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![PARA-TRICIPITAL (TRICEPS
PRESERVING) APPROACH [ALONSO-
LLAMES ]
Skin incision
• Make a straight incision beginning level with the
junction of the middle and distal thirds of, and
centered on, the humeral shaft. Some surgeons
make a straight incision, whereas others prefer to
curve the incision around the olecranon to the
radial side. The incision ends over the ulnar
diaphysis.
• An ulnar-based subcutaneous flap is developed.](https://image.slidesharecdn.com/distalhumerusfracture-180105154014/85/Distal-humerus-fracture-42-320.jpg)
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Distal humerus fracture
- 1. DISTAL HUMERUS FRACTURE DR.Dipendrasingh chhetri UCMS
- 2. ANATOMY • Hinged jointwith single axis of rotation (trochlear axis) • Trochlea is center point with a lateral and medial column
- 3. • Distal humerusis a cylindrical diaphysis that flattens above the elbow and diverges into triangular medial and lateral columns. • Each column is bounded on its outer border by supracondylar ridge and an outer non articular surface and inner articular surface
- 4. • The medialand 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.
- 5. • The trochleais 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.
- 7. Posterior Structures : •Skin & Subcutaneous Tissue • Triceps Muscle With Aponeurosis • Ulnar Nerve – Behind Medial Epicondyle • Posterior Capsule
- 10. 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
- 11. MEDIAL STRUCTURES: • MCL •Flexor Group Of Muscles • Ulnar Nerve passes from behind the medial epicondyle and distally between the FCU and FDP
- 12. LATERAL STRUCTURES: • LCL •Anconeus • Extensors Of The Wrist
- 13. • incidence – distalintercondylar fractures are the most common fracture pattern • demographics – most common in young males and older females
- 14. Pathophysiology • mechanism – lowenergy falls in elderly – high energy impact in younger population • pathoanatomy – elbow position affects fracture type • elbow flexed < 90 degrees – axial load leads to transcolumnar fracture – direct posterior blow leads to olecranon fracture with or without distal humerus involvement • elbow flexed > 90 degrees – may lead to intercondylar fracture
- 15. PRESENTATION • Symptoms – elbowpain and swelling • Physical exam – gross instability often present • avoid ROM due to risk of neurovascular damage – neurovascular exam • check function of radial, ulnar, and median nerve • check distal pulses – brachial artery may be injured – if pulse decreased, obtain noninvasive vascular studies; consult vascular surgery if abnormal – monitor carefully for forearm compartment syndrome
- 16. IMAGING • AP ANDLATRAL VIEW • CT
- 17. PROGNOSIS • majority ofpatients regain 75% of elbow motion and strength • goal is to restore elbow ROM 30-130 degrees of flexion • unsatisfactory outcomes in up to 25% – treatment of these fractures is complex due to: • low fx line of one or both columns • metaphyseal fragmentation of one or both columns • articular comminution • poor bone quality
- 18. OTA CLASSIFICATION Follows AOLong Bone System • Humerus (#1X-XX), distal segment (#X3XX) = 13- XX • 3 Main Types Extra-articular fracture (13-AX) Partial articular fracture (13-BX) Complete articular fracture (13-CX) Each broad category further subdivided into 9 specific fracture types
- 19. Humerus, distal segment(13) – Types • Extra-articular fracture (13-A) • Partial articular fracture (13-B) • Complete articular fracture (13-C)
- 21. TREATMENT • Conservative management: 1.Cast or splint stabilization 2. Traction 3. Bag of bones technique rarely recommended for young recommended for medical unfit weekly xray for 3-4 week
- 22. Cast or splintstabilization • It can be used in minimal or non displaced fractures. • Disadvantage is that poor maintenance of fractured fragments and lack of early mobilization
- 23. The bag ofbone technique -This technique involves placing the arm in a collar and cuff with the elbow in marked flexion. – allows gravity associate reduction - Recommended for surgical unfit patients and elderly whose functional goals are limited.
- 24. SURGICAL TREATMENT Single columnfracture(B1 and B2) Comprising 15% of all distal humerus fracture. -Lateral column fractures addressed with kocher approach - Medial column fractures are apporached with posterior triceps reflecting or transolecranon approach.
- 25. Bicolumn fractures - Distalhumerus are operated with olecranon osteotomy, triceps-splitting or Triceps Reflecting Anconeus Pedicle approach. - Orthogonal plate or parallel plate are usally used
- 27. TREATMENT PRINCIPLES 1. Anatomicarticular reduction 2. Stable internal fixation of the articular surface 3. Restoration of articular axial alignment 4. Stable internal fixation of the articular segment to the metaphysis and diaphysis 5. Early range of motion of the elbow
- 28. TECHNICAL OBJECTIVE FORFIXATION 1.Every screw should pass through a plate. 2. Each screw should engage a fragment on the opposite side that is also fixed to a plate. 3. As many screws as possible should be placed in the distal fragments. 4. Each screw should be as long as possible.
- 29. 5. Each screwshould engage as many articular fragments as possible. 6. The screws should lock together by interdigitation within the distal fragment, thereby creating a fixed-angle architecture that provides stability to the entire distal humerus.
- 30. 7. Plates shouldbe applied such that compression is achieved at the supracondylar level for both columns. 8. Plates used must be strong enough and stiff enough to resist breaking or bending before union occurs at the supracondylar level
- 31. SURGIGAL APPROACH • POSTERIOR 1.Olecranonosteotomy 2.tricep splitting 3.tricep reflecting 4.tricep detaching
- 32.
- 33. POSTERIOR APPROACH MOST COMMONFRACTURE FIXATION • 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
- 34. COMMON STEPS FORALL POSTERIOR APPROACHES 1. Lateral decubitus position also called as swimmer’s position. 2.Arm hanging over a post 3.With tourniquet.
- 35. • Longitudinal midlineskin incision over the posterior aspect of the elbow • 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
- 36. • Raising subcutaneous flaps on either side • Isolation of the ulnar nerve
- 37. OLECRANON OSTEOTOMY APPROACH Olecranon osteotomy. •There are two types 1. Transverse osteotomy 2. Chevron osteotomy.
- 39. • Exposure ofthe distal humreus especially the intercondylar area is excellent after an osteotomy
- 40. Osteotomy approach isbest used to visualise the distal humerus. • Most suited for all type Communited fractures Disadvantages are 1. Nonunion at the osteotomy site 2. Hardware irritation
- 41. • Rise thetricep with proximal olecranon,and direct the tricep musculature off the humerus preserving the periosteum • Plate the column with the better key to reduction first and than the opposite column • Reconstruct the articular surface around the clock • After proper fixation repair olecranon osteotomy and and transport the ulnar nurve
- 42. PARA-TRICIPITAL (TRICEPS PRESERVING) APPROACH[ALONSO- LLAMES ] Skin incision • Make a straight incision beginning level with the junction of the middle and distal thirds of, and centered on, the humeral shaft. Some surgeons make a straight incision, whereas others prefer to curve the incision around the olecranon to the radial side. The incision ends over the ulnar diaphysis. • An ulnar-based subcutaneous flap is developed.
- 44. Ulnar window • Asa first step, the ulnar nerve is isolated and protected with a vessel loop. • Proximally, the ulnar nerve is followed along its course on the medial intermuscular septum, and the triceps muscle is mobilized radially.
- 45. Radial window • Thetriceps fascia is split, and the muscle is mobilized from the lateral intermuscular septum and humerus towards the ulnar side. • Distally, the anconeus muscle is detached from the radial column as much as is necessary.
- 46. In the caseshown here, going up into the diaphysis, the radial nerve was identified and held with a vessel loop (1). The entire triceps muscle is isolated with a gauze wrap (2). This permits the whole triceps muscle to be moved towards either the lateral or medial side, in order to get access to the humerus ("triceps flip").
- 47. Posterior triceps-elevating approach •Incision as previously • The ulnar nerve is identified proximally along the medial border of the triceps. It is then released from the cubital tunnel distally, through the flexor pronator aponeurosis to the level of its first anterior motor branch. • A vessel loop is placed around the ulnar nerve, which is protected throughout the entire procedure.
- 48. This intraoperative viewshows the ulnar nerve freed and tagged with a vessel loop. Incise the fascia over the flexor carpi ulnaris muscle at the border of the ulnar bone, as the first step in the preparation of the extensor apparatus flap.
- 49. • Extensor apparatus Thefascia is detached subperiosteally from the ulna towards the radial side. At the level of the olecranon the extensor apparatus is detached together with a using a fine chisel.
- 50. • Proximal tothe olecranon the posterior capsule is incised. At the level of the humerus the extensor muscles are freed from the bone. • Now the entire extensor apparatus flap can be retracted to the radial side. • To enhance visualization of the articular surface, the elbow should be flexed beyond 100 degrees.
- 51. LATERAL APPROACH • Skinincision • The incision starts over the lateral supracondylar ridge, 5 cm proximal to the elbow joint. It passes distally to the lateral surface of the proximal forearm, posterior to the radial head
- 53. Deep dissection • Thedeep fascia is incised in line with the skin incision.
- 54. • The lateralhumeral epicondyle is exposed by developing the interval between the triceps muscle posteriorly, and the brachioradialis and extensor carpi radialis longus anteriorly. • The dissection is continued distally between the extensor carpi ulnaris and the anconeus muscles.
- 55. Opening the joint •The joint capsule is incised longitudinally from the distal part of the lateral humeral epicondyle, over the capitellum and then over the postero- lateral aspect of the radial head. Alternatively, the capsule can be incised as a proximally based U- shaped flap.
- 56. MEDIAL APPROACH Skin incision •An incision is started 5 cm above the elbow joint, centered over the medial supracondylar ridge and the medial epicondyle, and passes to below the elbow joint.
- 57. • Identification ofthe ulnar nerve • Identify the ulnar nerve proximally between the triceps and the medial intermuscular septum, in the groove posterior to the medial epicondyle and distally between two heads of the flexor carpi ulnaris. • Gently free and protect the ulnar nerve.
- 58. Release the medialintermuscular septum from the medial supracondylar ridge of the humerus for a distance of about 5 cm proximally. Retract anteriorly the flexor/pronator muscle mass to visualize the joint capsule. The planned capsulotomy is marked in red.
- 59. Reduction and fixation •Fixation for 13A-1 consist of medial epicondyle lateral epicondyle
- 60. Lateral epicondyle fixation PRINCIPLE •This is an avulsion fracture of the lateral epycondyle. By definition, there is no involvement of the joint (capitellum). The fracture is an equivalent of an avulsion of the origin of the extensor tendons. Typically, this injury occurs in young patients. In order to avoid varus instability of the elbow, the fragment should be fixed.
- 61. Mobilize the fragment •Open the fracture site by mobilizing the fragment. • Clean out the fracture by removing blood clots and interposed tissue. Reduction • Reduce the fragment. Hold it temporarily in place either with a dental hook or a K-wire.
- 62. Drilling • The fragmentis fixed with a lag screw. Usually the fragment is small and takes only 1 screw. If the fragment is large enough, you may use two screws. Screw insertion • Insert the screw.
- 63. Extraarticular fractures, metaphyseal simple,oblique downwards Principles Shear forces lead to an oblique separation of the metaphyseal Due to strong rotational forces at the level of the elbow, stabilization with plates on the ulnar and radial columns is preferred. The plates should be applied in a compression mode
- 64. Reduction • In asimple fracture with strong bone stock, the main fragments can be reduced anatomically. Preliminary fixation with axial K- wires may be helpful.
- 65. PLATE PREPERATION • Precontouredanatomic plates • one-third tubular plate may be used on the crest of the medial supracondylar ridge, • reconstruction plate on the posterior aspect of the lateral column. • If a stronger plate is required, a small fragment dynamic condylar plate may be used, but this is more difficult to contour.
- 66. • The platelength should allow for at least 2 screws in each fragment. • On the ulnar side, the plate is bent around the epicondyle, • on the radial side, the plate can be placed distally onto the back of the lateral condyle.
- 68. PLATE APPICATION • Theulnar plate is applied first. It serves as an antiglide plate. The plate is contoured around the medial epicondyle and fixed distally. The proximal fragment is then pulled underneath the plate with a first eccentrically drilled screw in the proximal fragment.
- 69. Radial plate The radialplate is applied dorsally on the radial column. Drilling of an eccentric hole for a load screw in the proximal fixation creates compression of the fracture plane.
- 70. Extraarticular fractures, metaphyseal multifragmentary,complex • In this fracture, both columns are comminuted with a wedge on each side. • Therefore, each column should be stabilized with an individual plate.
- 71. REDUCTION Reduction strategy -A goodway to build up stability stepwise is to reconstruct each column by anatomically reducing and fixing the respective wedge to the column -The radial wedge to the radial column (either to the proximal or to the distal fragment), and the ulnar wedge to the ulnar column (either to the proximal or to the distal fragment). • In this way, create a two-fragment fracture.
- 72. • Reduce fracture lines withWeber clamps • Replace Weber clamps with lag screws
- 73. PLATE SELECTION ANDAPPLICATION Preliminary consideration • Both the medial and lateral columns need protection with individual plates. • The plates should have secure purchase in both the distal and the proximal main fragments. • This allows bridging of the comminuted zone of the fracture. • Both plates need to be contoured before application
- 74. • One optionis to place the lateral column plate dorsally and the medial column plate medially. In this position they form an angle of approximately 90 degrees to each other
- 75. • Another optionis to place one plate directly laterally and another plate directly medially. This is referred to as parallel plating. The advantages of this technique include longer screws in the distal fragments and the ability to capture articular fragments with small screws in the subchondral bone.
- 76. • Apply bothplates. A minimum of two screws in each main fragment should be used. • the plates should not end at the same level proximally. One plate should be longer in order to avoid creating a stress
- 77. Complete articular fractures, multifragmentary PRINCIPLE Triangleof stability • Stability of the distal humerus is based on 3 columns: Medial, lateral, and the articular surface. In C-type fractures, all 3 columns have to be restored.
- 78. • Reconstruction ofthe articular surface Condylar reassembly -Reduce and hold the articular fragments using cannulated screw guide wires.
- 79. Definitive fixation ofarticular fragments • Insert a cannulated screw over the guide wire after pre-drilling the pil of hole. Alternatively, insert a non-cannulated screw in the standard manner parallel to the wire, and then remove the wire. • Insert the screw from the lateral to the medial side, so that the screw head does not irritate the ulnar nerve and conflict with the planned position of the medial plate.
- 81. Condylar reattachment • Temporaryfixation Reduce the reconstituted articular mass to the metaphysis and use K-wires for preliminary fixation.
- 82. PLATE PREPERATION • Theplates must be carefully contoured using an appropriate malleable template. • Pace the lateral column plate dorsally and the medial column plate medially. In this position their planes form an angle of approximately 90 degrees to each other.
- 83. DEFINITIVE FIXATION • Firstplace a 3.5 mm reconstruction plate posterolaterally. It may curve around the capitellum which has no cartilage cover posteriorly. • The comminution is bridged if it can not be precisely reduced and fixed with absolute stability. A slightly longer plate is used to provide additional stability.
- 84. • Placement ofthe lateral plate Insert a K-wire through the distal hole. As the plate is pulled proximally, stable contact with the bone is obtained. Now insert the proximal screw.
- 85. Medial plate -Place anotherplate medially on the crest of the medial supra candylar ridge, its plane at right angles to the lateral plate to increase stability. -It is recommended to insert the distal screw into the trochlea below the medial epicondyle.
- 86. • In parallelplating it is customary to reduce and provisional by secure all of the fracture fragments prior to plate application.
- 87. • Contoured 3.5-millimeterreconstruction plates or precontoured plates are selected for direct lateral positioning on the lateral column and direct medial positioning on the medial column.
- 88. • The platesshould extend distally enough to engage all fracture fragments and proximally enough so that 2 or 3 screws in each plate engage the proximal (shaft) fragment. • As many screws as possible are placed in the distal fragments.
- 89. • Proximal platefixation to be done • When there is solid bony contact across the articular and proximal fragments, compression is applied with pointed reduction forceps and eccentrically placed load screws, one column at a time.
- 90.