Distal humerus fracture

1. Complex Distal Humeral Fractures:
Internal Fixation with a Principle-Based
Parallel-Plate Technique
JOURNAL CLUB

3. • Article is published in ; JOURNAL OF BONE AND JOINT SURGERY(JBJS), VOLUME 89-A • 5 February 2013.
• Study done by Shawn W. O’Driscoll, Sanchez-Sotelo
• Study : prospective cohort study
• Conducted at Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minne.
• Impact factor is 4.578

4. Anatomy of Distal Humerus
The lower end of the humerus forms
the condyles which is expanded from
side to side, and has articular and
non articular parts.
-->The articular parts are:-
Capitellum articulate with head of
radius,
Trochlea articulate with trochlear
notch of ulna.
-->The non-articular parts are:-
Medial and lateral supra condylar
ridge,
Medial and lateral epicondyles,
Coronoid fossa,
Radial fossa,
Olecranon fossa.

5. BIOMECHANICS
The medial and lateral columns
support the articular segment.
The distalmost part of the lateral
column is the capitellum.
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
the medial epicondyle.
The articular segment functions
architecturally as a TIE ARCH.

6. The distal humerus articular surface is
aligned in
4 to 8 degrees of valgus relative to the shaft
.
Angulated 35 to 40 degrees anteriorly in the
sagittal plane.
The medial epicondyle is the termination of
the medial column and remains on the axis
of the shaft in the sagittal view.
while the lateral epicondyle follows the
capitellum into flexion.

7. Axially, the entire
distal humerus
articular surface is
internally rotated 3 to
8 degrees

8. FUNCTIONAL ANATOMY

9. Blood supply of distal humerus
By three arterial arcades
Medial , lateral and posterior .
Relatively water shed areas were to
shown exist in the territory between
these arterial arcades

10. MECHANISM OF INJURY (EXTENSION TYPE)
The linear applied force (large arrow)
leads to an anterior tension force.
Posteriorly, the olecranon is forced
into the depths of the olecranon fossa
(small arrow).
As the bending force continues, the
distal humerus fails anteriorly in the thin
supracondylar area.
When the fracture is complete, the
proximal
fragment can continue moving anteriorly
and distally, potentially harming adjacent
soft tissue structures such as the
brachialis muscle,brachial artery, and
median nerve.

11. FLEXION MECHANISM.
Flexion mechanism.
Flexion type fractures usually result from a blow
to the posterior aspect of the elbow. The obliquity
of the fracture line may be opposite that of an
extension type.
The large white arrows demonstrate the usual
direction of fragment displacement.

12. Elbow position will effects the fracture pattern
• Elbow flexed <90 degrees :
Axial load leads to trans columnar fracture
Direct posterior blow leads to olecranon fracture with or with out distal
humerus involvement .
• Elbow flexed >90 degree
May lead to intercondylar fracture.

13. AO CLASSIFICATION

15. HAHN-STEINTHAL
CLASSIFICATION
Kocher-Lorenz(type I) fracture of the
capitellum involves the articular surface
and a large portion of the subchondral
bone
The Kocher-Lorenz (type II) fracture
involves the articular surface of the
capitellum with a thin layer of subchondral
bone .

16. MILCH CLASSIFICATION

17. •Complex Distal Humeral Fractures:
Internal Fixation with a Principle-Based
Parallel-Plate Technique

18. INTRODUCTION
• Severe comminution, bone loss,and osteopenia predispose distal
humeral fractures to unsatisfactory results due to inadequate
fixation.
• Poor outcomes include contracture, secondary to prolonged
immobilization thought to be necessary to protect the fixation,and
nonunion.
• In an effort to reproducibly obtain stable fixation in the presence of
osteoporosis or comminution, have developed an improved fixation
technique for fractures of the distal part of the humerus

19. • Based on principles that enhance fixation in the distal fragments
and provide compression at the supracondylar level.
• The key to the stability achieved with this fixation construct is
that it combines the features and stability of an arch while
locking the two columns of the distal part of the humerus
together through the parallel plate fixation .

20. MATERIALS AND METHODS
• They have treated 33 patients with complex fractures of the distal part of the humerus .
• They treated all the patient with principle based internal fixation technique described in
the paper .
• The procedure is used in all the patient with complex fractures like
• Extensive comminution
• Missing bone
• Poor bone quality
• Initial failed attempt at internal fixation or
• Any combination of these factors.

21. • Out of 33 patient
• 19 patients were male & 14 patient were female .
• Out of 33 patient one patient was with bilateral distal humerus fracture
had underlying rheumatoid arthritis that involved both the elbows .
• Out of 33 :
• 9 fracture were result of RTA,
• 7 Due to high energy fall from height .
• 18 due to moderate energy fall at home
• 14 were open fractures

22. Surgical Technique

23. The screws in the distal fragments interlock, providing additional stability to the construct by “closing the
arch.” Interlocking is best achieved by contact between the screws. The combination of multiple screws
criss-crossing in close proximity with bone between them gives a “rebar” (reinforced concrete)-type
structure.

24. Principle-Based Fixation Technique:
To restore stability and function by achieving eight technical
objectives derived
• From the two principles of :
• (1) Maximizing fixation in the distal fragments and
• (2) Ensuring that all fixation in the distal segment contributes to
stability at the supracondylar level.

25. 8 Objectives concerning screws in the distal
fragments (articular segment)
Objective 1:
Each screw should
pass through a
plate.

26. OBJECTIVE - 2
Objective 2:
Each screw
should engage a
fragment on the
opposite side that
is also fixed to a
plate.

27. OBJECTIVE - 3
Objective 3:
An adequate number of
screws should be
placed in the distal
fragments.

28. OBJECTIVE -4
Objective 4:
Each screw should
be as long as
possible.

29. OBJECTIVE - 5
Objective 5:
Each screw should
engage as many
articular fragments as
possible.

30. OBJECTIVE -6
Objective 6:
The screws should lock
together by interdigitation,
thereby creating a fixed-
angle structure and linking
the columns together.

31. OBJECTIVE -7
Objective 7: Plates
should be applied such
that compression is
achieved at the
supracondylar level for
both columns

32. OBJECTIVE - 8
Objective 8:
Plates used must be
strong enough and stiff
enough to resist
breaking or bending
before union occurs at
the supracondylar level

33. SURGICAL TECHNIQUE
• Exposure
• A sterile tourniquet was used only for dissection of the ulnar nerve,
• which was transposed anteriorly in a subcutaneous pocket in every patient.
• The TRAP (triceps-reflecting anconeuspedicle) approach was used in seventeen
elbows;
• An olecranon osteotomy, in Five.
• Bryan-Morrey approach', in two; and
• Exposure through a traumatic triceps detachment, in two

34. SURGICAL
APPROACH
INDICATIONS CONTRAINDICATIO
NS
ADVANTAGES DISADVANTAGES
Olecranon
Osteotomy
ORIF for fractures
involving columns
and articular
surface
Total elbow
arthroplasty
Good access to
posterior articular
surfaces for
reconstruction
Nonunion and
failure
of fixation of
osteotomy
Poor anterior access
to capitellum
A. Olecranon osteotomy is marked in shape of shallow V or chevron.
B. Thin-blade oscillating saw is used to start osteotomy.
C. Osteotomized proximal olecranon fragment is elevated proximally; ulnar nerve is isolated, mobilized, and
protected.
MAC AUSLAND
(OLECRANON
OSTEOTOMY)

35. The triceps reflecting anconeus
pedicle (TRAP) approach is done
through a longitudinal posterior skin
incision after identification of the
ulnar nerve.
The intervalbetween anconeus and
extensor carpi ulnaris is used to
elevate the anconeus muscle and
develop the distal lateral portion of
the flap. The medial portion of the
flap is created by subperiosteal
dissection from the subcutaneous
border of the ulna. The anconeus
Expose the triceps insertion
which is also sharply released
The entire triceps–anconeus
flap is then reflected proximally
releasing the triceps muscle
from the posterior aspect of the
distal humerus.
TRAP
TRICEPS-REFLECTING
ANCONEUS PEDICLE APPROACH

36. SURGICAL
APPROACH
INDICATIONS CONTRAINDICATIONS ADVANTAGES DISADVANTAGES
TRAP ORIF intra-articular
Fractures
Total elbow
arthroplasty
Anterior coronal shear fractures of
capitellum or trochlea.
Prior olecranon osteotomy approach.
Traumatic triceps tendon tear.
Avoids complications
associated with olecranon
Osteotomy Preserves nerve
supply to anconeus
Limited visualization of anterior
articular surfaces
Risk of triceps insufficiency
TRAP
TRICEPS-
REFLECTING
ANCONEUS
PEDICLE
APPROACH

37. The triceps split approach described by
Campbell involves a midline split through the
triceps tendon and medial head (A).
The approach can be extended distally by
splitting the triceps insertion on the olecranon
and raising medial and lateral full-thickness
fasciotendinous flaps (B, C).
To gain further exposure of the posterior
trochlea, the elbow is flexed and the olecranon
tip may be
Excised.(d)
TRICEPS SPLIT APPROCH
CAMBELLS

38. TRICEPS SPLIT APPROCH
CAMBELLS
SURGICAL
APPROACH
INDICATIONS CONTRAINDICATIO
NS
ADVANTAGES DISADVANTAGES
Triceps-splitting
CAMBELL
ORIF for
fractures involving
columns and
articular surface
Previous olecranon
osteotomy approach
Patients atincreased
risk for healing
problems
Avoids
complications
associated with
olecranon
osteotomy
Poor access to
articular
surface for internal
fixation
Risk of triceps
detachment

39. SURGICAL
APPROACH
INDICATIONS CONTRAINDICATIO
NS
ADVANTAGES DISADVANTAGES
Triceps-reflecting
(BRYAN MORREY
APPROCH )
Fractures requiring
Total elbow
arthroplasty
Intra articular
Fractures
ORIF
Previous olecranon
osteotomy approach
Patients at risk for
healing problems
Avoids
complications
associated with
olecranon
osteotomy
Risk of triceps
Detachment
Limited visualization
of the anterior
articular surface
TRICEPS REFLECTING
BRYAN MORREY
APPROCH

40. •Surgical Technique

41. Step 1: Articular reduction. The articular
fragments, which tend to be rotated toward each
other in the axial plane, are reduced anatomically
and are provisionally held with K wires. It is
essential that the wires be placed close to the
subchondral level, to avoid interference with later
screw placement, and away from where the plates
will be placed on the lateral and medial columns.
One or two strategically placed pins can be used
to provisionally hold the distal fragments aligned
Step 2:Plate application and provisional fixation
Medial and lateral precontoured plates are placed
K wires through hole 2 of each plate
A screw is placed in the hole 5 of each plate but it is
not fully tightened, leaving some freedom for plate to
move proximally later during compression

42. Step 3: Articular fixation
Screw are inserted through the hole 1 of the lateral
plate and cross the distal articular fragments , from
lateral to medial , and are tightened .
This step is repeated on the medial side with use of
hole 3.
Step 4 : supracondylar compression
With the use of a large tenaculum to provide
interfragmentary compression across the fracture
at the fracture at the supracondylar level ,the
lateral column is fixed first .

43. Medial column is then compressed in the similar manner
with the large tenaculum, and a screw is inserted in the
medial plate in dynamic compression mode
K wires are removed and the remaining of the screws
are inserted
The distal screws interdigitate of maximum fixation in
the distal articular fragments .

44. CLINICAL EVALUATION
The over all clinical result was rated with the use of the
Mayo elbow performance score (MEPS)& System of Jupiter
29 elbows (91%) were stable as determined subjectively and objectively.
Moderate instability was present
1 st patient with posttraumatic arthritis.
Second following excision of heterotopic ossification and a capsular release.
Third patient in whom a deep infection had developed after excision of heterotopic
ossification and osseous ankylosis.

45. Mayo elbow performance score

46. CLINICAL EVALUATION
At the most recent evaluation, the mean MEPS was 85
points (range, 50 to 100 points).
According to this score, the result was graded as
Excellent for eleven elbows,
Good for sixteen,
Fair for two,
Poor for three.
According to the grading system of jupiter et al,'^ the result was graded as
excellent for five elbows, good for fourteen, fair for nine, and poor for four.

47. Radiographic Results
• Union of 31 fractures was achieved primarily.
• Two fracture united after one additional procedure consisting of bone-
grafting and fixation.
• There was no evidence of hardware failure in any of the elbows.

48. COMPLICATION AND REOPERATIONS
• Two patients underwent additional surgery for the purpose of
definitive wound closure following an open fracture.
• Complications requiring a reoperation occurred in nine additional
patients.

49. DISCUSSION :
• Management of distal humeral fractures is to obtain an anatomic reduction of the joint
surface and sufficient stability to allow intense rehabilitation to restore elbow motion
without failure of fixation.
• Technique proposed by the AO, in which fixation of the articular fragments with one or
two screws is followed by application of two plates at a 90° angle to one another, can
result in suboptimal anchorage of the articular fragments to the shaft due to the limited
number and length of screws that can be placed in the distal fragments.

50. In the presence of :
Severe comminution
Osteoporosis
Bone loss
The fixation can fail. Various authors have reported 20% to 25% rates of unsatisfactory
results after the use of this technique for internal fixation of DISTAL HUMERAL
FRACTURES(90 - 90 plates ).
• When fixation fails, it does so at the supracondylar level. For this reason, any
improvement in fixation must satisfy two principles:
1.There should be enhanced fixation in the distal fragments, and
2.Fixation in the distal segment should contribute to fracture stability at the supracondylar
level.

51. • The technique that used achieves these objectives by following architectural principles, in which
two columns are anchored at their base and are linked together at the top (by long screws from the
plates on each side interdigitating within the articular segment). Fixation of the bone fragments
thus relies not on screw purchase in the bone, but on the stability of the hardware superstructure.
The screws in the distal segment are converted into fixed-angle screws by two of the technical
objectives.
• First,several long screws in the distal fragments lock together by interdigitation.
• Second, these screws pass through a plate on one side and into a bone fragment on the other side,
which itself is also anchored by a plate.
• This technique enhances fixation in the distal fragments and stability between the distal segment
and the shaft.

52. • Of the five biomechanical studies of distal humeral fracture fixation in the
literature of which we are aware, only three compared so-called 90-90 plate
fixation (medial and posterolateral plates perpendicular to each other) to parallel
plate fixation (medial and lateral plates in the sagittal plane)

53. Of these four studies,
Two showed parallel plate fixation to be substantially more stable than 90-90
plateFixation and one demonstrated no differenced.
• In the presence of a supracondylar gap created to model comminution or bone
loss, parallel plate fixation was found to be substantially more stable than 90-
90 plates in all directions tested.

54. CONCLUSION
• In conclusion, the principle-based technique for internal fixation of distal humeral
fractures described in this study allows an intensive program of elbow motion
immediately after surgery and is associated with a high union rate.
• When elbow rehabilitation can be pursued postoperatively, restoration of painless
and satisfactory elbow function can be expected.
• The key to achieving these principles is the creation of a construct with the
features and stability of an arch, with the two columns locked together.
• Parallel plate fixation was found to be substantially more stable than 90-90 plates
in all directions tested.

55. • Thanku >>>