surgical approaches to distal humerus fractures - dr.s.senthil sailesh, m.s.ortho

$: Surgical Approaches to distal humerus fractures - DR.S.SENTHIL SAILESH, M.S.ORTHO$
APPROACHES TO THE DISTAL HUMERUS

DR.S.SENTHIL SAILESHSENIOR ASSISTANT PROFESSOR

INSTITUTE OF ORTHOPAEDICS & TRAUMATOLOGY

MADRAS MEDICAL COLLEGE & RGGGH, CHENNAI

GREETINGS FROM MMC, CHENNAI

CHOICE OF EXPOSURE - DETERMINANTS

• Age (paediatric / adult)

• Fracture pattern (articular comminution)

• Total Elbow Arthroplasty?

• Associated injuries ( Neurovascular injury)

APPLIED ANATOMY

OSSEOUS ANATOMY

POSTERIOR ASPECT ANTERIOR ASPECT

• The medial and lateral columns support the articular segment.

• The distal most part of the lateral column is the capitellum and the distalmost part of the medial column is the nonarticular medial epicondyle.

• The trochlea is the medial part of the articular segment and is intermediate in position between the capitellum and medial epicondyle.

• The articular segment functions architecturally as a tie arch.

Posterior Structures :• Skin & Subcutaneous

Tissue

• Triceps Muscle With Aponeurosis

• Ulnar Nerve – Behind Medial Epicondyle

• Posterior Capsule

SURGICAL ANATOMY

SURGICAL ANATOMY

Anterior Structures :• Skin, Subcutaneous Tissue With

Superficial Veins

• Layer 1: Biceps With Bicipital Aponeurosis

• Layer 2: Median Nerve With Brachial Vessels

• Layer 3: Brachialis, Brachio-radialis, Radial Nerve

• Layer 4: Anterior Capsule

SURGICAL ANATOMY

LATERAL STRUCTURES:

• LCL

• Anconeus

• Extensors Of The Wrist

SURGICAL ANATOMY

MEDIAL STRUCTURES:•MCL

•Flexor Group Of Muscles

•Ulnar Nerve passes from behind the medial epicondyle and distally between the FCU and FDP

WHY POSTERIOR APPROACH?

• Most orthopaedic procedures (m.c: fracture fixation) in and around the distal procedures predominantly done through posterior approaches owing to:• SAFER - Less chance of damage to vital structures (comparing anterior)

• EASIER - Posterior structures are aponeurotic and dissection is easier with less bleeding

• CLEARER – Better visualisation of articular surface

• Very few indications where other approaches may be necessary:• Anterior: excision of myositic mass, fractures associated with vascular injuy

• Medial & Lateral approaches – partially articular/condylar fractures

POSTERIOR APPROACHES TO THE DISTAL HUMERUS

POSTERIOR APPROACHES TO DISTAL HUMERUS

PATIENT POSITIONING

LATERAL DECUBITUS POSITION

(swimmer’s position)•Arm hanging over a post

•Sterile tourniquet if desired

•Very convenient for the surgeon

•Bit less convenient for the anaesthetist especially if the patient has to be intubated halfway during surgery following regional anaesthesia

COMMON STEPS FOR ALL POSTERIOR APPROACHES

1) Longitudinal midline skin incision over the posterior aspect of the elbow

2) Raising of subcutaneous flaps on either side to expose the tricipital aponeurosis

3) Isolation of ulnar nerve

1) SKIN INCISION

• Beginning atleast 5cm proximal to the tip of the olecranon, curving slightly laterally at the tip, then returning to the midline and extending 5 cm distal to the tip of the olecranon

2) RAISING OF SUBCUTANEOUS FLAPS

3) ISOLATION OF ULNAR NERVE

• Identification of the ulnar nerve first done proximally where the nerve pierces the septum

• Release it from its tunnel by dividing the arcuate ligament that passes between the two heads of the flexor carpi ulnaris muscle

• Gently retract it with a rubber sling or a penrose drain

• Extensive dissection of the nerve is inadvisable, as this increases the risk of tethering and damage to its vascularity.

ISOLATION OF ULNAR NERVE

OLECRANON OSTEOTOMY APPROACH

TRANSVERSE

• Technically easier to do

• 30% incidence of nonunion (Gainor et al, (1995) j south orthop assoc 4:263)

• Olecranon implant removal may be necessary due to irritation

CHEVRON

• Technically more difficult

• More stable

• Lesser incidence of non-union

• Olecranon implant removal may be necessary due to irritation


PLAN THE FIXATION OPTION BEFORE THE OSTEOTOMY

• If planning to use a screw for fixation (most common) of the osteotomy, pre-drill and tap for screw placement down the ulna canal

• Expose the tip by sharp dissection of soft tissues to see the bone


• A gauze swab is inserted from medial to lateral through the joint across the notch to protect the articular surfaces

• The line of osteotomy (“V” shaped) is marked with a pen or a cautery


• Small, thin oscillating saw used to cut 95% of the osteotomy along the line of marking

• Alternatively a 2mm drill bit can be used for multiple drilling and joining them


•Osteotome used to crack and complete it


Exposure of the distal humerus especially the inter condylar area is excellent after an osteotomy approach


OSTEOTOMY FIXATION OPTIONS

OSTEOTOMY FIXATIONSINGLE SCREW WITH TBW TECHNIQUE:

1) Expose the tip by sharp dissection of soft tissues to see the bone

2) Pre-drilling & tapping should be done prior to osteotomy

3) Beware of the varus bow of the proximal ulna, which may cause a malreduction of the tip of the olecranon after screw placement

4) We prefer using a 6.5mm cannulated cancellous screw of length 60-70mm

5) Large-diameter screw threads may engage ulnar diaphysis (small medullary canal) prior to full seating of screw head, “Bite” of screw may be strong without full compression

6) A Tension band wiring done before full tightening of the screw

Hak and Golladay, JAAOS, 8:266-75, 2000

Length of screw may be important to resist toggling and loss of reduction

OSTEOTOMY FIXATION

TENSION BAND TECHNIQUE WITH K-WIRES:

• Easy to place

•May be less stable than independent lag screw or plate

• Implant irritation is a problem

Mullett et al (2000) Injury 31:427,Prayson et al (1997) J Orthop Trauma 11:565

Engage anterior ulnar cortex here with wires to improve fixation stability/strength

OSTEOTOMY FIXATION

DORSAL PLATING• Low profile periarticular implants now

available

• When using this method the plate is prefixed to the olecranon and then removed before conducting the osteotomy.

• Axial screw through plate can be used

Hewin et al (2007) J Orthop Trauma 21:58Tejwani et al (2002) Bull Hosp Jt Dis 61:27

THE OSTEOTOMY APPROACH

PEARLS

•Provides The Best Visualization Of The Distal Humerus Articular Surface

PERILS

•Nonunion, malunion at the osteotomy site

•Hardware irritation due to osteotomy fixation

THE OSTEOTOMY APPROACH

INDICATIONS

•Although all articular fractures are best visualised by this approach, the AO/OTA type C3 fracture is best managed by this approach

CONTRAINDICATIONS (RELATIVE)•Very anterior articular fractures (AO/OTA type B3), which can be difficult to visualize through an osteotomy

• Total elbow arthroplasty

PARA-TRICIPITAL (TRICEPS PRESERVING) APPROACH

[ALONSO-LLAMES ]

• The medial and lateral borders of the triceps are incised or alternatively erased from their respective intermuscular septae and elevated from the posterior aspect of the distal humerus.

• The distal humerus can be button holed medially or laterally to gain access to the proximal forearm


[ALONSO-LLAMES ]

Full-thickness fasciocutaneous flaps are elevated

The medial and lateral borders of the triceps are incised and elevated from the posterior aspect of the distal humerus

PEARLS•Avoidance of an olecranon osteotomy, therefore the risks of nonunion and symptomatic olecranon hardware are avoided

•The triceps tendon insertion is not disrupted, allowing early active range of motion

•Preserves the innervation and blood supply of the anconeus muscle, which provides dynamic posterolateral stability to the elbow.

•If required, can be converted into an olecranon osteotomy

PERILS

•Limited visualization of the articular surface of the distal humerus

• The approach is usually inadequate for fixation of type c3 fractures.

The several advantages of this approach certainly indicate its use for AO/OTA types A2, A3, B1, B2, and possibly C1 and C2 fractures


[ALONSO-LLAMES ]

• Developed to attempt to overcome the morbidity & the risk of hardware complications associated with the use of olecranon osteotomy

• Although some authors have reported a better functional outcome following the use of a triceps-splitting approach compared with olecranon osteotomy, others have reported the converse

• The intact trochlear notch may be used as a template, against which the reduction of the trochlea can be assessed

• Either internal fixation or total elbow arthroplasty (TER) can be performed but internal fixation is technically difficult.

TRICEPS SPLITTING APPROACHES

• Splitting the triceps longitudinally through the midline of the triceps aponeurosis down to bone followed by sub-periosteal elevation of the triceps medially and laterally.

• Triceps split extends distally onto the olecranon and proximally, the radial nerve limits the extent of dissection.

TRICEPS- midline SPLITTING APPROACH (CAMPBELL)

• In order to improve triceps healing, GSCHWEND et al modified the approach to incorporate a flake of olecranon bone, to be later fixed

• Mckee et al compared the extensor mechanism strength of patients treated with an olecranon osteotomy versus a triceps splitting approach and found no statistical significant difference, concluding that both approaches are effective


PEARLS

•Relative technical ease

•The ability to convert from open reduction and internal fixation to total elbow arthroplasty with few consequences

PERILS

•Limited visibility of the articular surface

•Disruption of the extensor mechanism requiring postoperative protection and the risk of triceps dehiscence


• This Approach Was Described By Campbell, And Later Modified By Van Gorder And Wadsworth

• The deep head of the triceps is divided in its midline for a length of about 8 cm.

• The flap is distally based and should extend to the outer part of the humeral condyles in order to allow an adequate approach . Sufficient tendon tissue at both sides of the flap must be preserved to obtain a good repair.

• Thickness of flap: 1/3rd of the muscle thickness proximally, 2/3rd in the middle, full thickness distally

• To perform a V-Y advancement the triceps is sutured in the midline for the required length. the rest of the flap is then repaired at its new length to the outer edges of the aponeurosis with interrupted sutures.

Triceps V-Y splitting approach

(campbell – van gorder)

PEARLS

•Avoidance of an olecranon osteotomy, therefore the risks of nonunion and symptomatic olecranon hardware are avoided

•Lengthening of the extensor mechanism can be done if required

PERILS

•Limited visibility of the articular surface

•Risk of triceps necrosis

•Higher rate of infection

This approach is indicated for •Total Elbow arthroplasty•ORIF of distal humerus fractures when there is an associated complete or high grade partial triceps tendon laceration.•Chronic Elbow dislocations



• Medial edge of triceps and distal forearm fascia elevated as single unit off olecranon and reflected laterally along with a thin wafer of bone to facilitate bone-to-bone healing• Resection of extra-articular tip of

olecranon• Now the entire triceps muscle with

the posterior capsule is reflected upwards and laterally, and the elbow is flexed to expose the joint.

Triceps reflecting postero-medial approach (Bryan-

Morrey Approach)


Morrey Approach)

PEARLS

•Avoidance of an olecranon osteotomy & its complications

PERILS

•Risk of triceps pull out if careful transosseous resuturing is not done properly or if the tendon repair fails or the tissue quality is poor, as in rheumatoid patients.

•Delayed active mobilisation

This approach is best suited for unrepairable distal humerus fractures in which primary elbow arthroplasty is planned.


Morrey Approach)

• The approach begins laterally at the kocher interval, between the extensor carpi ulnaris and the anconeus.

• TRAP approach incorporates modified kocker's approach on lateral side and a triceps reflecting approach on the medial side. both approaches converge distally at the tip of the anconeus

Triceps-Reflecting Anconeus Pedicle (TRAP)

Approach

Anconeus

Triceps insertion

• The anconeus-triceps flap was detached from its distal attachment (5-7 cm from the tip of olecranon) and dissected off the lateral side of the elbow and proximal ulna, preserving the integrity of the lateral collateral ligament complex, including annular ligament

• The flap is reflected to expose the lower end of the humerus


Approach

• The dissection started distally and working proximally.

• The posterior capsule incised and the dissection was carried out proximally between the triceps and posterior humerus. the fibers of the deep head of the triceps were dissected off the posterior humerus by sharp and blunt dissection

• Fixation of the fracture proceeded

• The triceps was reattached with interrupted number-2 braided polyester sutures, with use of drill-holes through bone in the region of the olecranon


Approach

THE TRAP APPROACH

PEARLS

•Avoidance of an olecranon osteotomy & its complications

•Protects the neurovascular supply to the anconeus muscle

PERILS

•Risk of triceps dehiscence

•Possible extensor weakness

DON’T FORGET THE RADIAL NERVE…• Dissect and protect the radial nerve when

the exposure is extended on the lateral

aspect for fixing the lateral column

• Gerwin et al : if further proximal exposure is required for associated fractures of the humeral shaft, the lateral side of the approach can be converted into the Gerwin approach, which involves reflection of the triceps muscle unit from lateral to medial to expose 95% of the posterior humeral shaft and the radial nerve

MEDIAL & LATERAL APPROACHES

•LATERAL - Extended Kocher Approach

•MEDIAL – Campbell’s medial approach

CAMPBELL’S MEDIAL APPROACH

PLANE OF DISSECTION:

•PROXIMALLY:

The internervous plane lies between the brachialis muscle (musculocutaneous nerve) and the triceps muscle (radial nerve)

•DISTALLY

The plane lies between the brachialis muscle (musculocutaneous nerve) and the pronator teres muscle

• 10 cm “J” shaped incision centering joint on medial aspect

• Identify the ulnar nerve in the groove behind the medial condyle of the humerus, and isolate the nerve along the length of the incision

• Retract the skin anteriorly with the fascia to uncover the common origin of the superficial flexor muscles from the medial epicondyle

• Enter the interval between the pronator teres and the brachialis. retract the pronator teres medially

TECHNIQUE

• Make sure that the ulnar nerve is retracted inferiorly, osteotomize the medial epicondyle (pre drilling & tapping can be done) and retract it with its attached flexors.

• Superiorly, continue the dissection between the brachialis, retracting it anteriorly, and the triceps, retracting it posteriorly

• The medial side of the joint now can be seen. incise the capsule and the medial collateral ligament to expose the joint

CAMPBELL’S MEDIAL APPROACH

INDICATIONS :•Removal of loose bodies •Fixation of fractures of the coronoid process of the ulna •Fixation of fractures of the medial humeral condyle and epicondyle

PEARLS

•Avoidance of disruption of extensor mechanism

•No risk of postoperative triceps pull out, dehiscence, need for immobilisation

PERILS

•Inadequate visualisation of inter condylar region

•Cannot approach the lateral aspect

THE MEDIAL APPROACH

EXTENDED KOCHER APPROACH • Utilizes the intermuscular interval between the anconeus and

the extensor carpi ulnaris. TECHNIQUE :

• The anconeus and extensor carpi ulnaris muscles are identified by palpation. A thin strip of fat can almost always be observed in the interval between these muscles

• The muscle fibres of the anconeus and the extensor carpi ulnaris muscles tend to blend together towards the insertion, so it is easier to develop the interval distally and then progress proximally.

• The deep fascia is then opened , the anconeus is dissected posteriorly

• The lateral elbow capsule with the annular ligament is identified and incised longitudinally anterior to the lateral ulnar collateral ligament

IDENTIFYING THE KOCHER’S INTERVAL

Anconeus

ECU

EXTENDED THE KOCHER’S INTERVAL PROXIMALLY TO EXPOSE THE LATERAL

ASPECT OF DISTAL HMERUS

INDICATIONS :•Fixation of lateral condylar fractures•Partially articular fractures •Repair or reconstruction of the lateral ligaments.

PEARLS

•Avoidance of disruption of extensor mechanism

•No risk of postoperative triceps pull out, dehiscence, need for immobilisation

PERILS

•Inadequate visualisation of inter condylar region

•Cannot approach the medial aspect of distal humerus

THE EXTENDED KOCHER’S APPROACH

TAKE HOME MESSAGE

•Choose the appropriate approach

•Safeguard the ulnar & radial nerve

•Respect the soft tissues

•Get familiarized with a particular approach

PROGRAMME SCHEDULE

surgical approaches to distal humerus fractures - dr.s.senthil sailesh, m.s.ortho

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