1. Distal Humerus Fractures in Adults
Christian Veillette M.D., M.Sc., FRCSC
Assistant Professor, University of Toronto
Shoulder & Elbow Reconstructive Surgery
Toronto Western Hospital University Health Network

2. Outline Anatomy Diagnosis Pathophysiology & Etiology
Patient History, Physical Exam, Imaging, Other Tests
Pathophysiology & Etiology
Incidence, Classification, Mechanism
Management Options
Considerations, Indications, Contraindications, Complications
Surgical Procedures
ORIF
Outcomes
Cases

3. Anatomy Column concept (Jupiter) Joint surface-shaft axis
4 to 8 degrees of valgus
carrying angle
Articular segment
forward from the line of the shaft at 40 degrees
Medial epicondyle
on the projected axis of the shaft
Lateral epicondyle
projected slightly forward from the axis
Fossae

4. Diagnosis Not complicated
trauma to limb (fall, MVC)
complaints of pain, instability, deformity
signs of bruising, swelling, crepitus, abnormal motion
Soft tissue status (open or closed, abrasions, deep contusions)
Careful neurologic examination
pulses (strength/quality compared to contralateral side)
perfusion (capillary refill)
motor and sensory function in the ulnar, median and radial nerves

5. Imaging Plain radiographs (AP/lateral/oblique films)
Sufficient detail of fracture pattern & fragment position often difficult
Out of splint
Traction radiographs quite helpful
Comparison views of opposite humerus are helpful for preoperative templating
CT scan sometimes required and helpful
Findings to look for in less obvious cases include
Fat pad sign
Alignment of the radial head with the capitellum on all views
Relationship of the capitellum position to that of the shaft
Distal articular step-off or gap on the AP view

6. Classification OTA/AO Comprehensive Classification
Type 13, 1=humerus, 3=distal
Distal distinguished from shaft by the rule of squares (length of the side is the widest width of the distal humerus on the AP view)
Includes fractures commonly called supracondylar, condylar, transcondylar, epicondylar, T-type, H-type, trochlear, and capitellar fractures
Additional levels of classification based on position and orientation of the fracture line and degree of comminution
The partial articular fractures can be described as “unicolumnar” fractures and are rare in adults (2 percent to 3 percent) although they are more common in children and adolescents.
Fractures of the lateral column are more common than those of the medial column.
Unicolumnar fractures have been divided into “high” which involve most of the trochlea, and “low” which involve a lesser portion of the trochlea.
In high unicolumnar fractures, the ulna displaces with the fractured column, while in the low variety, it does not.
Capitellar fractures are a special instance of partial articular fractures (OTA 13B3), representing a shearing injury with very little soft-tissue attachment to the anterior fragment. Three types have been described by Bryan and Morrey

7. Capitellar Fractures OTA 13B3
shearing injury with very little soft-tissue attachment to the anterior fragment

8. Intercondylar Fractures
Riseborough and Radin
Type I – Nondisplaced fracture between capitellum and trochlea
Type II – Separation of the capitellum and trochlea without appreciable rotation of the fragments in the frontal plane
Type III – Separation of the fragments with rotational deformity
Type IV – Severe comminution of the articular surface with wide separation of the humeral condyles
J Bone Joint Surg Br Jul;82(5):
Interobserver and intraobserver variation in classification systems for fractures of the distal humerus. Wainwright AM, Williams JR, Carr AJ. John Radcliffe Hospital and Nuffield Orthopaedic Centre, Oxford, England. We assessed the inter- and intraobserver variation in classification systems for fractures of the distal humerus. Three orthopaedic trauma consultants, three trauma registrars and three consultant musculoskeletal radiologists independently classified 33 sets of radiographs of such fractures on two occasions, each using three separate systems. For interobserver variation, the Riseborough and Radin system produced 'moderate' agreement (kappa = 0.513), but half of the fractures were not classifiable by this system. For the complete AO system, agreement was 'fair' (kappa = 0.343), but if only AO type and group or AO type alone was used, agreement improved to 'moderate' and 'substantial', respectively (kappa = 0.52 and 0.66). Agreement for the system of Jupiter and Mehne was 'fair' (kappa = 0.295). Similar levels of intraobserver variation were found. Systems of classification are useful in decision-making and evaluation of outcome only if there is agreement and consistency among observers. Our study casts doubt on these aspects of the systems currently available for fractures of the distal humerus.

9. Incidence <0.5% of adult fractures, ~ 10% of children fractures
Severe injuries often with associated injuries
Type C (85%) > Type A (10%) > Type B (5%)
Neurovascular injuries - 23% in Type C
Open injuries – 41% in Type C
Evidence that incidence is increasing
Palvanen M et al. (1998)
retrospective review of hospital admission records
found age-adjusted increase in incidence >2x in women older than 60 years between 1970 and 1995
12/100,000 women in 1970 to 28/100,000 women in 1995
Mechanism for production of the fracture is axial load through the elbow with the joint flexed beyond 90 degrees. When the load is applied with the elbow at 90 degrees, an olecranon fracture is produced

10. Treatment Options Non-operative management
Open reduction and internal fixation
Hinged external fixation
Hall et al. J Orthop Trauma Aug;14(6):442-5.
Total elbow arthroplasty

11. Considerations
Factors to be considered in treatment selection include:
Fracture location, pattern, comminution
Local soft-tissue status
Bone quality: osteopenia, pre-existing deformity, history of infection, presence of pathologic lesions
Patient age, health, functional expectations
Surgeon’s experience and abilities, availability of instruments and implants

12. Non-operative Splinting or casting (1 to 2 weeks)
Early gentle active and passive motion
Olecranon pin traction
“Bag of bone” technique

13. Indications for Surgery
Displaced or unstable fractures
Previous functional extremity
Ability to tolerate the surgical procedure
Open fracture
Neurovascular compromise
Compartment syndrome

14. Contraindications to ORIF
Inability to tolerate surgery due to health status
Inability to benefit from surgery, due to neurologic impairment of the limb
Excessively high risk local complications, due to infected or deficient soft tissues
Inability to achieve stability, due to severe osteopenia or deficient bone
Locking compression plates?
Several studies show good results if apply principles

15. Complications Postoperative infection Nerve injury Vascular injury
ulnar neuritis 15%
Vascular injury
Elbow stiffness
Hardware prominence
Loss of fixation
Delayed/Non-union
Malunion
Heterotopic bone formation

16. Goals of ORIF Anatomic restoration of articular surface
Restoration of joint-shaft alignment
Stable fixation of joint fragments to shaft
Early active rehabilitation

17. Type A Nondisplaced fractures Displaced fractures
nonoperative methods with close follow-up
Displaced fractures
use triceps-splitting approach
alignment of the joint to shaft should be restored
fixation performed in bicolumnar fashion with 2 plates
Isolated epicondylar fractures
can be fixed with lag screws only, in many cases

18. Type B Nondisplaced fractures
Nonoperative methods with close follow-up to identify displacement
Displaced fractures
Need operative reduction and fixation
Lag screws alone may be adequate fixation, if the bone quality is good
Otherwise a buttress or antiglide plate should be used.
Type I capitellar fractures
Use a lateral or posterior approach with lag screws placed from posterior to anterior
Consider Bioabsorbable implants and headless screws (eg. Herbert, Acutrack)
Type II and III capitellar fractures
rarely amenable to fixation, excision is usually required

19. Type C ORIF can be performed through several approaches
Extensile medial approach (Bryan and Morrey)
Extensile lateral approach (Kocher)
Posterior trans-olecranon approach
Triceps split
Placement of implants
greatest sagittal plane stiffness without loss of coronal or torsional stiffness
medial positioned reconstruction plate
posterolateral applied small fragment compression plate
Schemitsch EH, Tencer AF, Henley MB. Biomechanical evaluation of methods of internal fixation of the distal humerus. J Orthop Trauma 1994;8:468–475
“Two-plate constructs do not require placement at 90o to obtain sufficient rigidity, but do require placement on separate bony pillars and different surfaces”

20. Surgical Technique Preoperative Plan Positioning Posterior incision
Lateral decubitus/Prone/Supine
Sterile tourniquet
Iliac crest prepped
Posterior incision
Identify ulnar nerve, release cubital tunnel
Articular exposure
Olecranon Osteotomy
Intraarticular
Waist of olecranon – 3 cm from tip
Predrill, 6.5 or 7.3 mm cancellous tap
Chevron – apex distal
Complete cut with osteotome
Extraarticular
Triceps Splitting
McKee, JBJS-Br 2000 – open displaced SC fractures
J Bone Joint Surg Br Jul;82(5): Related Articles, Links
Functional outcome after open supracondylar fractures of the humerus. The effect of the surgical approach. McKee MD, Kim J, Kebaish K, Stephen DJ, Kreder HJ, Schemitsch EH. Department of Surgery, St Michael's Hospital, University of Toronto, Canada. We reviewed 26 patients who had had internal fixation of an open intra-articular supracondylar fracture of the humerus. All operations were performed using a posterior approach, 13 with a triceps split and 13 with an olecranon osteotomy. The outcome was assessed by means of the Mayo Elbow score, the Disability of the Arm, Shoulder and Hand (DASH) score and the SF-36 Physical Function score. Patients with an olecranon osteotomy had less good results

21. Surgical Technique Reduction and Provisional Fixation
Clean fracture surfaces, distal to proximal reconstruction
Restore articular surface
Use K-wires
Inside out technique
Herbert screws/Minifrag. screws to attach small fragments
If middle articular comminution – use placement screws NOT lag screws
Attach articular surface to shaft
Two K-wires up both columns
Check alignment on x-rays
Definitive Fixation
Transverse lag screws or position screws
Plate fixation:
Posterolateral position along the straight lateral column - small fragment (3.5-mm) compression plate
Medial surface using a 3.5-mm pelvic reconstruction plate contoured to lay over the medial epicondyle

22. Surgical Technique Olecranon fixation
Tension band + K-wires or 6.5/7.3 mm screw
Ulnar nerve transposed anterior subcutaneous position
Test stability of fixation/elbow and ROM
Intra-operative X-rays

23. Outcomes
Functional Outcome Following Surgical Treatment of Intra-articular Distal Humerus Fractures, McKee et al. JBJS 82-A, 2000.
25 patients, closed, intra-articular fracture
Flex contracture 25o (5-60)
Flexion-extension arc 108o (55-140)
75% strength
DASH 20 points – mild impairment
Several studies report consistent outcomes with non-validated tools
75 percent or more of good and excellent results, 10 to 15 percent fair, 5 to 15 percent poor outcomes

24. Role of Total Elbow Arthroplasty in Distal Humerus Fractures
A comparison of ORIF and primary TEA in the treatment of intraarticular distal humerus fractures in women >65 Frankle MA et al J Orthop Trauma Aug;17(7):
Retrospective review, Level 1 trauma center
24 women >65 yr, sustained distal humerus fractures, required surgical treatment, clinical follow-up minimum 2 yr
All fractures were OTA classification 13.C2 or 13.C3.
ORIF or TEA was the treatment method
Mayo Elbow Performance score
12 patients treated with ORIF were as follows: 4 excellent, 4 good, 1 fair, and 3 poor (cases that required conversion to TEA)
12 patients treated with TEA were as follows: 11 excellent and 1 good.
No fair or poor outcomes in the TEA group
No patients treated with TEA required revision surgery
Canadian Randomized Trial on TEA vs ORIF in elderly patients

25. References OTA Basic Fracture Course Orthopaedic Knowledge Online
Orthopaedic Knowledge Online
Rockwood and Green