Fractures of the Distal Humerus

Dr. Abdul Karim FCPS-II resident Orthopaedic Surgery PGMI/LGH

Functional Anatomy

Hinged joint with single axis of rotation (trochlear axis) Trochlea is center point with a lateral and medial column

distal humeral triangle

Functional Anatomy

The distal humerus angles forward Lateral positioning during ORIF facilitates reconstruction of this angle

Surgical Anatomy

The trochlear axis compared to longitudinal axis is 4-8 degrees in valgus The trochlear axis is 38 degrees externally rotated The intramedullary canal ends 2-3 cm above the olecranon fossa

Surgical Anatomy

Medial and lateral columns diverge from humeral shaft at 45 degree angle The columns are the important structures for support of the distal humeral triangle

Mechanism of Injury

The fracture is related to the position of elbow flexion when the load is applied

Evaluation

Physical exam

Soft tissue envelope Vascular status

Radial and ulnar pulses Radial nerve - most commonly injured

Neurologic status

14 cm proximal to the lateral epicondyle 20 cm proximal to the medial epicondyle

Median nerve - rarely injured Ulnar nerve

Evaluation

Radiographic exam

Anterior-posterior and lateral radiographs Traction views are necessary to evaluate intraarticular extension and for pre-operative planning

Traction removes overlap

CT scan helpful in selected cases

Comminuted capitellum or trochlea

OTA Classification

Humerus, distal segment (13) Types Extra-articular fracture (13-A) Partial articular fracture (13-B) Complete articular fracture (13-C)

OTA Classification

Humerus, distal segment (13) Types Extra-articular fracture (13-A) Partial articular fracture (13-B) Complete articular fracture (13-C)

OTA Classification

Humerus, distal segment (13) Types Extra-articular fracture (13-A) Partial articular fracture (13-B) Complete articular fracture (13-C)

Mehne and Matta

According to pattern of fracture line in the distal humerus.

Riseborough and Radin

Type I - Fractures involving minimally displaced articular fragments Type II - Fractures involving displaced fragments that are not rotated Type III - Fractures involving displaced and rotated fragments Type IV - Fractures involving comminuted fracture fragments

Capitellar and trochlear fractures

Type I - These are isolated capitellar fractures involving a large portion of cancellous bone; they are known as HahnSteinthal fractures. Type II - These are fractures involving the anterior cartilage, with a thin-sheared layer of subchondral bone; they are known as Kocher-Lorenz fractures. Type III fractures - These are comminuted osteochondral fractures. Type IV fractures - Classified by McKee and associates, these involve the capitellum and one half of the trochlea; they often result in the double-arc sign observed on lateral radiographs.

Anatomical Classifications(1) supracondylar fractures (2) transcondylar fractures (3) intercondylar fractures (4) fractures of the condyles (lateral and medial) (5) fractures of the articular surfaces (capitellum and trochlea), and (6) fractures of the epicondyles.

Treatment Principles1. 2.

3. 4.

5.

Anatomic articular reduction Stable internal fixation of the articular surface Restoration of articular axial alignment Stable internal fixation of the articular segment to the metaphysis and diaphysis Early range of motion of the elbow

Technical objectives for fixation of distal humerus Every screw should pass through a plate fractures*

Every screw should engage a fragment on the opposite side that is also fixed to a plate As many screws as possible should be placed in the distal fragments Each screw should be as long as possible Every screw should engage as many articular fragments as possible Plates should be applied such that compression is achieved at the supracondylar level for both the columns Plates used must be strong enough and stiff enough to resist breaking or bending before union occurs at supracondylar level.*campbell 11th edition

AO Implants

3.5 or 4.5mm recon plate

3.5mm LCP

3.5mm LCPCP,DCP

3.5mm LCP distal humerus

AO Implants3.5mm LCP extra articular distal humerus 4.5mm can.screw

3mm headless compression screw

LCP 1/3rd tubular plate

AO Implants

Ex fix. Modular frame

Ring fixator

Elbow hinge fixator

SUPRACONDYLAR FRACTURES

Careful neurovascular examination of the arm is essential, especially in extension-type (apex anteriorly angulated) supracondylar fractures.

The brachial artery may be lacerated by the proximal fracture fragment, either at the time of injury or during reduction, and a compartment syndrome may develop. All three major nerves that cross the elbow can be injured, but the radial and median nerves are those most commonly affected.

Treatment

Conservative:

hanging arm cast coaptation splint. Overhead olecranon skeletal traction

Open reduction and internal fixation are used as a rule only

in the presence of neurovascular damage or when a satisfactory position of the fracture is not obtained by closed methods.

Open reduction and internal fixation

Crossed screws or crossed threaded pins.

The screws or pins should be placed in the medial and lateral pillars and should engage the posterior cortex of the bone. Overdrilling of the distal fragment to allow compression when the screws are tightened.

When one or both columns are comminuted, handcontoured plates can be used to reconstruct the humeral pillars

Pre-contoured DuPont plate fixation

Goal should be stable, rigid internal fixation.

Olecranon pin traction

If operative treatment is postponded because of severe swelling, traumatized, contused skin, or the patients overall condition, displaced supracondylar fractures --- side arm or overhead olecranon pin traction until operative treatment can be performed.

TRANSCONDYLAR FRACTURES

Often grouped with supracondylar fractures Rare injury requires special consideration. The fracture line usually extends transversely across the condyles and often is intraarticular. Quite unstable and unite slowly when treated conservatively.

Implant options

Percutaneous threaded Steinmann pins AO-type lag screws Newer cannulated screw systems allow provisional percutaneous pin fixation, followed by screw fixation without removal of the provisional pins.

This injury, especially if it is intraarticular with loss of fixation of the fracture, can be complicated by avascular necrosis

INTERCONDYLAR FRACTURES

Most difficult challenge of the fractures of the lower end of the humerus Classification

Mehne and Mehta classification Riseborough and Radin classification

Classification

Mehne and Mehta classification system

Riseborough and Radin Classification of intercondylar fractures of distal humerus. Types 2 and 3 fractures are treated by open reduction and internal fixation. Most type 4 fractures are treated nonoperatively unless reconstruction is technically possible

Treatment

Type 1 fractures plaster splint immobilization, with gradual motion being permitted once sufficient healing has occurred. Types 2 and 3 fractures ORIF esp.when pt. is young and active Open fractures upto Gustilo type II. Surgery is best performed within the first 24 to 48 hours.

Type 4 fractures a bag of bones.

Usually treated nonoperatively

sling and early motion if the patient is elderly or with skeletal traction through an olecranon pin if the patient is younger

When the patient is young, open reduction and internal fixation of two or three of the major articular fragments,followed by skeletal traction and early motion, may be preferred

Hinged-type distraction external fixator that allows early motion can be a satisfactory treatment option for intercondylar fractures for which total reconstruction is not possible (Ciullo and Melonakos and Bolano) More cost effective than traction and may yield similar results.

Exposures

Exposure affects ability to achieve reduction Reduction influences outcome in articular fractures Exposure influences outcome! Choose the exposure that fits the fracture pattern

Approaches

Campbell posterior approach Advantages:

only approach to the elbow that affords a clear view of all the articular surfaces good exposure allows more freedom in the selection of the type of internal fixation after the ulnar nerve has been identified and retracted medially, no large vessels or nerves lie in the area of the incision.

Olecranon osteotomy approach

McConnell cosmetic extensile approach to posterior elbow.

Triceps reflecting approach

TRAP approach

Triceps-sparing posteromedial approach (ByranMorrey Approach)

Midline incision Ulnar nerve identified and mobilized Medial edge of triceps and distal forearm fascia elevated as single unit off olecranon and reflected laterally Resection of extra-articular tip of olecranon

Bryan-Morrey Approach

A full complement of equipment for internal fixation, including

long screws, ordinary plates, malleable plates, fine Kirschner wires, and large and small threaded wires or pins should be available.

Literature (ORIF)

Henley 75% good or excellent results in 33 intercondylar humeral fractures treated with open reduction and internal fixation. Letsch et al. 81% good or very good results in 104 intraarticular distal humeral fractures Gabel et al. 90% good or excellent results in 10 fractures fixed with dual contoured plates. Helfet and Schmeling, experienced surgeon can expect 75% good to excellent results. Poor results are due to heterotopic ossification, infection, ulnar nerve palsy,fixation failure, and nonunion.

Literature:

Schemitsch, et al, 1994

Tested 2 different plate designs in 5 different configurations Conclusions:

For stable fixation the plates should be placed on the separate columns but not necessary 90 degrees to each other

Jacobson, et al, 1997

Tested five constructs Strongest construct

medial reconstruction plate with posterolateral dynamic compression plate

Literature:

Korner, et al, 2004

Biomechanically compared double-plate osteosynthesis using conventional reconstruction plates and locking compression plates Conclusions

Biomechanical behavior depends more on plate configuration than plate type.

Literature:

Cobb & Morrey, 1997

20 patients

(avg age 72 yrs) TEA for distal humeral fracture Conclusion

TEA is viable treatment option in elderly patient with distal humeral Fracture

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Result Excellent Good Fair/poor

Literature:

Frankle et al, 2003

Comparision of ORIF vs. TEA for intra-articular distal humerus fxs (type C2 or C3) in women >65yo Retrospective review of 24 patients ORIF: 4 excellent, 4 good, 1 fair, 3 poor TEA: 11 excellent, 1 good TEA is a viable treatment option for distal intra-articular humerus fxs in women >65yo, particularly true for women with assoc comorbidities such as osteoporosis, RA, and conditions requiring the use of systemic steriods

Outcomes

Conclusions:

Open reduction and internal fixation

TECHNIQUE

Prone position with elbow flexed over arm board facilitates open reduction of fractures involving elbow joint and lower metaphyseal region of humerus.

Other positions

Posterior approach

Incision

5 cm distal to the tip of the olecranon and extending proximally medial to the midline of the arm to 10 to 12 cm above the olecranon tip.

Reflect the skin and subcutaneous tissue to either side carefully to expose the olecranon and triceps tendon. Isolate the ulnar nerve and gently retract it from its bed with a Penrose drain or a moist tape.

Open reduction and internal fixation of Y fracture of condyles through posterior approach.

Osteotomy of olecranon. A, Preparation of hole for 6.5-mm cancellous screw. B, Incomplete osteotomy made with thin saw or osteotome. C, Osteotomy completed by cracking bone.

Reduction of fracture segments

Assemble the fragments of the distal humerus in three steps:(1) Reduce and fix the condyles together, (2) If it is fractured, replace and fix the medial or lateral epicondylar ridge to the humeral metaphysis, and (3) Fix the reassembled condyles to the humeral metaphysis.

Reduction and fixation of condyles

Reduce the condyles and hold them firmly with a bone-holding clamp. Fix small fragments temporarily one at a time with small Kirschner wires inserted with power equipment.

Insert malleolar or cancellous AO screws across the major fragments. Then remove as many of the previously inserted Kirschner wires as possible and still maintain fixation. Newer 4-mm cannulated screws can be inserted over the Kirschner wires with the wires in place. When the bone is osteoporotic, use special washers to prevent the screw heads from sinking through the cortex. Ordinarily countersink screw heads to prevent excessive bulk outside the bone in and around the elbow joint.

Take particular care in reassembling the condyles that the fixation device does not encroach on the olecranon or coronoid fossae. When encroachment occurs, some loss of flexion or extension of the elbow will result.

Reduction and fixation of epicondylar ridge

Reduce the fragment, hold it with a boneholding clamp, temporarily secure it with a Kirschner wire, and then with lag screws secure it to the metaphysis. When the site of the insertion of the screw is a sharp edge or ridge, nip out a small bit of the ridge with a rongeur before trying to place the screw. Finally, after the lag screws are inserted, remove the temporary Kirschner wire.

Reduction and fixation of reassembled condyles to metaphysis

After the reduction of the condyles, screws, threaded pins, or plates may be required to rigidly attach them to the metaphysis.

Double tension band wiring Vs Double plating technique

Houben, Bongers, and von den Wildenberg found that when bicondylar intraarticular fractures without severe comminution were treated with double tension band wiring, the results were equivalent to those achieved with a double plating technique

Comminuted fractures

If there is comminution of pillars handcontoured, one-third tubular plate is applied to the medial edge of the medial humeral pillar and a contoured 3.5-mm reconstruction plate may be applied to the posterior aspect of the lateral humeral pillar

Lateral comminution

If the medial pillar is not severely comminuted, a rigid, prebent DuPont plate can be applied alone to the lateral pillar

Mini-fragment plates

Thoroughly irrigate the joint of all debris and bone graft defects as necessary. When using the posterior Campbell approach, repair the tongue defect in the triceps tendon with multiple interrupted sutures.

Osteotomy Fixation

When using the transolecranon approach, reduce the proximal fragment and insert a cancellous screw using the previously drilled and tapped hole in the medullary canal. Use no.20G wire for tension band in a figure of eight manner.

Tension band screw

Tension band Wire

Osteotomy Fixation

Dorsal plating

Low profile periarticular implants now available allowing antishear screw placement through the plate No clinical or biomechanical studies yet published using these plates

Aftertreatment.

Light posterior plaster splint is applied from the posterior axillary fold to the palm of the hand. At 7 days, the posterior plaster splint is removed periodically, and gentle active and active-assisted exercises are carried out. By 3 weeks the posterior plaster splint can be removed, and the arm is supported by a sling with active motion in the elbow as pain permits. Vigorous stretching by a therapist, forced motion, whether active or passive, and manipulation under anesthesia are contraindicated. Results in increased periarticular hemorrhage and fibrosis, heterotrophic calcification, increased joint irritability, and decreased rather than increased motion.

FRACTURES OF CONDYLES OF HUMERUS (MEDIAL OR LATERAL)

Isolated fractures of the medial or lateral condyle of the humerus in adults are uncommon. When the condyle is displaced, open reduction and internal fixation are the best treatment.

Treatment

Exposed through either a medial or lateral incision, depending on the fracture, and the fractured condyle is secured to the uninvolved condyle with lag screws

Aftertreatment

Usually fixation is sufficiently rigid to permit early active motion. Aftertreatment is similar to that described for intercondylar fractures, but usually rehabilitation advances at a more rapid pace.

FRACTURES OF ARTICULAR SURFACE OF DISTAL HUMERUS

Fracture of the capitellum is one of the most common purely intraarticular fractures that occur about the elbow. It usually is caused by a fall on the outstretched upper extremity, with the radial head impacting against the anterior portion of the lateral humeral condyle (capitellum), resulting in a varying sized shear fracture Fractures of the capitellum involve only the articulating surface, producing an intraarticular fragment, but elbow stability is maintained.

Classification of fractures of the capitellum

Depends on the size of the articular fragment and its comminution. A good quality Lateral view Type 1 fracture a large fragment of bone and articular cartilage Type 2 fracture a small shell of bone and articular cartilage Type 3 fracture comminuted fracture

Treatment options

Closed reduction

usually not successful

Open reduction with and without internal fixation

type I & II (large fragment) type II and most of type III fractures. not proven successful or practical in literature

Excision of the fragments

Insertion of a prosthesis

TECHNIQUE

Lateral approach Detach the extensor muscles from the lateral epicondyle by sharp dissection Carefully replace the large articular fragment in its normal position. With a small AO lag screw /Herbert screw, secure the fragment in place and countersink the screw head by overdrilling the posterior cortex. Reattach the extensor muscles to the lateral epicondyle. Apply a posterior plaster splint.

New implants

A small osteochondral fracture is being fixed with absorbable screws.

Outcomes

Outcomes based on pain and function Flexion is the first to return usually

Within the first two months Usually returns 4-6 months

Extension comes more slowly

Supination/pronation usually unaffected 25 % of patients describe exertional pain

Summary of the Medical Co-Morbidities Commonly Associated with Increased Risk of Surgical Complications

Co-morbidity Dementia/mental impairment Diabetes mellitus Immunocompromise Parkinson's disease Rheumatoid arthritis Disseminated malignancy Steroid medication Heavy tobacco usage Alcohol abuse

Operative Risk Poor compliance with rehabilitation Deep infection Nonunion/infection Fixation failure Nonunion/infection Nonunion/infection Nonunion/infection Nonunion Nonunion, poor compliance with rehabilitation

Complications

Painful retained hardware

The most common complaint Common location Olecranon Medial hardware Hardware removal After fracture union One plate at a time in bicolumn fractures

Removal of both plates with a single surgery is a fracture risk

Complications

Ulnar nerve palsy

8-20% incidence Reasons:

operative manipulation hardware prominence inadequate release 1 excellent result 17 good results 2 poor results (secondary to failure of reconstruction)

Results of neurolysis (McKee, et al)

Prevention best treatment

Complications

Heterotopic ossification Up to 50% of cases after treatment of distal humerus fractures. Posterolateral aspect of the elbow,

Hastings and Graham functional classification system

Class I

These fractures are associated with no functional limitations.

Class II

Class IIA - functional limitation of flexion and extension; Class IIB - functional limitation of supination and pronation

Class III

These fractures are associated with ankylosis that eliminates elbow ROM.

Complications

Heterotopic ossification

Preventive measures

Early operative treatment (24 to 48 hours) Nonsteroidal anti-inflammatory drugs (NSAIDs) Low-dose radiation therapy Continuous passive ROM exercises. Indomethacin

Treatment

Recommended dose is 75 mg orally B.D for 3 weeks. Single doses of 600-700 cGy The timing of the irradiation (preoperative vs postoperative) does not seem to affect operative outcomes

Low-dose radiation therapy

Operative excision of heterotopic ossification is recommended 12 months after the injury

Complications

Failure of fixation

Associated with stability of operative fixation K-wires fixation alone is inadequate If diagnosed early, revision fixation indicated Late fixation failure must be tailored to radiographic healing and patient symptoms

Complications

Nonunion of distal humerus

Uncommon Usually a failure of fixation Symptomatic treatment Bone graft with revision plating

Complications

Non-union of olecranon osteotomy

Rates as high as 5% or more Chevron osteotomy has a lower rate Treated with bone graft and revision tension band technique Excision of proximal fragment is salvage

50% of olecranon must remain for joint stability

Complications

Infection

Range 0-6% Highest for open fractures No style of fixation has a higher rate than any other

Case ExamplesCase 1: 18 y/o H/o fall Lateral epicondyle and capitellum Fxs

Lateral approach Capitellum: Post to Ant lag screws Epicondyle: Screw + buttress plate Healed Loss of 20 degs ext

Case 2: 43 y/o female fell from horse

Chevron intra-articular approach Tension band screw ORIF medial column Fx Extensile exposure required intra-op

Antegrade IM nail for humeral Fx

Healed Lacks 10 degs elbow extension Full shoulder motion Olecranon hardware tender

Case 3: 20 y/o male Distal, two column Fx NV intact

Transverse intra-articular approach Lag screw and bi-column plating Tension band wire with cable

Healed Lacks 20 degs flex & ext. Osteotomy healed without complications