distal humerus fractures
DESCRIPTION
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 - PowerPoint PPT PresentationTRANSCRIPT
Distal Humerus FracturesDistal 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, 3rd edition
Anatomy
Medial and lateral columns form triangle with trochlea
Medial column diverges 45 deg
Lat column 20 deg
Skeletal Trauma, 3rd 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, 3rd edition
Classification
Extraarticular (A)
Partial Articular (B)
Complete Articular (C)
Müller ME, Nazareon S, Koch P, Schaftsker J: Comprehensive Classificationof 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: 1701-1707
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
90-90
180 or med/lat
2 plates dorsal
Locked vs. non-locked
Korner 2004– Locked or not, dorsal
plates failed vs. 90-90
– 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 SxRing 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– 15-140 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: 1701-1707
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
90-90 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