Distal humerusfrakturer

Eythór JónssonOrtopedÖvre extremitetsteamet, Sahlgrenska

• <1% av alla frakturer hos vuxna

• 1/3 är C-frakturer enligt AO (många bitar!)

• Sverige: 300-400 C-frakturer/år

• 50 sjukhus – 8 frakturer/sjukhus/år

Distal humerus frakturer

Fall

54 årig manVurpade på cykelnÖppen 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

Phys (tillväxtzon)

VAR PÅ BENET-TUMREGLER OM LÄKNINGSTID

DIAPHYS-3 MÅNADER+

METAPHYS-6 VECKOR

EPIPHYS – MOTSVARAR INTRAARTKIULÄRTFRAKTURLÄGE SOM ÄR ETT BEGREPP SOM ANVÄNDS I KLINISK VARDAG. BENVÄVNADEN HAR SAMMA EGENSKAPER SOM METAPHYSEN

VARFÖR FINNS SKILLNAD I LÄKNINGSTID?

BIOLOGISK AKTIVITET

Periosteum

Non-union (icke-läkning)

DIAPHYSÄRA FRAKTURER HAR STÖRRE RISK ATT GÅ TILL ICKE-LÄKNING ÄN METAPHYSÄRA!

DEFINITION:A. INTE LÄKT INOM 6

MÅNADERB. INTE LÄKT INOM

FÖRVÄNTAT TID

Läkning av distal humerus frakturer

Fracture forces

Varus, internal rotation forces

Rotational forces not controlled by plaster

Gips behandling inte braDåligt intern fixation inte bra

O’Driscoll 2000Acumed precontoured ”antomical plates”Parallell plating

Operativ behandling – första val1. 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 borderneeds to be extended proximally the radial nervecan 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 approachis limited, so it is not suitable for complex intra-articular distal humerus fractures.

Posterior triceps-splitting approachesThe triceps tendon and muscle are incised at itsmidline exposing the humerus and dissecting eachhalf of the triceps toeither side (Fig.7).8,9 Ulnar nerveidentification and protection is advised. Distally, theincision runs over the olecranon and separates theanconeus laterally and the FCU medially. Accessto the posterior and posterolateral aspect of the hu-merus is readily available but positioning of truelateral plates can be cumbersome. Meticulousclosure of the triceps with side-to-side sutures andadditional transosseous sutures at the level of theolecranon is recommended.

Olecranon osteotomyThis is probably the most used approach to treatdistal humerus fractures because it provides greataccess to the articular surface and the

supracondylar columns (Fig. 8). The chevron os-teotomy is favored over transverse osteotomybecause of added intrinsic stability.

After the olecranon is identified, the ulnar nerveshould be located and protected. The ulnohumeraljoint is opened laterally to the olecranon andprotected with a sponge when performing theosteotomy.

A distal chevron is made at the level of the barespot of the greater sigmoid notch of the ulna. Thecut is started with a saw and finished with an os-teotome. The proximal olecranon and tendon areretracted proximally and separated from capsularattachments and collateral ligaments. The dissec-tion can be carried out proximally as in a bilatero-tricipital approach. At the end of the procedure theolecranon is reduced and fixed with a cerclage andK-wires, a lag screw, an intramedullary nail, or aplate.

To avoid denervation of the anconeus, some au-thors favor dissecting the anconeus distally, re-flecting it from the ulna without detaching it fromthe triceps to preserve its innervation.10

Bryan-Morrey approachA posterior skin incision is performed just slightlylateral 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 tricepsdetachment.

Anatomy and Exposures in Elbow Trauma 513

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Immobilisering - rehabilitering

Plattfixation

traction injuries to the nerve. If the lateral borderneeds to be extended proximally the radial nervecan 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 approachis limited, so it is not suitable for complex intra-articular distal humerus fractures.

Posterior triceps-splitting approachesThe triceps tendon and muscle are incised at itsmidline exposing the humerus and dissecting eachhalf of the triceps toeither side (Fig.7).8,9 Ulnar nerveidentification and protection is advised. Distally, theincision runs over the olecranon and separates theanconeus laterally and the FCU medially. Accessto the posterior and posterolateral aspect of the hu-merus is readily available but positioning of truelateral plates can be cumbersome. Meticulousclosure of the triceps with side-to-side sutures andadditional transosseous sutures at the level of theolecranon is recommended.

Olecranon osteotomyThis is probably the most used approach to treatdistal humerus fractures because it provides greataccess to the articular surface and the

supracondylar columns (Fig. 8). The chevron os-teotomy is favored over transverse osteotomybecause of added intrinsic stability.

After the olecranon is identified, the ulnar nerveshould be located and protected. The ulnohumeraljoint is opened laterally to the olecranon andprotected with a sponge when performing theosteotomy.

A distal chevron is made at the level of the barespot of the greater sigmoid notch of the ulna. Thecut is started with a saw and finished with an os-teotome. The proximal olecranon and tendon areretracted proximally and separated from capsularattachments and collateral ligaments. The dissec-tion can be carried out proximally as in a bilatero-tricipital approach. At the end of the procedure theolecranon is reduced and fixed with a cerclage andK-wires, a lag screw, an intramedullary nail, or aplate.

To avoid denervation of the anconeus, some au-thors favor dissecting the anconeus distally, re-flecting it from the ulna without detaching it fromthe triceps to preserve its innervation.10

Bryan-Morrey approachA posterior skin incision is performed just slightlylateral 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 tricepsdetachment.

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

*HEA = hemi elbow arthroplasty (distal humerus ersätts)

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 37.5months (range 6 months to 127 years). The mean age ofthe patients was 72.6 years (range 29 years to 92 years).

Functional outcome scores

All studies report using the MEPS, whereas some alsoused the Quick Disabilities of Arm, Shoulder and Hand(qDASH) score,18,20–24 American Shoulder and ElbowScore 18,21 and Oxford Elbow Score.23

The mean reported MEPS was 87.6 (SD 14.5) (107patients). According to the MEPS, the outcome wasclassified as excellent in 65 patients (61%), good in 27(25%), fair in nine (8%) and poor in six (6%). Thecharacteristics of the 15 patients with fair or poorMEPS are shown in Table 5. Patients who had an olec-ranon osteotomy had significantly lower MEPS thanpatients with all other approaches (mean: 75.1, SD:14.8 versus mean: 90.7, SD: 9.5) (p! 0.001, independentStudent’s t-test). There was a nonsignificant trend thatyounger patients also had a lower MEPS score.

Most studies report using the DASH or quickDASH score to assess their patient measured functionaloutcomes.18,20–24 The mean quick DASH score (94patients) 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 thegood results reported for TEA performed forfracture.6,7,26,32,33

Range of motion

All studies reported the postoperative range of motion(ROM). The mean flexion arc and pronosupinationarcs achieved were 108" (SD 19.6") and 176" (SD15.3"), 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-operativemotion emphasizes that any intervention should permitearly 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 lesstorque on the implant–cement and cement–bone inter-face than a linked device. There is also no potential forpolyethylene-induced osteolysis.

Figure 2. Reconstruction of fractured condyles. (a) Drill holes made in medial and lateral condylar fragments. (b, c) 2-0 Fibre wirepassed through cannulation in spool and pre-made drill holes, then whip-stitched into collateral ligaments. (d) Condyles reduced toimplant and humeral columns and tied firmly to each other through the cannulated spool. (e, f) Condyles further secured with tensionband 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)

Nestorson, Ekholm, Etzner, Adolfsson 2015

Icke-operativ behandling82 årig kvinna. Fallit

• Parkinson• Alzheimer 2 månader6 veckor gips

Capitellum frakturer – obs ledband!

Komplikationer

• Infektion• Plattor sticker ut• Ulnaris besvär• Non-union