This ppt explains distal humerus fractures, its classification, its treatment and surgical approaches to it.

1. Dr. Kunal Arora
PG Orthopaedics

2.  Hippocrates stated that most closed fractures of
the humerus healed with splinting. He described
methods of immobilization, using bandaging and
splinting rods, with the elbow held in extension.
 Despite the discovery of antisepsis and
anesthesia in the 19th century, most fractures
continued to be treated nonoperatively, by
manipulation and immobilization.
 Popular methods of treatment in the 20th century
included closed manipulation, overhead
transolecranon traction and a bag of bones
treatment, which were essentially refinements of
previous nonoperative methods of treatment.

4.  In the last quarter of the 20th
century, the important concepts in
the operative internal fixation of
these fractures were defined in
AO centers and elsewhere.
 For the first time, a pain-free,
functional elbow could be
regained following reconstruction,
and the indications have since
expanded to include most
displaced fractures of the distal
humerus.

5.  Fractures of the adult distal humerus are
relatively uncommon, comprising
approximately 2% of all fractures and a third
of all humeral fractures .
 Overall incidence is increasing worldwide
particularly in developed countries due to the
rising incidence of osteoporotic fractures
from low-energy falls in the elderly.
 Age and Gender Distribution- Bimodal
distribution, with peaks of incidence in males
aged 12 to 19 years and females aged 80
years and over .

6.  Most low-energy distal humeral
fractures are produced from
simple domestic falls in middle-
aged and elderly females in which
the elbow is either struck directly
or axially loaded in a fall onto the
outstretched hand.
 Road-traffic accidents and sport
are a more common cause of
injury in younger males.

7.  The distal humerus consists of the
expanded portion of the metaphysis,
including the joint surfaces for articulation
with the corresponding surfaces of the
proximal ulna and radial head.
 Although fractures may extend proximally
into the diaphysis,they are usually
considered to be metaphyseal if the major
fragments are located within a hypothetical
square, with sides equal the widest portion
of the distal metaphysis.

9.  The ulnotrochlear joint moves through a
single axis of rotation, subserving flexion and
extension of the elbow.
 The trochlea is shaped in the form of a pulley
and has an articular arc of 270°. It is
composed of medial and lateral eminences,
with an intervening sulcus, which articulates
with the semilunar notch of the proximal
ulna.
 Radiocapitellar joint is mechanically linked to
the distal radioulnar joint, and both subserve
forearm rotational movements, independent
of the position of the ulnotrochlear joint.

10.  The pulley-like trochlea forms the central
articulating axis of the ulnotrochlear joint and
acts as a tie-arch•between the two thickened
condensations of bone along the medial and
lateral epicondylar ridges of the distal
humeral metaphysis, which constitute the two
columns of the elbow.
 Restitution of the mechanical stability of the
fractured distal humerus is dependent upon
re-creating this triangle of stability.
 Weakening of any component in the
reconstruction increases the risk of fixation
failure. The columns and the trochlea are also
anatomically the area of greatest bone mass,
and serve as corridors in which internal
fixation can be placed.

12.  The normal carrying angle of the
elbow is produced by the valgus offset
of the longitudinal axis of the
trochlea, with respect to the
longitudinal axis of the humerus .
 The trochlear axis is also internally
rotated between 3 and 8 degrees with
respect to a line connecting the
medial and the lateral epicondyles.
 Both the trochlea and capitellum
project forward at an angle of
approximately 40 degrees from the
long axis of the humerus.

14.  Before 1970, these fractures were classified
by anatomical regions, using terms such as
condylar, epicondylar, supracondylar, and by
displacement
 The first comprehensive classification was
produced by the AO Group and the original
OTA classification has now been modified, so
that it is identical.
 Both use an alphanumeric system, with
subclassification according to the degree of
articular involvement.
 Type A fractures are extra-articular,
 Type B fractures are partial articular,
 Type C are complete articular.

21.  The other recent classification system has
been produced by Jupiter et al .
 based upon the concept of the two column
and tie-arch elbow. The columns of the elbow
correspond closely to the condyles described
in the AO system.
 The classification also allows distinction of
the level of the fracture, which is a major
determinant of the complexity of any
reconstructive procedure.
 Jupiter classification provides a better guide
to the problems of reconstruction.

24.  Fractures of the distal humerus present with
pain, swelling, bruising, and the elbow may
appear deformed and shortened.
 If there is a fracture of the capitellum there may
be more specific pain on rotational movements
of the forearm.
 The degree of swelling is often a poor marker of
the severity of the underlying bony injury.
 Excessive pain in a patient with a history of a
high-energy injury should raise the suspicion of
a concomitant compartment syndrome of the
forearm.
 Open fractures of the distal humerus are
relatively common, and careful circumferential
inspection of the elbow is required, prior to
application of a temporary, well-padded plaster
back-shell

25.  Vascular injuries are rarely associated with distal
humeral fracture in adults, assessment of the
circulation distal to the fracture is mandatory.
 These are particularly associated with the flexion
transcolumn fracture subtypes, where the distal
humerus projects forward and comes into close
proximity to the brachial artery.
 careful assessment of the neurological status of
the hand must also be made. Specific assessment
of the ulnar, median and radial nerve is difficult
immediately after trauma because hand
movements may be inhibited by pain, or the
elbow may have been placed in a plaster back-
shell.
 The radial and median nerve palsies are more
commonly associated with flexion-type
transcolumn or bicolumn fractures,
 whereas injury to the ulnar nerve is more
commonly associated with extension injuries and
medial epicondyle fractures.

26.  Anteroposterior and lateral views.
 Posterior displacement of the fat pad on the
lateral x-ray (positive fat pad sign), is
pathognomic of a significant joint effusion or
hemarthrosis in these circumstances .
 A positive sign raises the possibility of an
undisplaced or radiologically occult intra-
articular fracture .
 However the sign is nonspecific, and can be
positive with a variety of other pathologies,
including osteochondral fracture, ligament
injury, or synovial tear.

27. Fat Pad Sign and Joint effusion
Normally on a lateral view of the elbow flexed in 90° a fat pad is seen on the
anterior aspect of the joint .
This is normal fat located in the joint capsule.
On the posterior side no fat pad is seen since the posterior fat is located within
the deep intercondylar fossa.

29. Positive fat pad sign
Distention of the joint will cause the anterior fat pad to become elevated and
the posterior fat pad to become visible.
An elevated anterior lucency or a visible posterior lucency on a true lateral
radiograph of an elbow flexed at 90° is described as a positive fat pad sign

30. Hemarthros results in an upward
displacement of the anterior fat pad
and a backward displacement the
posterior fat.

31.  The views obtained during the initial phases
of treatment are often of poor quality, or
difficult to interpret if they are taken with
the elbow in flexion in a plaster cast.
 Traction views for preop planning or to see
intraarticular extension.
 An oblique view may be useful in
differentiating a lateral column fracture
from a fracture of the capitellum. However,
these investigations have been largely
superseded by computerized tomography
(CT), with three-dimensional
reconstruction, which is being increasingly
used to provide a better appreciation of the
configuration of more complex fractures

32. Left) An x-ray of a healthy elbow. (Right) In this x-ray, the distal
humerus fracture is severely displaced

37. The proximal radial line is a line drawn through the middle of the radius that
should bisect the capitellum. If it does not divide the capitellum into halves, it
could indicate a dislocated radial head. Another useful feature of the proximal
radial line is that it should always bisect the capitellum in any projection. The
proximal radial line can therefore be utilised to identify the capitellum except
when the radial head is dislocated.

38. Anterior humeral line.
A line drawn on a lateral view along the anterior surface of the humerus should
pass through the middle third of the capitellum.
This line is called the Anterior Humeral line .
In cases of a supracondylar fracture the anterior humeral line usually passes
through the anterior third of the capitellum or in front of the capitellum due to
posterior bending of the distal humeral fragment.

39. The radial head is well profiled facilitating the capitellum
using the radiocapitellar gap. The distal humeral structure
overlying the radial head ifs the medial lip of the trochlea.
The capitellum is separated from the radial head by a
narrow gap- the radiocapitellar gap.

40. The radiocapitellar gap identifies the
capitellum as too posterior.

41.  The goal of treatment of these injuries is to
promote complication-free healing in order
to recreate a pain-free, mobile, and
functional elbow joint.
 For the majority of medically fit patients, any
displacement of an intra-articular fracture
>2mm is an indication for operative
intervention,however, in frail, elderly patients,
limited life expectancy, consideration may
have to be given to nonoperative treatment,
irrespective of the radiological severity of the
fracture.

42. Assessment of Functional Outcome.
 The strength in the injured elbow in flexion,
extension, forearm pronation and supination,
and grip strength are assessed and compared
with the normal uninjured side, along with pain
movement.
The Expected Functional Outcome after Distal
Humeral Fracture,
 Recovery of flexion is usually rapid, whereas
extension recovers more slowly and is more
often incomplete, with a residual lag of 20 to 30
degrees after more severe injuries. With early
mobilization of the elbow, the range of
supination and pronation movements are usually
unaffected. Most activities of daily living can be
performed with a pain-free functional arc of 100°
of elbow movement or a range of 30 to 130
degrees

43. The lateral trochlear eminence is the
key to analyzing single column distal
humeral fractures. In low lateral
column (Milch Type I) fractures the
lateral trochlear eminence is intact and
provides medial to lateral elbow
stability (A). In high lateral column
(Milch Type II) fractures the eminence
is a part of the fractured column,
which may allow the elbow to dislocate
laterally, if the medial ligament
complex is disrupted (B). In low medial
column (Milch Type I) fractures the
lateral ridge is intact and provides
medial to lateral stability (C). In high
medial column (Milch Type II)
fractures, the lateral trochlear ridge is
again part of the fractures column and
the elbow can potentially dislocate in a
medial direction, if the lateral

44.  Single column fractures are rare, comprising
approximately 15% of all distal humeral
fractures.
 Most single column fractures are displaced,
although Type I (low•) injuries are more stable
fractures than the Type II subtype, because
the lateral trochlear eminence remains intact .
In Type II injuries the eminence forms part of
the fracture and in the presence of a
concomitant collateral ligament injury a
dislocation of the elbow can occur

45.  Completely undisplaced fractures should be
immobilized for 4 to 6 weeks, with careful x-
ray monitoring to ensure secondary
displacement does not occur.
 Early open reduction and internal fixation
(ORIF) is now recommended for any fracture
that is displaced, irrespective of their
classification.

47.  Nonunion rarely occur following ORIF .
 However, nonunion and malunion are more
frequently encountered following
nonoperative treatment, typically of lateral
condylar fractures in childhood.
 Severe ulnar neuritis may be present
following malunion or nonunion of a lateral
condylar fracture. Satisfactory results may be
achieved following ORIF with bone grafting,
combined with neurolysis and transposition
of the ulnar nerve.

48.  In the AO/OTA system, bicolumn fractures
are classified as Type C fractures. They
become more comminuted, both in the
metaphysis and in the articular segment.
 Fractures involving both columns are the
most common type of distal humeral fracture,
accounting for more than one-third
 These fractures occur in the middle-aged and
elderly females during simple falls, and in
younger individuals during high-energy
sporting injuries or road traffic accidents

49. 1. Anatomic articular reduction.
2. Stable internal fixation of articular
surface.
3. Restoration of articular axial
alignment.
4. Stable internal fixation of articular
segment to diaphysis and
metaphysis.
5. Early ROM of elbow.

50.  Access to the distal humerus can be gained using
either the olecranon osteotomy, triceps-splitting,
or TRAP approaches. The former is most
commonly used and remains the gold standard
 The fracture hematoma is gently irrigated away,
and the raw cancellous surfaces are cleaned of
loose debris. All attempts are made to minimize
further soft-tissue detachment. The usual
protocol is to reconstruct the articular surface
tie-arch first, and then reconstruct the two
columns.
 Whichever approach is used, the ulnar nerve
must be clearly identified, to avoid inadvertent
injury by reduction forceps, screws, or guide
wires.

51.  The articular fracture is reduced and internally
fixed, normally using one or two partially
threaded cancellous screws inserted across the
capitellar-trochlear axis. It is important to ensure
central placement of the screws, to avoid
inadvertent anterior joint penetration. The use of
3.5-mm cannulated screws make this part of the
procedure technically easier as the guide wire can
be inserted across one condyle, and can then be
used as a reduction aid to transfix the other
articular fragment. The self-tapping screw is
then inserted over the guide wire. If there is
significant articular comminution, it is preferable
to use a fully threaded screw, rather than a
partially threaded lag screw, to avoid
compressing the joint surface in the area of
comminution.

52.  The distal portions of the medial and lateral
columns attached to the reconstructed
articular surface are now reduced and fixed
to their respective columns. The use of two
orthogonal plates is the most stable method
of treating these fractures.
 Three-dimensional contouring is required to
make plates conform to the complex shape of
the two columns and reconstruction plates
are therefore preferable to dynamic
compression plates. One-third tubular plates
should not be used, as they are too weak and
prone to breakage

53.  Screw insertion through the plates should proceed in
a distal to proximal direction. Consecutive screws
should be inserted eccentrically to each other, to
improve the rigidity of fixation.
 The internal fixation is always weakest distal to the
fracture and failure usually occurs in this area. This is
due to the poor purchase of screws in the cancellous
bone of the distal metaphysis, and the small number
of screws that can be inserted distal to the fracture,
especially with low•fracture configurations.
 On the medial side, the distal part of the plate may
be bent through 90° to allow it to cradle the medial
epicondyle to facilitate screw placement, such that a
column screw can sometimes be placed through the
most distal hole.
 The lateral plate should be applied as close as
possible to the capitellar articular surface, without
causing impingement. This is so that it can gain the
best possible purchase of its screws in the distal
fragment.

55.  Many implant manufacturers are now producing specially
precontoured distal humeral plates , which may reduce the
risk of implant breakage .
 A third posterolateral plate may be used to increase the
rigidity of fixation , if extra stability is required . It may be
possible to insert column•screws through the most distal
holes in two of the plates to further improve stability.
 Polymethyl-methacrylate bone cement or bone substitutes
may augment distal fixation in osteoporotic bone . In
addition, cancellous autograft has sometimes been used to
improve the prospects of primary healing in elderly
osteoporotic individuals.
 Locking compression plates are now generally available,
although there are no clinical series reporting their use.
However, these plates may prove to be a major advance in
treatment, because of the greater stability of fixation they
obtain in osteoporotic fractures.
 With severe comminution, a temporary hinged external
fixator may be used to confer extra stability to the ORIF in
the first few weeks postsurgery

56. Schematic picture of a reconstruction
of a low T fracture using standard
plate fixation (A). The intermediate
third plate is optional if the bone
quality is good and the reconstruction
with two plates is stable. Preoperative
x-rays of a 17-year-old girl who
sustained a low bicondylar fracture,
with comminuted wedge extension into
the medial epicondyle and
considerable comminution in the
olecranon fossa (B,C). Reconstruction
through an olecranon osteotomy, using
precontoured plate fixation was useful,
as enhanced fixation using three
screws below the fracture on the
lateral column (arrow) and two screws
below the fracture of the medial
epicondyle was possible (D). UN, ulnar
nerve. Solid internal fixation permitted
mobilization of the elbow in the early
postoperative period. Postoperative x-
rays (E,F).

57. Closure and Postoperative Regime
 The stability of the reconstruction, and lack of
impingement from the inserted metal work should be
tested by moving the elbow through a full range of
movement. If instability is detected at the fracture,
consideration should be given to revision of the
fixation
 Following stable fixation, passive range of movement
exercises, under physiotherapy supervision, should
be commenced in the early postoperative period. The
elbow should be rested in a splint and sling during
the intervening periods. If absolute stability has not
been restored, the elbow should be immobilized in
the first 4 weeks after surgery.
 Regular clinical and x-ray review should continue for
the first year after surgery, with review appointments
at 1 week, 6 weeks, 3 months, 6 months, and 1 year.
Active range of movement and strengthening
exercises are commenced at 6 weeks, if there is
evidence of early fracture consolidation on x-rays.

58.  Nonunion
 Fixation Failure
 The terms fixation failure and nonunion have often
been used interchangeably in the literature, and the
two frequently coexist
 Fixation failure is usually clearly apparent on
postoperative x-rays as implant breakage, migration,
or loosening. Nonunion following nonoperative
treatment, or technically inadequate ORIF, is usually
easily detected by pain, loss of function, and
abnormal movement at the fracture, at more than 6
months after the injury. In x-rays, there are signs of
early failure of fixation and lack of healing across
fracture gaps.

59.  Malunion.
 Wound Complications and Infection.
 Nerve Injury. Neural injuries are commonly
associated with bicolumn fractures and are
classified according to when they occur.
 Intraoperative nerve division, manipulation
and devascularization, inadequate release,
impingement, or injury by bony fragments or
hardware, and postoperative fibrosis may all
contribute to the development of neural
problems after surgery.
 Ulnar neuritis may develop at a later stage of
treatment, and may be associated either with
nonunion or a cubitus valgus deformity

60.  the ulnar nerve is the most commonly
involved, both at the time of injury and
intraoperatively. During ORIF, the ulnar nerve
is more at risk in triceps-reflecting
approaches.
 The radial nerve is at risk with triceps-
splitting approaches, if the split is continued
too far proximally .
 Elbow Stiffness and Heterotopic Ossification.
Risk factors include head injury , severe soft-
tissue and bony trauma, and delayed surgical
intervention.
Prophylactic Bisphosphonates, NSAIDs, or
radiation may help to reduce the formation of
heterotopic bone, but may retard bone
healing

62.  Osteoarthritis.
 Early rapid progression to symptomatic
osteoarthrosis is more likely if the fracture is
initially treated nonoperatively or restoration
of articular congruity has not been achieved
following surgical reconstruction

64.  Currently the use of TER has been confined
largely to elderly, low-demand patients with
bicolumn fractures that are not amenable to
reconstruction by ORIF (typically lowT•
fractures, and some comminuted multiplane,
H and lambda fractures), or who have
preexisting conditions of the elbow, most
notably rheumatoid arthritis

65.  Fractures of the articular surface of the
capitellum or trochlea of the distal humerus
are a distinct and complex subgroup of
injuries. They are distinguished from single
and bicolumn fractures by the lack of any
metaphyseal extension of fracture lines into
either column above the olecranon fossa.
 Most articular surface fractures involve the
capitellum, with variable additional
components of the trochlea and/or
epicondyles. Isolated fractures of the trochlea
are extremely rare, and more commonly a
portion of the trochlea is fractured with the
capitellum

66.  Three simple subtypes of fracture have been
recognized.
 The first is a complete fracture of the
capitellum, comprising the hemisphere of the
articular surface and the underlying
cancellous bone. This fracture is usually
referred to as the Hahn-Steinthal or Type I
fracture .
 The second and more uncommon type
consists of an osteochondral shell of the
anterior cartilage and is referred to as the
Kocher-Lorenz fracture or Type II fracture.
 An uncommon third type of injury (Type III)
has been described, where there is significant
comminution of the fragment.

67. Classification of articular surface
fractures, according to the traditionally
used system and the newer
classification of Ring and Jupiter (i). A.
The type I (Hahn-Steinthal) capitellar
fracture. A portion of the trochlea may
be involved in this fracture. In the type
II (Kocher-Lorenz) capitellar fracture
(ii), very little subchondral bone is
attached to the capitellar fragment.
There is no fracture through the lateral
condyle in the sagittal plane in either
the Type I or II capitellar fracture

68. Simple•Fractures.
Completely undisplaced fractures may be treated
nonoperatively,
The preferred approach to all of these fractures is the
direct lateral (Kocher) approach. Following
arthrotomy, the capitellar fragment is initially
reduced, and temporarily stabilized with either a
reduction forceps or with K-wires. Permanent internal
fixation can be carried out either using countersunk
cancellous screws placed from anterior to posterior
through the articular cartilage, or from posterior to
anterior
The Herbert or Acutrak screw can also be used for
internal fixation through the articular cartilage in an
anteroposterior direction . Both of these implants
have been shown to be more stable than more
traditional methods of screw or K-wire fixation

70.  Stable internal fixation of Type II and III
fractures is not easily accomplished, due to
the small size of the fracture fragment or the
comminution. Although prosthetic
replacement of the capitellum has been
described, this has not been widely used and
excision of the fragment is the preferred
option in most cases

71.  The principal complication of a capitellar fracture is
loss of elbow movement. Restriction does not tend
to be confined to pronation and supination
movements, and frequently there is also a loss of
the full arc of elbow flexion and extension.
 Malunion or nonunion may occur if there is a delay
in diagnosis
 with more severe initial displacement and
devascularization of the capitellar fragment, which
causes ON

72.  Undisplaced fractures of both epicondyles are
generally treated nonoperatively, by
immobilization in a splint for 2 weeks, with
the elbow flexed at 90 degrees and the
forearm pronated, to relax the common
flexor origin muscles.
 Fractures displaced by more than 1 cm, or
entrapped within the elbow joint should be
treated by ORIF
 For large fragments, lag screw fixation is
most appropriate, whereas smaller fragments
are best secured using interosseous wires, or
using bone suture anchors with
nonabsorbable sutures

74. Thank you for attention !
abhishek 74