Distal Humerus Fractures

Outline Distal Humerus –Preop Planning –Surgical Technique Olecranon

Demographics Distal humerus Fx’s –2-3% of all fx’s 2 groups –High energy in young –Low energy in elderly

Anatomy Hinged joint with single axis of rotation 4 deg (males) to 8 deg (females) valgus, 3-8 deg ER Skeletal Trauma, 3 rd edition

Anatomy Medial and lateral columns form triangle with trochlea Medial column diverges 45 deg Lat column 20 deg Skeletal Trauma, 3 rd edition

Anatomy The distal humerus angles forward Lateral or prone positioning during ORIF facilitates reconstruction of this angle Slide courtesy of Stephany & Schmeling; OTA Resident Library

Fracture Pattern Fracture pattern determined by load direction and position of elbow Skeletal Trauma, 3 rd edition

Classification Extraarticular (A) Partial Articular (B) Complete Articular (C) Müller ME, Nazareon S, Koch P, Schaftsker J: Comprehensive Classification of Fractures of Long Bones. Berlin, Germany: Springer-Verlag, 1990, p 330.)

Treatment Principles Anatomic articular reduction Stable internal fixation Preservation of blood supply Early ROM Avoidance of complications

Pre-op Planning Intraarticular vs Extraarticular –Triceps splitting or sparing –Olecranon osteotomy Age and function of patient –ORIF –TEA –“Bag of Bones”

Triceps Splitting Best for extraarticular fx’s No worse than olecranon osteotomy for strength or outcome McKee et al JBJS-Am 2000; 82:

Triceps Sparing Bryan-Morrey –Approach started medially, reflecting triceps off olecranon –Anconeus reflected with flap as it is brought lateral

Triceps-Reflecting Anconeus Pedicle (TRAP) O’Driscoll –Modified Kocher and Bryan-Morrey –Anconeus preserved –Reflect Anconeus and Triceps proximally as you would osteotomy –Extreme flexion needed to see anterior articular surface Anconeus FCU

Extraarticular osteotomy Good for low extraarticular fx’s or “simple” intraarticular fx’s Still has complications associated with hardware (up to 30%) Anglen JAAOS 2005; 13, 291-7

Intraarticular Osteotomy Chevron osteotomy Apex distal Pre-drill for fixation of osteotomy (if using screw) Jupiter Master Techniques

Intraarticular Osteotomy Place Joker or gauze in joint Bare spot, just proximal to coronoid Complete osteotomy with osteotome Jupiter Master Techniques

Intraarticular Osteotomy Triceps reflected Place olecranon and muscle in moist gauze Don’t forget the radial nerve! Jupiter Master Techniques

Steps to fixation Articular reduction first Don’t lag trochlea if comminution present Fix articular surface to columns, columns to shaft Jupiter Master Techniques

Fixation or med/lat 2 plates dorsal

Locked vs. non-locked Korner 2004 –Locked or not, dorsal plates failed vs –Plate configuration more important than locking technology Korner J Orthop Trauma 2004;18:286–293

90-90 vs 180 Jacobsen et al., 1997 –Tested five constructs (direct lateral, posterolateral, medial combo’s) –All were stiffer in the coronal plane than compared to the sagittal plane –Strongest construct medial reconstruction plate with posterolateral dynamic compression plate

Repair osteotomy K-wires and tension band 6.5 screw w/ washer and tension band Parallel small frag screws (lag techique) Jupiter Master Techniques

Complications of Repair Osteotomy Coles 2006 –70 pts –IM screw and tension band –30% HWR, 8% due to Sx Ring 2004 –45 pts –K-wires and tension band –27% HWR, 13% due to Sx

Ulnar Nerve Transposition? Routine transposition –Plenty of level 5 evidence –Don’t have to worry about it if you go back –Strip blood supply –May do worse?

Post-op Soft dressing vs. splint at 90 vs splint in extension Early ROM (AROM/AAROM) Consider NSAIDs for thermal and head injuries (4% HO), but risking nonunion

Outcomes Most daily activities can be accomplished: –30 –130 degrees extension-flexion –50 – 50 degrees pronation-supination Good functional outcome – degrees of motion 75% strength to contralateral arm, regardless of approach (osteotomy vs triceps-splitting) Slide courtesy of Stephany & Schmeling; OTA Resident Library McKee et al JBJS-Am 2000; 82:

Complications Non-union of olecranon osteotomy –5% or more –Chevron osteotomy has a lower rate –Bone graft and revision tension band technique –Excision of proximal fragment is salvage 50% of olecranon must remain for joint stability Slide courtesy of Stephany & Schmeling; OTA Resident Library

Complications Infection –Range 0-6% –Highest for open fractures –No style of fixation has a higher rate than any other Slide courtesy of Stephany & Schmeling; OTA Resident Library

Complications Ulnar nerve palsy –8-20% incidence –Reasons: operative manipulation, hardware prominence, 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 Slide courtesy of Stephany & Schmeling; OTA Resident Library

Pearls Learn one extraarticular approach and one intraarticular approach well before trying new ones or 180 plating more important than locked plates, but locked plates may be helpful with comminution TEA may be better choice for osteopenic patient than locking plates

Case DM 34 yo M fell 15 feet from roof Open wound posterior distal L arm NVI