DISTAL HUMERUS FRACTURE

1. DISTAL HUMERUS FRACTURE
DR.Dipendra singh chhetri
UCMS

2. ANATOMY
• Hinged joint with single axis of rotation
(trochlear axis)
• Trochlea is center point with a lateral and
medial column

3. • Distal humerus is 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 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.

5. • 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.

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
– distal intercondylar fractures are the most
common fracture pattern
• demographics
– most common in young males and older females

14. Pathophysiology
• mechanism
– low energy 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
– elbow pain 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 AND LATRAL VIEW
• CT

17. PROGNOSIS
• majority of patients 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 AO Long 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 splint stabilization
• 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 of bone 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 column fracture(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
- Distal humerus 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. Anatomic articular 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 FOR FIXATION
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 screw should 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 should be 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.Olecranon osteotomy
2.tricep splitting
3.tricep reflecting
4.tricep detaching

32. ANTERIOR
MEDIAL
LATERAL

33. POSTERIOR APPROACH
MOST COMMON FRACTURE 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 FOR ALL POSTERIOR
APPROACHES
1. Lateral decubitus position also called as
swimmer’s position.
2.Arm hanging over a post
3.With tourniquet.

35. • Longitudinal midline skin 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 subcutaneo us 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 of the distal humreus especially the
intercondylar area is excellent after an
osteotomy

40. Osteotomy approach is best 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 the tricep 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
• As a 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
• The triceps 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 case shown 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 view shows 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
The fascia 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 to the
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
• Skin incision
• 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
• The deep fascia
is incised in line
with the skin
incision.

54. • The lateral humeral
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 of the 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 medial intermuscular
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 fragment is
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 a simple fracture with strong bone stock,
the main fragments can be reduced
anatomically. Preliminary fixation with axial K-
wires may be helpful.

65. PLATE PREPERATION
• Precontoured anatomic 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 plate length 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
• The ulnar 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 radial plate 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 good way 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
with Weber
clamps
• Replace Weber
clamps with
lag screws

73. PLATE SELECTION AND APPLICATION
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 option is 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 option is 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 both plates. 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
Triangle of 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 of the articular surface
Condylar reassembly
-Reduce and hold the articular fragments
using cannulated screw guide wires.

79. Definitive fixation of articular
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
• Temporary fixation
Reduce the reconstituted articular mass to
the metaphysis and use K-wires for preliminary
fixation.

82. PLATE PREPERATION
• The plates 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
• First place 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 of the 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 another plate 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 parallel plating it is customary to reduce
and provisional by secure all of the fracture
fragments prior to plate application.

87. • Contoured 3.5-millimeter reconstruction
plates or precontoured plates are selected for
direct lateral positioning on the lateral column
and direct medial positioning on the medial
column.

88. • The plates should 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 plate fixation 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. • The end