distal humerus fracture

1. GRAND ROUND
Dr. Yasir Jameel
Clinical Fellow Orthopedic Trauma

2. • 25 year old young male H/O fall at work, C/o
pain and swelling left elbow.

3. • History

4. • Age, sex, occupation
• Presenting complain
• History of PC
• Past medical history
• Past surgical history
• Drugs, Allergies
• Social history

5. Investigations
• X-Ray
• Blood works
• CT scan?

6. X-rays

7. X-rays

8. X-rays

9. Distal Humerus Fracture
• Approx. 2% of all fractures
• 15% of all humerus fractures.
• Young patient due to high energy trauma
• Older patients due to (low energy)slip and fall
• Male young age
• Female elderly >60

10. Mechanism of injury
• The fracture pattern
may be related to the
position of elbow
flexion when the load
is applied
• A elbow bent at 90deg
• B elbow loaded
directly on olecranon
• C elbow bent >
110deg loaded at
olecranon

11. Distal Humerus Fracture
• Consists of
• supracondylar fractures
• single column (condyle) fractures
• bicolumn fractures
• coronal shear fractures
• Most common distal humerus
intercondyler fracture

12. osteology
• Constrained hinge joint
• 2 columns Medial and
lateral
• Trochlea as tie arch
• Angulation
– 4-8 deg valgus
– 3-8 deg ER
– Medial 45deg flexion
– Lateral 20 deg flexion
• Articular cartilage
– Trochlea 300deg
– Capitellum 180 deg

13. osteology
•Very thin sections
of bone at
olecranon fossa,
radial fossa,
coranoid fossa
•Provide room
for ROM without
impingment
•Weak area

14. Evaluation
• Clinical Symptoms
– elbow pain and swelling/open wounds.
• Physical exam
– gross instability often present
– avoid ROM due to risk of neurovascular damage
• neurovascular exam
– check function of radial, ulnar, and median nerve
• Distal vascularity:
– brachial artery may be injured
– if pulse decreased, obtain noninvasive vascular studies;
consult vascular surgery if abnormal
– monitor carefully for forearm comparment syndrome

15. Classification.A0OTA
• A –Extra Articular
• B –Partial Articular
• C –Total articular –No
continuity of shaft to
articular surface

16. Jupiter classification
• A -High T
• B -Low T
• C -Y
• D -H
• E -Medial lambda
• F -Lateral lambda

17. 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

18. Historical overview.
• Pionering operative tactics-Lambotte 1913
• ”Bag-of- bones” -Eastwood 1937.Brown & Morgan 1971-
• Scharphlatz and allgower 1975 articular reduction, articular
diaphyseal continuity and olecranon osteotomy.
• Stable fixation- Morrey et al 1981
• Jupitar 1985 – reduction techniques 27 of 36 pts with good
to excellent results
• Helfet and schmeling 1993- sumrised principal of reduction
and dual platting and anatomical reduction with 75% good
to excellent results, first time described early ROM.
• Precontoured plates-Shawn O’Driscol 2002

19. Treatment options
• Non operative
– Elderly not fit for surgery ( cast imobilization)
• Operative
– Distal humerus fracture displaced / undisplaced
Extraarticular / intraarticular

20. Surgical technique

21. Positioning
• Lateral decubitus position
• Prone positioning possible
– Arm hanging over a post
– Sterile tourniquet if
desired
• Exposure dependent on
fracture pattern.
• Exposure affects ability to
achieve reduction
• Exposure influences
outcome!
• Choose the exposure that fits
the fracture pattern.

22. Approaches
• Direct posterior/triceps
split .
• Triceps-sparing postero-
medial approach (Bryan-
Morrey Approach)
• Needs experience
– Midline incision
– Ulnar nerve identified and
mobilized
– Medial edge of triceps and
distal forearm fascia
elevated as single unit off
olecranon and reflected
laterally
– Resection of extra-articular
tip of olecranon

23. Olecranon osteotomy
• Improves visualisation –distal comminution.
• Types-
-transverse-technically easier to do.
-higher incidence of nonunion-Gainor et al
1995
-chevron-apex distal-more stable,technically
difficult.

24. Chevron osteotomy.
• Pre-drill and tap olecranon
• –Create chevron apex
distal
• –Protect the articular
surface by going through
the last milimeterwith an
osteotome
• –Aim for the ‘bare patch’at
the apex of the trochlear
notch

25. Fixation of the osteotomy.
• Tension band wire
• Plate and screw
• 6.5 cancellous screw and
tbw

26. Chevron osteotomy.
• Coles et al (2006) J Orthop Trauma 20:164
• 70 chevron osteotomies
– All fixed with screw plus tension band or with
plate-and-screw construct
– 67 with adequate follow-up: all healed
– 2 required revision fixation prior to healing
– 18 of 61 with sufficient follow-up required implant
removal

27. Principle based parallel plate technique
Shawn W. O’Driscoll,jbjs 2007.
• Treatment fails bc of non union at sc level or
stiffness resulting from prolonged immob in
an attempt to avoid hardware failure.
• Either way limiting factor is fixation of distal
fragment to the shaft.
• To obtain union and mobility.
-maximal fixation in distal fragment.
-stability between distal fragment and shaft.

28. Controlling fragment rotation.

29. Plate application,provisional fixation.

30. Distal fixation.

31. Supracondylar compression.

32. In order to do this 7 objectives
• Every screw in major distal fragment-
1.should pass thru a plate
2.engage a fragment on the opposite side.
3.be as long as possible.
4.engage as many fragments as possible.
Additional:
1.As many screws as possible should be placed in
the distal fragment.
2.Plates should allow union at sc level.
3.Plates strong enough to resist before union
occurs.

33. Final construct
• The screws in the distal
fragments interlock,
providing additional stability
to the construct.
• “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

34. Ulnar nerve transposition
• Identification and
mobilization of the
ulnar nerve is often
required
• Ulnar nerve palsy may
be related to injury,
surgical
exposure/mobilization/
stripping, compression
by implant, or scar
formation

35. Ulnar nerve transposition
• Wang et al (1994) J Trauma 36:770
– consecutive series of distal humeral fractures
treated with ORIF and anterior ulnar nerve
transposition had no post-operative ulnar nerve
compression syndrome.
– overall results: Excellent/Good 75%, Fair 10%, and
Poor 15%.
– conclusion: routine anterior transposition
indicated.

36. Ulnar nerve transposition
• Chen et al (2010) J Orthop Trauma 24:391
– Retrospective cohort comparison
–89 patients underwent transposition, 48
patients did not
– 4x greater incidence of ulnar neuritis in patients
receiving transposition
– Conclusion: routine ulnar nerve transposition not
recommended during ORIF of distal humerus
fractures

37. Post op care.
• Measure and document rom obtained
• Therapist will blame implants for loss of rom.
• Bulky splint applied intra-op
• Elbow position
– 90 degrees of flexion or extension?
– Authors support either and proponents strongly
argue that their position is the best
• Extension is harder to recover than flexion
• Final arc of motion recovered is more functional
if centered on 90 degrees of flexion
• Use what works in your hands and rehab
protocol

38. complications
• Ulnar nerve injury( in type c up to 25%)
• Elbow stiffness
– most common flexion contracture mainly loss of terminal extension
• Heterotopic ossification
– reported rate of 8%
– routine prophylaxis is not warranted
• increased rate of nonunion in patients treated with indomethacin
• Nonunion
– low incidence(2-10%) mainly supracondyler then trochlear grove.
– avoide excessive soft-tissue stripping
• Malunion
– avoided by proper surgical technique
• cubitus valgus (lateral column fxs)
• cubitus varus (medial column fxs)
• DJD

39. Cassebaum 1969
• Described criteria for range of motion of
elbow as an outcome meassure post ORIF
• As excellent being 15 deg to 130 deg range of
motion arc

40. Orif of distal humerus fractures.
• Average 75% good to excellent results.
- jupiter et al-jbjs 1985
- sanders et al –orthopaedics 1992
- caja et al-injury 1994
- wang et al-trauma 1994
- papalonnou et al-injury 1995
- mckee et al-jbjs 1996

41. Non operative vs operative
• Zagorski 1986 : 76% good to excellent result in
ORIF, 8% in non-operative
• Robinson 2003 : 2.9% delayed union and 2.9%
nonunion in ORIF, 12% delayed union,17%
nonunion in non-operative.
• Sirinivasan 2005: 52% mild to no-pain, ROM
22- 100, non-op 25 % mild to no-pain and
ROM 36-70. articular step-off 1.2mm in op vs
2.6 in non-op.

42. Recent studies
• Sanchez and sotelo JBJS 2007 : parallel locked
platting, flexion contracture 26 deg, ARC Of
motion 99 deg, HTO 38% (69% in open frX)
• Doomberg jbjs 2007: 19 year follow up after
ORIF, flexion contracture 23 deg, Arc of
motion 106deg, subsequent procedures 40%,
arthrosis 80%.

43. Comparison of different plate
constructs
• J Orthop Trauma. 1994 Dec;8(6):468-75.
• Biomechanical evaluation of methods of internal fixation of the distal humerus.
• Schemitsch EH, Tencer AF, Henley MB.
• University of Toronto, St. Michael's Hospital, Ontario, Canada.
• Abstract
• The best results following fractures of the distal humerus are provided by anatomic
reduction and rigid internal fixation. Plates of two designs placed in five different fixation
configurations were used to determine the construct that would maximize rigidity of fixation
of the distal humerus. Using a cadaver distal humerus osteotomy, with and then without
cortical contact, motion of the distal fragment was measured with respect to the proximal
fragment in axial and torsional loading, anterior to posterior and posterior to anterior
bending, and lateral to medial and medial to lateral bending. With cortical contact, two
plates when placed medial and lateral or at 90 degrees to each other provided equivalent
rigidity. However, with a cortical gap, the combination of a specially designed anatomic
lateral buttress "J" plate and a medial reconstruction plate gave the greatest rigidity (ANOVA,
p < 0.05). Two-plate constructs do not require placement at 90 degrees to obtain sufficient
rigidity, but do require placement on separate bony pillars and different surfaces

44. Summary Distal Humerus
• Preoperative planning CT scans Approach
• ORIF successful in the majority of patients
• Reestablish joint surface anatomically
• Stability between distal fragment and
Humeral shaft
• Early Rehabilitation Active and passive ROM
• Severe bone loss (low demand seniors)
Consider primary elbow arthroplasty !

45. THANK YOU