dis 61:27 36. Chevron Osteotomy Expose olecranon and mobilize ulnar nerve If using screw/TBW fixation, pre-drill andtap for screw placement down the ulnacanal Small, thin oscillating saw used to cut 95%of the osteotomy Osteotome used to crack and complete it 37. Chevron osteotomy Coles et al (2006) J Orthop Trauma 20:164 70 chevron osteotomies All fixed with screw plus tension band or withplate-and-screw construct 67 with adequate follow-up: all healed 2 required revision fixation prior to healing 18 of 61 with sufficient follow-up requiredimplant removal 38. Surgical exposure Triceps-sparing postero-medial approach(Byran-Morrey Approach) Midline incision Ulnar nerve identified and mobilized Medial edge of triceps and distal forearm fasciaelevated as single unit off olecranon andreflected laterally Resection of extra-articular tip of olecranon 39. Bryan-MorreyApproach 40. Surgical exposure Medial and lateral exposures triceps sparing Triceps-sparing Good for extra-articular fractures and some simpleintra-articular fractures (OTA type 13-C1 or 13-C2) Can split triceps tendon for further visualization ofarticular surface Can resect tip of olecranon to improvevisualization without detaching triceps 41. Surgical Treatment Lateral decubitus position (or prone) Arm hanging over a post Sterile tourniquet if desired Midline posterior incision Exposure dependent upon fracture pattern Reduction and provisional K-wire fixation Lag screws inserted and K-wires removed BEWARE: Do not compress a comminuted articular fracture Bi-columnar plating Reconstruction of triceps insertion per exposurechosen 42. To transpose or not to transpose? Identification and mobilization of the ulnarnerve is often required Ulnar nerve palsy may be related to injury,surgical exposure/mobilization/stripping,compression by implant, or scar formation 43. To transpose or not to transpose? Wang et al (1994) J Trauma 36:770 consecutive series of distal humeral fracturestreated with ORIF and anterior ulnar nervetransposition had no post-operative ulnar nervecompression syndrome. overall results: Excellent/Good 75%, Fair 10%,and Poor 15%. conclusion: routine anterior transpositionindicated. 44. To transpose or not to transpose? Chen et al (2010) J Orthop Trauma 24:391 Retrospective cohort comparison 89 patients underwent transposition, 48 patientsdid not 4x greater incidence of ulnar neuritis in patientsreceiving transposition Conclusion: routine ulnar nerve transpositionnot recommended during ORIF of distalhumerus fractures 45. To transpose or not to transpose? Vazquez et al (2010) J Orthop Trauma 24:395 Retrospective series 69 distal humerus fracture patients withoutpreoperative ulnar nerve dysfunction 10% with immediate postoperative nervedysfunction,16% with late nerve dysfunction Transposition not effective at protecting nerve Large prospective cohort series are likelyneeded to answer this question definitively 46. To transpose or not to transpose? If transposing, methods: Anterior sub-cutaneous technique fascialsling (off of flexor mass) attached to skin toprevent loss of transposition Intramuscular Submuscular 47. Post-operative careBulky splint applied intra-opElbow position 90 degrees of flexion or extension? Authors support either and proponents stronglyargue that their position is the best Extension is harder to recover than flexion Final arc of motion recovered is more functional if centered on 90 degrees of flexion Use what works in your hands and rehab protocol 48. Post-operative careRange-of-motion begun 1-3 days Tailored to the fixation and soft tissue envelopeAROM / AAROM (PROM may be used but may promote heterotopic ossification)Anti-inflammatory for 6 weeks or single- dose radiation therapy used occasionally if at high risk for heterotopic ossification Recent report documents dramatically-increased complication risk of olecranonosteotomy after radiation therapy (Hamid et al(2010) JBJS-A 92:2232 49. Outcomes Most daily activities can be accomplishedwith the following final motion arcs: 30 130 degrees extension-flexion 50 50 degrees pronation-supination Outcomes based on pain and function Patients not necessarily satisfied with abovemotion arcs 50. Outcomes Good elbow flexion is often the first toreturn Extension seems to progress more slowly Supination/pronation usually unaffected Pain- 25 % of patients describe exertionalpain 51. Outcomes What patients may expect, for example: Lose 10-25 degs of flexion and extension Maintain full supination and pronation Decrease in muscle strength Overall: Good/excellent 75% Factors most likely to affect outcome Severity of injury Occurrence of a complication 52. Complications Failure of fixation Associated with stability of operative fixation K-wire fixation alone is inadequate Adult distal humerus is much different from pediatric distal humerus If diagnosed early, revision fixation indicated Late fixation failure must be tailored toradiographic healing and patient symptoms 53. Complications Nonunion of distal humerus Uncommon Usually a failure of fixation Symptomatic treatment Bone graft with revision plating 54. Complications Non-union of olecranon osteotomy Rates as high as 5% or more Chevron osteotomy has a lower rate Treated with bone graft occasionally andrevision fixation Excision of proximal fragment is salvage 50% of olecranon must remain for joint stability 55. Complications Infection Range 0-6% Highest for open fractures No style of fixation has a higher rate than anyother 56. Complications Ulnar nerve palsy 8-20% incidence Reasons: operative manipulation, hardwareprominence, 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 (although routinetransposition is of unknown importance) 57. Complications Painful implants The most common complaint Common location Olecranon Medial implants (over medial epicondyle) Lateral implants (some plates prominent overposterior-lateral aspect of lateral condyle) Implant removal After fracture union Patient may need to restrict activity for 6-12 weeks 58. Summary ORIF indicated for most displaced patterns Total elbow arthroplasty excellent alternativein patient with poor bone quality and lowfunctional demands Chevron osteotomy is preferred type ofolecranon osteotomy when needed Routine transposition of ulnar nerve has notbeen demonstrated to be beneficial 59. Case Examples Lateral column fracture Medial column fracture Intra-articular distal humeral fracture Extra-articular distal humeral fracture Fixation failure olecranon osteotomy Fixation failure distal humeral fracture 60. Case 1: 18 y/o s/p fallLateral epicondyle and capitellumFxs 61. Lateral approachCapitellum: Post to Ant lag screwsEpicondyle: Screw + buttress plateHealedLoss of 20 degs ext 62. Case 2:43 y/o female fell from horse 63. Chevron intra-articular approachTension band screwORIF medial column FxExtensile exposure required intra-op 64. Antegrade IM nail for humeral FxHealedLacks 10 degs elbow extensionFull shoulder motionOlecranon implants tender 65. Case 3: 20 y/o male MCCDistal, two column FxNV intact 66. Transverse intra-articular approachLag screw and bi-column platingTension band wire (medullaryplacement of K-wires) 67. HealedLacks 20 degs flex & ext.Osteotomy healed without complications 68. References Hamid et al. Radiation therapy for heterotopicossification prophylaxis acutely after elbowtrauma. JBJS-A (2010) 92:2032. Vazquez et al. Fate of the ulnar nerve afteroperative fixation of distal humerus fractures.J Orthop Trauma (2010) 24:395. Chen et al. Is ulnar nerve transpositionbeneficial during open reduction internalfixation of distal humerus fractures? J OrthopTrauma (2010) 24:391. 69. References Coles et al. The olecranon osteotomy: a six-year experience in the treatment ofintraarticular fractures of the distal humerus. JOrthop Trauma (2006) 20:164. Tejwani et al. Posterior olecranon plating:biomechanical and clinical evaluation of a newoperative technique. Bull Hosp Jt Dis (2002)61:27. Gainor et al. Healing rate of transverseosteotomies of the olecranon used inreconstruction of distal humerus fractures JSouth Orthop Assoc (1995) 4:263. 70. References John, H, Rosso R, Neff U, Bodoky A,Regazzoni P, Harder F: Operative treatment ofdistal humeral fractures in the elderly. JBJS76B: 793-796, 1994. Pereles TR, Koval KJ, Gallagher M, Rosen H:Open reduction and internal fixation of thedistal humerus: Functional outcome in theelderly. J Trauma 43: 578-584, 1997 Hewins et al. Plate fixation of olecranonosteotomies. J Orthop Trauma (2007) 21:58. 71. References Cobb TK, Morrey BF: Total elbow arthroplasty asprimary treatment for distal humeral fractures inelderly patients. JBJS 79A: 826-832, 1997 Frankle MA, Herscovici D, DiPasuale TG et al: Acomparison of ORIF and Primary TEA in thetreatment of intraarticular distal humerus fracturesin women older than age 65. J Orthop Trauma17(7):473-480, 2003. Mullett et al. K-wire position in tension bandwiring of the olecranon: a comparison of twotechniques. Injury (2000) 31:427. 72. References Schemitsch EH, Tencer AF, Henley MB:Biomechanical evaluation of methods of internalfixation of the distal humerus. J Orthop Trauma 8:468-475, 1994 Korner J, Diederichs G, Arzdorf M, et al: ABiomechanical evaluation of methods of distalhumerus fracture fixation using locking compressionversus conventional reconstruction plates. J OrthopTrauma 18(5):286-293, 2004. Prayson et al. Biomechanical comparison of fixationmethods in transverse olecranon fractures: a cadavericstudy. J Orthop Trauma (1997) 11:565. 73. References Jacobson SR, Gilsson RR, Urbaniak JR:Comparison of distal humerus fracturefixation: A biomechanical study. J SouthOrthop Assoc 6: 241-249, 1997 Voor, MJ, Sugita, S, Seligson, D:Traditional versus alternative olecranonosteotomy. Historical review andbiomechanical analysis of severaltechniques. Am J Orthop 24: Suppl, 17-26,1995 74. References Wang KC, Shih, HN, Hsu KY, Shih CH: Intercondylar fractures of the distal humerus: Routine anterior subcutaneous transposition of the ulnar nerve in a posterior operative approach. J Trauma 36: 770-773, 1994 McKee MD, Jupiter JB, Bosse G, Hines L: The results of ulnar neurolysis for ulnar neuropathy during post- traumatic elbow reconstruction. Orthopaedic Proceedings JBJS-B 77 (Suppl):75, 1995If you would like to volunteer as an author for the ResidentE-mail OTAReturn toSlide Project or recommend updates to any of the following aboutUpper Extremityslides, please send an e-mail to [email protected]/CommentsIndex