This document discusses the challenges and solutions in the management of distal humerus fractures. Some key points: - Distal humerus fractures are challenging due to metaphyseal comminution and the complex anatomy of the elbow joint. - Surgical approaches such as the triceps-sparing and olecranon osteotomy approaches each have benefits and limitations. - Parallel plate fixation has been shown to provide better stability than orthogonal plating, though both can achieve good outcomes. - Techniques like ulnar nerve transposition and closed arch plate fixation aim to maximize stability while minimizing complications. - Total elbow arthroplasty or hemiarthroplasty may be considered for unreconstructable fractures

1. Challenges and Solutions in
Management of Distal Humerus Fractures
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2. • Epidemiology
• Anatomy
• Classification
• Controversies and Recent studies
• Approach
• Implants selection
• Plate configuration
• Ulnar nerve transposition
Role of total elbow arthroplasty in DHF
Role of hemiarthroplasty in DHF
Objectives

3. Why do distal humerus fractures
being a challenge?
• Metaphyseal comminution –
• Anatomic complexity of the distal humerus
• Positioning of the plates
• TBW –
• Skin closure
• Osteoporotic nature of the bone –
• Less BMD/Thin metaphysis
• Screw Pullout strength is low

4. Epidemiology
DHF account for 2% of all adult fractures
The common pattern of fracture
• Intraarticular and involves both columns
Bimodal distribution
• Peak incidence in young male and in older female patients
• Young male – High-velocity injury
• Older female - Osteoporosis

5. Anatomy - Column
The distal humerus is flattened and expanded
bony structure
It is composed of lateral and medial columns with
the trochlea situated between these columns.
The location of the trochlea is central rather than
medial

6. Anatomy – Medial column
Formed by Medial SCR + M/Epicondyle
The distal end has 450 angulation with humeral shaft
M/ Epicondyle gives attachment for MCL & Common
Flexor Origin
The MCL originates from the undersurface of the
medial epicondyle where it is vulnerable to excessive
dissection
Ulnar nerve
Ulnar nerve

7. Anatomy - Lateral column
• Formed by Lateral SCR and L/Epicondyle
and Capitulum
• Distal end has 200 with humeral shaft
• L/ epicondyle gives attachment for LCL
& common extensor origin
• Its posterior surface is non articular and
can be used as a site for a plate fixation

8. Anatomy
The lateral column curves anteriorly
Placement of a straight plate on
the posterolateral surface of the
humerus risks straightening of
distal humerus.
The medial column including the medial
epicondyle is in line with the humeral shaft.

9. Anatomy - Trochlea
• It forms the center of the triangle
• It has 30 - 80 – external rotation & 250
anterior divergent with the shaft
• It forms a 40 - 80 degree valgus direction

10. Blood supply
• Medial column -
• Lateral column -

11. Blood supply & Posterior plating

12. The goal of Evaluation – History and Examination
• Determine the extent of soft tissue injury –
• Skin condition - Swelling / Open fracture
• Vascular status
• Radial and ulnar pulses
• Neurologic status
• Radial nerve - Most commonly injured
• Ulnar nerve -
• Median nerve - rarely injured
• Determine the existence of previous symptomatic elbow pathology –

13. Radiographic Investigation
X-ray -
Anterior-posterior view
lateral View
Traction View – This can help to define articular
fragments and aid in pre-operative classification of
the fracture.
NCCT – Elbow
Articular surfaces
Position of the fracture fragments
useful for identifying impacted fracture fragments
that make reduction challenging…
Traction view

14. Classification - AO classification
• Three Main Types
• Extra-articular Fracture - 13A
• Partial Articular Fracture - 13B
• Complete Articular Fracture - 13C
• Each broad category further subdivided into 9 specific
fracture types

15. Classification - AO classification
Extra articular – 13A Partial articular – 13B

16. Coronal plane fractures – 13B3
Complete articular fractures – 13C
Classification - AO classification

17. Surgical options
• ORIF
• Reconstruction plates
• Anatomically contoured locking plate
• Total Elbow Arthroplasty
• Distal humerus Hemiarthroplasty

18. Surgical Approaches

19. Selection of surgical approach
• Successful management of distal humerus fractures depends on the
right selection of surgical approach.
• The approach depends on these factors
1. Individual fracture pattern -
2. The patient’s bone biology - Osteoporosis
3. Planned procedures – Total Elbow Arthroplasty

20. Olecranon Osteotomy Approach – 52-57%
Indications
Good access to Type C3 fractures
Limitations
Poor anterior access to capitellum
Complications
• Nonunion
• failure of the fixation of the
osteotomy site
• Implant removal

21. • Done in 2014/China
• Complication rates up to nearly 50 % have been highlighted.
• in their study 14 out of 33 patients with osteotomy-related complications.
1. one patient presented with non-union
2. two with delayed-union
3. five with implant loosening
4. Six patients complained about prominent implants
5. Nine underwent a removal of the osteotomy fixation
6. Six cases needed a total implant removal for other reasons

22. Triceps reflecting approach – 26%
This spares the triceps mechanism by reflecting from the
medial and lateral direction and has the advantage of
avoiding damage to the extensor mechanism.
Indications
ORIF ( Type A, B and simple C fractures)
Benefits
The lower postoperative complication rate
Shorter rehabilitation time
Limitations
Poor access to the articular surface for internal fixation

23. Triceps splitting approach – 35- 37%
Indications –
1. ORIF ( Type A,B and simple C fractures)
2. TEA
Complications
1. Risk of triceps detachment

24. Triceps sparing VS Olecranon osteotomy approach
• Done in 2014
• In this study, they found better functional outcomes for type C1 and
C2 distal humerus fractures that were exposed using the triceps-
sparing approach rather than olecranon osteotomy.
• Even for the most complex type of fracture, C3 fractures, similar
recoveries in elbow function were achieved using either approach.

25. ORIF - Implant options
Reconstruction VS locking plates

26. • Done in 2008
• They found that locking constructs are not needed in good quality bone
• Locking plates are indicated only
• In the presence of severe comminution
• Poor bone quality
• In a low intra-articular fracture of the distal humerus

27. Plate configuration
Orthogonal plating technique Parallel plating technique

28. Advantages
Coronal fractures can be fixed well in this configuration
Problems with orthogonal plating -
1.Biomechanics
Orthogonal plating…..

29. The lateral column was often the first to
fail as a result of excessive varus forces
acting on the elbow during normal
activities of daily living.
Problems with orthogonal plating…..

30. • Varus stresses pull the lateral column
and capitulum away from the posterior
plate.
• Screw failure occurs by direct pullout
from the soft and/or comminuted bone
Conclusion
Posterior plating is less resistant to varus
forces than a parallel plating technique.
Problems with orthogonal plating…..

31. 2. Small anterior-posterior diameter
• Smaller diameter of the humerus, permitting only one or two short
screws for fixation.
3. Interruption of blood supply to the lateral column
• blood supply to the lateral column is also derived from posterior
segmental vessels. Sagittal plane plating has less risk of injuring these
structures, which may improve the chances of union
Problems with orthogonal plating…..

32. Parallel versus orthogonal plate osteosynthesis
Done in2019
A meta-analysis of 17 biomechanical
studies demonstrated greater strength
and stiffness in axial and torsional loads
in parallel plating compared with
orthogonal plating.

33. Which plating technique is superior?

34. Parallel versus orthogonal plate osteosynthesis
Done on 2009
Conclusion
• a parallel plating method appears to better provide rigid fixation that is adequate for
obtaining bone union.
• However, no significant differences were observed between the orthogonal and
parallel double plating methods in terms of clinical outcomes and complication rates.
• If appropriately applied with suitable plates, both parallel and orthogonal positioning
can provide adequate stability and anatomic reconstruction of the distal humerus
fractures

35. Done in 2019/ China
Conclusion
• Both orthogonal plating and parallel plating method could achieve
satisfactory outcomes with similarly low complications.
• The parallel plating group had significantly shorter union time than the
orthogonal plating group.
• However, taking the heterogenicity and small sample size into
consideration, more high-quality RCTs are required to go a step further in
demonstrating the benefits of parallel plating fixation in the treatment of
distal humerus fracture

36. Strategy focuses on maximizing stability between the distal fragments and the
shaft of the humerus at the metaphyseal level

37. Closed arch construction technique
Principles of fixation for distal humerus
fractures – Proposed O`Driscoll
1- Maximize fixation in the distal fragments.
2- All fixation in the distal fragments should
contribute to stability between the shaft and
the distal fragments

38. Technical objective - 1
Every screw in the distal fragment
should pass through a plate.

39. Every screw in the distal fragment should be
anchored in a fragment on the opposite side
that is fixed by a plate.
Technical objective - 2

40. As many screws as possible should be
placed in the distal fragments.
Technical objective - 3

41. Every screw in the distal fragment
should be as long as possible
Technical objective - 4

42. Technical objective 5
Every screw in the distal fragment
should engage as many articular
fragments as possible.
Technical objective - 5

43. The screws in the distal fragments
should lock together by interdigitation,
creating a fixed-angle structure, thereby
completing the arch or closing the loop
Technical objective - 6

44. The plates should be applied with
compression at the supracondylar
level
Technical objective – 7

45. The plates should be strong enough and
stiff enough to resist bending or breakage
before union occurs.
Technical objective - 8

46. Other Surgical Techniques….
• In the presence of supracondylar comminution, shortening of the
metaphysis is acceptable.
• The anterior and posterior fossae must be clear of metal or scar tissue
and are recreated with a burr when metaphyseal shortening exists.
• Care must be taken to never shorten the trochlea; in patients with
comminution, position screws are used and bone defects are grafted
to maintain trochlear width.
• A free and decompressed ulnar nerve should be confirmed

47. • The capitellum is often driven into the radial column, requiring
disimpaction to restore articular anatomy.
• Interfragmentary compression
• Under contouring of the plates
• Usage of DCP holes of the plates
• Clamps
Surgical Techniques….

48. Ulnar nerve transposition continues to be a controversial.
The benefits of transposition
1. Minimizing intraoperative traction
2. Prevention of future subluxation
3. Avoidance of irritation by prominent implants.
The Risks of transposition
1. Microtrauma
2. Devascularization
3. Scarring to the nerve
4. May paradoxically cause constriction anteriorly or at the sites of inadequate
release.
Ulnar nerve transposition

49. Ulnar nerve transposition
• One level II paper looked at 29 patients with a distal humeral fracture with pre-
operative ulnar nerve symptoms, and compared anterior transposition with in situ
decompression. They found a statistically improved rate of complete ulnar nerve
recovery (80%) in the anterior transposition group, compared with in situ
decompression alone (57%).
• Conversely, a number of studies have looked at routine anterior nerve transposition
in patients who had normal preoperative ulnar nerve function. The rate of
postoperative ulnar neuropathy was found to be between 0-12.5%
• Doornberg et al. analyzed 30 patients treated without ulnar nerve decompression,
with a follow-up between 12 and 30 years. Only one patient had signs of ulnar nerve
dysfunction at the final follow-up. They, therefore, concluded that routine ulnar
nerve decompression was not routinely indicated.

50. Done in 2021/ Canada
Conclusion
No any significant difference in outcomes when comparing ulnar nerve mobilization and
in situ placement and anterior subcutaneous transposition after bicolumnar plate fixation
of a distal humerus fracture.
Either strategy for managing the ulnar nerve is acceptable and can be used at the
discretion of the treating surgeon.

51. The role of total
elbow arthroplasty
(TEA)
Indications
Patients with unreconstructable complex fracture patterns
Limitations
lifelong lifting restriction - 4-5Kg
Revision surgery is somewhat limited and the chance of
failure rate is high.
Contraindications
1. Physiologically young
2. high-demand patients

52. Risks and Benefits
• In properly selected patients, early TEA offers a more predictable
early return to function because it does not rely on bony healing and
it preserves the extensor mechanism
• Aseptic loosening, polyethylene wear, osteolysis and periprosthetic
fracture are all documented complication
The role of total elbow arthroplasty (TEA)

53. Elbow Hemiarthroplasty
EHA is considered as an alternative form
of arthroplasty in active elderly/ young
patients with an unreconstructed acute
distal humeral fracture.

54. THE ROLE OF ELBOW HEMIARTHROPLASTY (EHA)
• Requires
• Anatomic distal humerus component
• An intact coronoid process and radial head
• Good healing potential of the collateral
ligaments.
• Theoretical benefits
• Shorter surgical times
• Lower rates of loosening
• Avoidance of polyethylene wear
• Better durability
• Avoidance of the lifting restrictions.
Drawbacks
• Increased risk of instability
• ulnar wear

55. Thank you