Fractures of the Distal Humerus

Gregory J. Della Rocca, MD, PhD

Original 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

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

Functional AnatomyThe distal humerus angles forwardLateral positioning during ORIF facilitates reconstruction of this angle

Surgical AnatomyThe trochlear axis compared to longitudinal axis is 94-98 degrees in valgusThe trochlear axis is 3-8 degrees externally rotatedThe intramedullary canal ends 2-3 cm above the olecranon fossa

Surgical AnatomyMedial and lateral columns diverge from humeral shaft at 45 degree angleThe columns are the important structures for support of the distal humeral triangle

Mechanism of InjuryThe fracture pattern may be related to the position of elbow flexion when the load is applied

EvaluationPhysical examSoft tissue envelopeVascular statusRadial and ulnar pulsesNeurologic statusRadial nerve - most commonly injured14 cm proximal to the lateral epicondyle20 cm proximal to the medial epicondyle Median nerve - rarely injuredUlnar nerve

EvaluationRadiographic examAnterior-posterior and lateral radiographsTraction views may be helpful to evaluate intra-articular extension and for pre-operative planning (creates a partial reduction via ligamentotaxis)Traction removes overlapCT scan helpful in selected casesComminuted capitellum or trochleaOrientation of CT cut planes can be confusing

OTA ClassificationFollows AO Long Bone SystemHumerus (#1X-XX), distal segment (#X3-XX) = 13-XX3 Main TypesExtra-articular fracture (13-AX)Partial articular fracture (13-BX)Complete articular fracture (13-CX)Each broad category further subdivided into 9 specific fracture types

OTA ClassificationHumerus, distal segment (13)TypesExtra-articular fracture (13-A)Partial articular fracture (13-B)Complete articular fracture (13-C)

OTA ClassificationHumerus, distal segment (13)TypesExtra-articular fracture (13-A)Partial articular fracture (13-B)Complete articular fracture (13-C)

OTA ClassificationHumerus, distal segment (13)TypesExtra-articular fracture (13-A)Partial articular fracture (13-B)Complete articular fracture (13-C)

Summary - ClassificationsA good classification should do the following:Describe injuryDirect treatmentDescribe prognosisBe useful for researchHave good inter-observer reliabilityHave good intra-observer reliabilityMost classification schemes fail in some of these categories

Treatment PrinciplesAnatomic articular reductionStable internal fixation of the articular surfaceRestoration of articular axial alignmentStable internal fixation of the articular segment to the metaphysis and diaphysisEarly range of motion of the elbow

Treatment: Open FractureUrgent I&DDefinitive reduction and internal fixationPrimary closure acceptable in some circumstancesTemporary external fixation across elbow if definitive fixation not possibleDefinitive fixation at repeat evaluationAntibiotic therapyRepeat evaluation in OR as necessary until soft tissue closure

FixationImplants determined by fracture patternExtra-articular fractures may be stabilized by one or two contoured platesLocked vs. nonlocked based upon bone quality, working length for fixation, surgeon preferenceIntra-articular fracturesDual plates most often used in 1 of 2 configurations90-90: medial and posterolateralMedial and lateral plating

Dual plating configurationsSchemitsch et al (1994) J Orthop Trauma 8:468Tested 2 different plate designs in 5 different configurationsDistal humeral osteotomy with and without bone contactConclusions:For stable fixation the plates should be placed on the separate columns but not necessarily at 90 degrees to each other

Dual plating configurationsJacobson et al (1997) J South Orthop Assoc 6:241.Biomechanical testing of five constructsAll were stiffer in the coronal plane than the sagittal planeStrongest constructmedial reconstruction plate with posterolateral dynamic compression plate

Dual plating configurationsKorner et al (2004) J Orthop Trauma 18:286Biomechanically compared double-plate osteosynthesis using conventional reconstruction plates and locking compression platesConclusionsBiomechanical 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)

Other Potential Surgical OptionsTotal elbow arthroplastyComminuted intra-articular fracture in the elderlyPromotes immediate ROMUsually limited by poor remaining bone stockBag of bones techniqueRarely indicated if at allCast or cast / braceIndicated for completely non-displaced, stable fractures

Fixation in elderly patientsJohn et al (1993) Helv Chir Acta 60:21949 patients (75-90 yrs)41/49 Type CConclusionsNo increase in failure of fixation, nonunion, nor ulnar nerve palsyAge not a contra-indication for ORIF

Total elbow arthroplastyCobb and Morrey (1997) JBJS-A 79:82620 patients avg age 72 yrsTEA for distal humeral fractureConclusionTEA is viable treatment option in elderly patient with distal humeral fracture

ORIF vs. elbow arthroplastyFrankle et al (2003) J Orthop Trauma 17:473Comparision of ORIF vs. TEA for intra-articular distal humerus fxs (type C2 or C3) in women >65yoRetrospective review of 24 patientsOutcomesORIF: 4 excellent, 4 good, 1 fair, 3 poorTEA: 11 excellent, 1 goodConclusions: 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

Surgical TreatmentLateral decubitus positionProne positioning possibleSupine position difficultArm hanging over a postSterile tourniquet if desiredMidline posterior incisionExposure ?

ExposuresReduction influences outcome in articular fracturesExposure affects ability to achieve reductionExposure influences outcome!Choose the exposure that fits the fracture pattern

Surgical exposuresTriceps splittingAllows exposure of shaft to olecranon fossaExtra-articular olecranon osteotomyAllows adequate exposure of the distal humerus but inadequate exposure of the articular surface

Surgical exposuresIntra-articular olecranon osteotomyTypesTransverseIndicated for intra-articular Group II fracturesTechnically easier to do30% incidence of nonunion (Gainor et al, (1995) J South Orthop Assoc 4:263)Olecranon implant removal may be necessary due to irritation

Surgical exposuresIntra-articular olecranon osteotomyTypesChevronIndicated for intra-articular Group II fracturesTechnically more difficultMore stableOlecranon implant removal may be necessary due to irritation

Osteotomy Fixation OptionsTension band techniqueDorsal platingSingle screw

Osteotomy FixationSingle screw techniqueLarge screw +/- washerBeware 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 of screw may be helpfulHak and Golladay, JAAOS, 8:266-75, 2000

Osteotomy FixationSingle screw techniqueLarge screw +/- washerBEWARE: large-diameter screw threads may engage ulnar diaphysis (small medullary canal) prior to full seating of screw headBite of screw may be strong without full compressionCareful scrutiny of lateral radiograph important to assure full seating of screw headHak and Golladay, JAAOS, 8:266-75, 2000

Osteotomy FixationSingle screw techniqueLong screw may be beneficial for adequate fixationShort screw may loosen or toggle with contraction of triceps against olecranon segmentHak and Golladay, JAAOS, 8:266-75, 2000

Osteotomy FixationTension band techniqueK-wires or screw with figure-of-8 wireEasy to place (?)May be less stable than independent lag screw or plateImplant irritationK-wires try to engage anterior ulnar cortex near coronoid baseMullett et al (2000) Injury 31:427,Prayson et al (1997) J Orthop Trauma 11:565

Tension band screwTension band wireEngage anterior ulnar cortex here with wires to improve fixation stability/strengthLength of screw may be important to resist toggling and loss of reduction

Osteotomy FixationDorsal platingLow profile periarticular implants now availableAxial screw through plateGood results after plate fixationHewin et al (2007) J Orthop Trauma 21:58Tejwani et al (2002) Bull Hosp Jt Dis 61:27

Chevron OsteotomyExpose olecranon and mobilize ulnar nerveIf using screw/TBW fixation, pre-drill and tap for screw placement down the ulna canalSmall, thin oscillating saw used to cut 95% of the osteotomyOsteotome used to crack and complete it

Chevron osteotomyColes et al (2006) J Orthop Trauma 20:16470 chevron osteotomiesAll fixed with screw plus tension band or with plate-and-screw construct67 with adequate follow-up: all healed2 required revision fixation prior to healing18 of 61 with sufficient follow-up required implant removal

Surgical exposureTriceps-sparing postero-medial approach (Byran-Morrey Approach)Midline incisionUlnar nerve identified and mobilizedMedial edge of triceps and distal forearm fascia elevated as single unit off olecranon and reflected laterallyResection of extra-articular tip of olecranon

Bryan-Morrey Approach

Surgical exposureMedial and lateral exposures triceps sparingTriceps-sparingGood for extra-articular fractures and some simple intra-articular fractures (OTA type 13-C1 or 13-C2)Can split triceps tendon for further visualization of articular surfaceCan resect tip of olecranon to improve visualization without detaching triceps

Surgical TreatmentLateral decubitus position (or prone)Arm hanging over a postSterile tourniquet if desiredMidline posterior incisionExposure dependent upon fracture patternReduction and provisional K-wire fixationLag screws inserted and K-wires removedBEWARE: Do not compress a comminuted articular fractureBi-columnar platingReconstruction of triceps insertion per exposure chosen

To transpose or not to transpose?Identification and mobilization of the ulnar nerve is often requiredUlnar nerve palsy may be related to injury, surgical exposure/mobilization/stripping, compression by implant, or scar formation

To transpose or not to transpose?Wang et al (1994) J Trauma 36:770consecutive series of distal humeral fractures treated with ORIF and anterior ulnar nerve transposition had no post-operative ulnar nerve compression syndrome. overall results: Excellent/Good 75%, Fair 10%, and Poor 15%. conclusion: routine anterior transposition indicated.

To transpose or not to transpose?Chen et al (2010) J Orthop Trauma 24:391Retrospective cohort comparison89 patients underwent transposition, 48 patients did not4x greater incidence of ulnar neuritis in patients receiving transpositionConclusion: routine ulnar nerve transposition not recommended during ORIF of distal humerus fractures

To transpose or not to transpose?Vazquez et al (2010) J Orthop Trauma 24:395Retrospective series69 distal humerus fracture patients without preoperative ulnar nerve dysfunction10% with immediate postoperative nerve dysfunction,16% with late nerve dysfunctionTransposition not effective at protecting nerveLarge prospective cohort series are likely needed to answer this question definitively

To transpose or not to transpose?If transposing, methods:Anterior sub-cutaneous technique fascial sling (off of flexor mass) attached to skin to prevent loss of transpositionIntramuscularSubmuscular

Post-operative careBulky splint applied intra-opElbow position90 degrees of flexion or extension?Authors support either and proponents strongly argue that their position is the bestExtension is harder to recover than flexionFinal arc of motion recovered is more functional if centered on 90 degrees of flexionUse what works in your hands and rehab protocol

Post-operative careRange-of-motion begun 1-3 daysTailored 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 ossificationRecent report documents dramatically-increased complication risk of olecranon osteotomy after radiation therapy (Hamid et al (2010) JBJS-A 92:2232

OutcomesMost daily activities can be accomplished with the following final motion arcs:30 130 degrees extension-flexion50 50 degrees pronation-supinationOutcomes based on pain and functionPatients not necessarily satisfied with above motion arcs

OutcomesGood elbow flexion is often the first to returnExtension seems to progress more slowlySupination/pronation usually unaffectedPain- 25 % of patients describe exertional pain

OutcomesWhat patients may expect, for example:Lose 10-25 degs of flexion and extensionMaintain full supination and pronationDecrease in muscle strengthOverall:Good/excellent75%Factors most likely to affect outcomeSeverity of injuryOccurrence of a complication

ComplicationsFailure of fixationAssociated with stability of operative fixationK-wire fixation alone is inadequateAdult distal humerus is much different from pediatric distal humerusIf diagnosed early, revision fixation indicatedLate fixation failure must be tailored to radiographic healing and patient symptoms

ComplicationsNonunion of distal humerusUncommonUsually a failure of fixationSymptomatic treatmentBone graft with revision plating

ComplicationsNon-union of olecranon osteotomyRates as high as 5% or moreChevron osteotomy has a lower rateTreated with bone graft occasionally and revision fixationExcision of proximal fragment is salvage50% of olecranon must remain for joint stability

ComplicationsInfectionRange 0-6% Highest for open fracturesNo style of fixation has a higher rate than any other

ComplicationsUlnar nerve palsy8-20% incidenceReasons: operative manipulation, hardware prominence, inadequate releaseResults of neurolysis (McKee, et al)1 excellent result17 good results2 poor results (secondary to failure of reconstruction)Prevention best treatment (although routine transposition is of unknown importance)

ComplicationsPainful implantsThe most common complaintCommon locationOlecranon Medial implants (over medial epicondyle)Lateral implants (some plates prominent over posterior-lateral aspect of lateral condyle)Implant removalAfter fracture unionPatient may need to restrict activity for 6-12 weeks

SummaryORIF indicated for most displaced patternsTotal elbow arthroplasty excellent alternative in patient with poor bone quality and low functional demandsChevron osteotomy is preferred type of olecranon osteotomy when neededRoutine transposition of ulnar nerve has not been demonstrated to be beneficial

Case ExamplesLateral column fractureMedial column fractureIntra-articular distal humeral fractureExtra-articular distal humeral fractureFixation failure olecranon osteotomyFixation failure distal humeral fracture

Case 1: 18 y/o s/p fallLateral epicondyle and capitellum Fxs

Lateral approachCapitellum: Post to Ant lag screwsEpicondyle: Screw + buttress plateHealedLoss of 20 degs ext

Case 2:43 y/o female fell from horse

Chevron intra-articular approachTension band screwORIF medial column FxExtensile exposure required intra-op

Antegrade IM nail for humeral FxHealedLacks 10 degs elbow extensionFull shoulder motionOlecranon implants tender

Case 3: 20 y/o male MCCDistal, two column FxNV intact

Transverse intra-articular approachLag screw and bi-column platingTension band wire (medullary placement of K-wires)

HealedLacks 20 degs flex & ext.Osteotomy healed without complications

ReferencesHamid et al. Radiation therapy for heterotopic ossification prophylaxis acutely after elbow trauma. JBJS-A (2010) 92:2032.Vazquez et al. Fate of the ulnar nerve after operative fixation of distal humerus fractures. J Orthop Trauma (2010) 24:395.Chen et al. Is ulnar nerve transposition beneficial during open reduction internal fixation of distal humerus fractures? J Orthop Trauma (2010) 24:391.

ReferencesColes et al. The olecranon osteotomy: a six-year experience in the treatment of intraarticular fractures of the distal humerus. J Orthop Trauma (2006) 20:164.Tejwani et al. Posterior olecranon plating: biomechanical and clinical evaluation of a new operative technique. Bull Hosp Jt Dis (2002) 61:27.Gainor et al. Healing rate of transverse osteotomies of the olecranon used in reconstruction of distal humerus fractures J South Orthop Assoc (1995) 4:263.

ReferencesJohn, H, Rosso R, Neff U, Bodoky A, Regazzoni P, Harder F: Operative treatment of distal humeral fractures in the elderly. JBJS 76B: 793-796, 1994.Pereles TR, Koval KJ, Gallagher M, Rosen H: Open reduction and internal fixation of the distal humerus: Functional outcome in the elderly. J Trauma 43: 578-584, 1997Hewins et al. Plate fixation of olecranon osteotomies. J Orthop Trauma (2007) 21:58.

ReferencesCobb TK, Morrey BF: Total elbow arthroplasty as primary treatment for distal humeral fractures in elderly patients. JBJS 79A: 826-832, 1997Frankle MA, Herscovici D, DiPasuale TG et al: A comparison of ORIF and Primary TEA in the treatment of intraarticular distal humerus fractures in women older than age 65. J Orthop Trauma 17(7):473-480, 2003.Mullett et al. K-wire position in tension band wiring of the olecranon: a comparison of two techniques. Injury (2000) 31:427.

ReferencesSchemitsch EH, Tencer AF, Henley MB: Biomechanical evaluation of methods of internal fixation of the distal humerus. J Orthop Trauma 8: 468-475, 1994Korner J, Diederichs G, Arzdorf M, et al: A Biomechanical evaluation of methods of distal humerus fracture fixation using locking compression versus conventional reconstruction plates. J Orthop Trauma 18(5):286-293, 2004.Prayson et al. Biomechanical comparison of fixation methods in transverse olecranon fractures: a cadaveric study. J Orthop Trauma (1997) 11:565.

ReferencesJacobson SR, Gilsson RR, Urbaniak JR: Comparison of distal humerus fracture fixation: A biomechanical study. J South Orthop Assoc 6: 241-249, 1997Voor, MJ, Sugita, S, Seligson, D: Traditional versus alternative olecranon osteotomy. Historical review and biomechanical analysis of several techniques. Am J Orthop 24: Suppl, 17-26, 1995

ReferencesWang 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, 1994McKee 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, 1995E-mail OTA about Questions/CommentsIf you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an e-mail to ota@aaos.orgReturn to Upper Extremity Index