Normal Anatomy, Mech. of Injury, Classification, Radiological Diagnosis , Management and Complications.

1. DISTAL END HUMERUS
FRACTURES
BY:-Dr. Anshu sharma
Guide:- Dr.A.K. Mathur

2. • Fractures of adult distal humerus areFractures of adult distal humerus are
relatively uncommon comprisingrelatively uncommon comprising
approximately 2%of all fractures and one-approximately 2%of all fractures and one-
third of all humerus fractures.third of all humerus fractures.

3. Anatomy of Distal HumerusAnatomy of Distal Humerus
-->The lower end of the humerus forms the condyles-->The lower end of the humerus forms the condyles
which is expended from side to side, and has articularwhich is expended from side to side, and has articular
and nonarticular parts.and nonarticular parts.
-->The articular parts are:--->The articular parts are:-
Capitellum articulate with head of radius,Capitellum articulate with head of radius,
Trochlea articulate with trochlear notch of ulna.Trochlea articulate with trochlear notch of ulna.
-->The non-articular parts are:--->The non-articular parts are:-
Medial and lateral supra condylar ridge,Medial and lateral supra condylar ridge,
Medial and lateral epicondyles,Medial and lateral epicondyles,
Coronoid fossa,Coronoid fossa,
Radial fossa,Radial fossa,
Olecranon fossa.Olecranon fossa.

6. Ossification center
 There are six epiphysis
around the elbow.
 Time of their
appearance:-
C-1
R-3
I-5 “CRITOL”
T-7
O-9
L-11.
-->These epiphysis
generally unite 2 years
after they first appear.

7. Surgical Anatomy
 Medial and lateral columns diverge from
humeral shaft at 45 degree angle
 The columns are the important structures for
support of the “distal humeral triangle”.

8. SurgicalSurgical
AnatomyAnatomy
The articulating surfaces of
capitellum and trochlea projects
distally and anteriorly at an
angle of 40 to 45 degrees.
-The trochlear axis compared to
longitudinal axis is 4-8 degrees
in valgus.
-The trochlear axis is 3-8
degrees externally rotated.
-The intramedullary canal ends
2-3 cm above the olecranon
fossa.

9. distal
humeral
triangle
Functional Anatomy
 Hinged joint with
single axis of
rotation (trochlear
axis).
 Trochlea is center
point with a lateral
and medial column.

10. The blood supply of the distal humerus. A. Anterior view. B. Posterior
view.
SUC, superior ulnar collateral artery; B, brachial artery; IUC, inferior
ulnar collateral artery; RR, radial recurrent artery; PUR, posterior ulnar
recurrent artery; R, radial artery; RC, radial collateral artery; MC, middle
collateral artery; IR, interosseous recurrent artery.

11. Blood supplyBlood supply
• The distal humerus thus has a richThe distal humerus thus has a rich
anastomotic blood supply and problemsanastomotic blood supply and problems
with healing and osteonecrosis arewith healing and osteonecrosis are
therefore relatively uncommon.therefore relatively uncommon.
• During reduction and internal fixation ofDuring reduction and internal fixation of
complex closed distal humeral fractures,complex closed distal humeral fractures,
retention of even completelyretention of even completely
devascularized fragments is appropriate ifdevascularized fragments is appropriate if
they are large and contributing to thethey are large and contributing to the
stability of the reconstruction.stability of the reconstruction.

12. ImagingImaging
• RadiographsRadiographs
– recommended viewsrecommended views
• obtain AP and lateral of humerus and elbow.obtain AP and lateral of humerus and elbow.
• include entire length of humerus and forearm.include entire length of humerus and forearm.
– additional viewsadditional views
• obtain wrist radiographs if elbow injury present or distal tenderness on examobtain wrist radiographs if elbow injury present or distal tenderness on exam
• oblique radiographs may assist in surgical planningoblique radiographs may assist in surgical planning
• traction radiographs may assist in surgical planningtraction radiographs may assist in surgical planning
– specifically evaluate if there is continuity of the trochlear fragment to medialspecifically evaluate if there is continuity of the trochlear fragment to medial
epicondylar fragment, this can influence hardware choiceepicondylar fragment, this can influence hardware choice
• CTCT
– often obtained for surgical planning.often obtained for surgical planning.
– especially helpful when shear fractures of the capitellum and trochleaespecially helpful when shear fractures of the capitellum and trochlea
are suspected.are suspected.
– 3D CT scan.3D CT scan.
• MRIMRI
– usually not indicated in acute injury.usually not indicated in acute injury.

13. Radiograph Anatomy/LandmarksRadiograph Anatomy/Landmarks
Fat pad signFat pad sign
-Note the non- displaced
fracture (Red Arrow).
-Note the posterior fat pad
(Yellow Arrows).

14. Radiograph Anatomy/LandmarksRadiograph Anatomy/Landmarks
Baumann’s angleBaumann’s angle
Baumann’s angle is formed by a line
perpendicular to the axis of the humerus,
and a line that goes through the physis of
the capitellum.
A normal angle is approximately 85-9°, and
so when reducing paediatric supracondylar
humerus fractures, a deviation of more
than 5° from the contralateral side should
not be accepted.

15. Radiograph Anatomy/LandmarksRadiograph Anatomy/Landmarks
Ant.humeral lineAnt.humeral line
• Anterior HumeralAnterior Humeral
LineLine
– Drawn along theDrawn along the
anterior humeralanterior humeral
cortexcortex
– Should pass throughShould pass through
the middle of thethe middle of the
capitellumcapitellum
– Variable in veryVariable in very
young childrenyoung children-Rogers. Plastic bowing, torus and greenstick supracondylar
fractures of the humerus: radiographic clues to obscure
fractures of the elbow in children. Radiology. 1978;128:145.
-Herman. Relationship of the anterior humeral line to the
capitellar ossific nucleus: variability with age. J Bone Joint

16. Radiograph Anatomy/LandmarksRadiograph Anatomy/Landmarks
Humerocapitellar angleHumerocapitellar angle
• The capitellumThe capitellum
is angulatedis angulated
anteriorly aboutanteriorly about
30 degrees.30 degrees.
• TheThe
appearance ofappearance of
the distalthe distal
humerus ishumerus is
similar to asimilar to a
hockey stick.hockey stick.
30

17. Radiograph Anatomy/LandmarksRadiograph Anatomy/Landmarks
Radiocapitellar lineRadiocapitellar line
• RadiocapitellarRadiocapitellar
line shouldline should
intersect theintersect the
capitellumcapitellum in allin all
views.views.
• Make it a habitMake it a habit
to evaluate thisto evaluate this
line on everyline on every
pediatric elbowpediatric elbow
film.film.

18. Classification of FracturesClassification of Fractures
• The AO-ASIF Group have defined threeThe AO-ASIF Group have defined three
types of distal humeral fractures:-types of distal humeral fractures:-
-->Type A-An extra articular supracondylar-->Type A-An extra articular supracondylar
fractures,fractures,
-->Type B-An intracondylar unicondylar-->Type B-An intracondylar unicondylar
fractures,fractures,
-->type C-Bicondylar fractures with varying-->type C-Bicondylar fractures with varying
degree of comminution.degree of comminution.

19. Supracondylar Humerus FracturesSupracondylar Humerus Fractures
• Most common fracture around the elbow inMost common fracture around the elbow in
children.children.
– 60 percent of elbow fractures.60 percent of elbow fractures.
• 95 percent are extension type injuries.95 percent are extension type injuries.
– Produces posterior angulation/displacement of theProduces posterior angulation/displacement of the
distal fragment.distal fragment.
• Occurs from a fall on an outstretched hand.Occurs from a fall on an outstretched hand.
– Ligamentous laxity and hyperextension of the elbowLigamentous laxity and hyperextension of the elbow
are important mechanical factors.are important mechanical factors.
• May be associated with a distal radius orMay be associated with a distal radius or
forearm fractures.forearm fractures.

20. Supracondylar Humerus FracturesSupracondylar Humerus Fractures
Associated InjuriesAssociated Injuries
• Nerve injury incidence is high, between 7 and 16 %.Nerve injury incidence is high, between 7 and 16 %.
– Radial nerve,Radial nerve,
– Median nerve,Median nerve,
– Ulnar nerve (flexion type).Ulnar nerve (flexion type).
• Radial nerve injury is most commonly injured nerve.Radial nerve injury is most commonly injured nerve.
• In many cases, assessment of nerve integrity is limitedIn many cases, assessment of nerve integrity is limited
because children can not always cooperate.because children can not always cooperate.
• 5% have associated distal radius fracture.5% have associated distal radius fracture.
Physical exam of distal forearm and Radiographs ifPhysical exam of distal forearm and Radiographs if
needed.needed.
• Vascular injuries are rare, but pulses should always beVascular injuries are rare, but pulses should always be
assessed before and after reduction.assessed before and after reduction.
• In the absence of a radial and/or ulnar pulse, theIn the absence of a radial and/or ulnar pulse, the
fingers may still be well-perfused, because of thefingers may still be well-perfused, because of the

21. Supracondylar Humerus Fractures
Gartland’s Classification
 Type 1
 An undisplaced fracture.
 Type 2
 Angulated/displaced fracture
with intact posterior cortex.
 2A-a less severe injury with
distal fragment merely
angulated,
 2B-a severe injury with
distal fragment is both
angulated and malroated.
 Type 3
 Complete displacement,
with no contact between
fragments.

22. Supracondylar Humerus FracturesSupracondylar Humerus Fractures
TreatmentTreatment
• Type 1 FracturesType 1 Fractures
– In most cases, these can be treated withIn most cases, these can be treated with
immobilization for approximately 3 weeks, at 90immobilization for approximately 3 weeks, at 90
degrees of flexion.degrees of flexion.
– If there is significant swelling, do not flex to 90If there is significant swelling, do not flex to 90
degrees until the swelling subsides.degrees until the swelling subsides.
– It is essential to obtain an x ray 5-7 days later toIt is essential to obtain an x ray 5-7 days later to
check that there has been no displacement.check that there has been no displacement.

23. Supracondylar Humerus FracturesSupracondylar Humerus Fractures
TreatmentTreatment
• Type 2 Fractures: Posterior AngulationType 2 Fractures: Posterior Angulation
– If minimally displaced (anterior humeral line hitsIf minimally displaced (anterior humeral line hits
part of capitellum)part of capitellum)
• Immobilization for 3 weeks.Immobilization for 3 weeks.
• Close follow-up is necessary to monitor for loss ofClose follow-up is necessary to monitor for loss of
reduction.reduction.
– Displaced (anterior humeral line missesDisplaced (anterior humeral line misses
capitellum)capitellum)
• Reduction may be necessary.Reduction may be necessary.

24. Type 2 FracturesType 2 Fractures
TreatmentTreatment
• Reduction of these fractures is usually notReduction of these fractures is usually not
difficultdifficult
– Maintaining reduction usually requires flexion beyondMaintaining reduction usually requires flexion beyond
90°90°
• Excessive flexion may not be toleratedExcessive flexion may not be tolerated
because of swellingbecause of swelling
– May require percutaneous pinning to maintainMay require percutaneous pinning to maintain
reductionreduction
• Most authors suggest that percutaneousMost authors suggest that percutaneous
pinning is the safest form of treatment forpinning is the safest form of treatment for
many of these fracturesmany of these fractures
– Pins maintain the reduction and allow the elbow to bePins maintain the reduction and allow the elbow to be
immobilized in a less flexed position.immobilized in a less flexed position.

25. Supracondylar Humerus FracturesSupracondylar Humerus Fractures
TreatmentTreatment
• Type 3 FracturesType 3 Fractures
– These fractures have a high risk of neurologic and/orThese fractures have a high risk of neurologic and/or
vascular compromise.vascular compromise.
– Can be associated with a significant amount ofCan be associated with a significant amount of
swelling.swelling.
– Current treatment protocols use percutaneous pinCurrent treatment protocols use percutaneous pin
fixation in almost all cases.fixation in almost all cases.
– In rare cases, open reduction may be necessary.In rare cases, open reduction may be necessary.
• Especially in cases of vascular disruption.Especially in cases of vascular disruption.

26. Supracondylar Humerus FracturesSupracondylar Humerus Fractures
Pin FixationPin Fixation
• Different authors have recommendedDifferent authors have recommended
different pin fixation methods.different pin fixation methods.
• The medial pin can injury the ulnar andThe medial pin can injury the ulnar and
median nerve.median nerve.
– Some advocate 2 or 3 lateral pins to avoid injuring theSome advocate 2 or 3 lateral pins to avoid injuring the
nerve.nerve.
• Space pins as widely as possibleSpace pins as widely as possible
– If the lateral pins are placed close together at theIf the lateral pins are placed close together at the
fracture site, the pins may not provide muchfracture site, the pins may not provide much
resistance to rotation and further displacement.resistance to rotation and further displacement.
• Some recommend one lateral, and oneSome recommend one lateral, and one
medial pinmedial pin

27. Pin ConfigurationPin Configuration

28. Supracondylar Humerus Fractures
 If pin fixation is used, the
pins are usually bent and
cut outside the skin.
 The arm is immobilized.
 The pins are removed in
the clinic 3 to 4 weeks
later.
 In most cases, full
recovery of motion can
be expected.

29. Supracondylar Humerus Fractures:
Complications
 Immediate:-
Vascular injury to brachial
artery.
Nerve injury to radial
nerve, median nerve
(AIN) and ulnar nerve(in
flexion type).
 Early:-
Volkmann’s ischemia and
Compartment syndrome.
 Late:-
Malunion-Cubitus varus
Myositis ossificans,
Volkmann’s ischemic

30. Intercondylar fractureIntercondylar fracture
• Most common distal humeral fracture in adults.Most common distal humeral fracture in adults.
• Comminution is common.Comminution is common.
• Fracture fregments are often displaced byFracture fregments are often displaced by
unapposed muscle pull at the medial and lateralunapposed muscle pull at the medial and lateral
epicondyles which rotate the articular surfaces.epicondyles which rotate the articular surfaces.
Mechanism of injury:Mechanism of injury:
ForceForce is directed against the posterior aspect of is directed against the posterior aspect of
an elbow which is flexed > 90° which causesan elbow which is flexed > 90° which causes
the ulnathe ulna to driveto drive into the into the trochlea.trochlea.

31. Clinical FeaturesClinical Features
1. The elbow maybe held in 90° flexion1. The elbow maybe held in 90° flexion
and forearm is kept pronated.and forearm is kept pronated.
2. Crepitus may be elicited.2. Crepitus may be elicited.
3. Independent mobility of the medial and3. Independent mobility of the medial and
lateral condyle can be elicited.lateral condyle can be elicited.
4. The normal 3 point bony relationship4. The normal 3 point bony relationship
between the olecranon, medial epicondylebetween the olecranon, medial epicondyle
and lateral epicondyle is lost.and lateral epicondyle is lost.

32. Riseborough and Radin
classification
 Type I - Fractures involving
minimally displaced articular
fragments.
 Type II - Fractures involving
displaced fragments that are
not rotated .
 Type III - Fractures involving
displaced and rotated
fragments.
 Type IV - Fractures involving
comminuted fracture
fragments.

33. Jupiter, Mehne and Matta
classification
 According to pattern of
fracture line in the distal
humerus.
 1. High T.
2. Low T
3. Y-type
4. H-type.
5. Medial lambda.
6. Lateral lambda.
 The Mehne and Matta
classification describes the
most often encountered
fracture patterns
intraoperatively.

34. Nonoperative TreatmentNonoperative Treatment
-->Nonoperative treatment indicated in:--->Nonoperative treatment indicated in:-
-Nondisplaced fractures,-Nondisplaced fractures,
-Elderly patients with displaced fractures and severe-Elderly patients with displaced fractures and severe
osteopenia and comminution,osteopenia and comminution,
-Patients with significant co-morbid conditions.-Patients with significant co-morbid conditions.
-->Non operative methods are:--->Non operative methods are:-
-Cast immobilization:- rarely indicated.-Cast immobilization:- rarely indicated.
““worst of both worlds”worst of both worlds”
inadequate reduction and prolonged immobilization.inadequate reduction and prolonged immobilization.
-Bag of bones:-arm is placed in a collar and cuff with as-Bag of bones:-arm is placed in a collar and cuff with as
much flexion as possible after initial reduction.much flexion as possible after initial reduction.
Aim is to obtain a painless pseudoarthrosis byAim is to obtain a painless pseudoarthrosis by
gravity traction effect.gravity traction effect.

35. Operative treatmentOperative treatment
• Indicated in displaced reconstructible fracture.Indicated in displaced reconstructible fracture.
• Aim is to restore articular congurity and toAim is to restore articular congurity and to
secure supracondylar component.secure supracondylar component.
• Methods of fixation:-Methods of fixation:-
-Interfragmentry screws,-Interfragmentry screws,
-Dual plate fixation by olecranon osteotomy-Dual plate fixation by olecranon osteotomy
approach or triceps sparing extensile posteriorapproach or triceps sparing extensile posterior
approach.approach.
-->Total elbow arthroplasty in markedly-->Total elbow arthroplasty in markedly
comminuted fractures and with osteoporosis.comminuted fractures and with osteoporosis.

36. ComplicationsComplications
• Elbow stiffness,Elbow stiffness,
• Failure of fixation,Failure of fixation,
• Nerve injury to ulnar nerve,Nerve injury to ulnar nerve,
• Posttrumatic arthritis,Posttrumatic arthritis,
• Heterotopic bone formation,Heterotopic bone formation,
• Nonunion of osteotomy,Nonunion of osteotomy,
• Infection.Infection.

37. Condylar fracturesCondylar fractures
• Rare in adults and more common inRare in adults and more common in
pediatric age group.pediatric age group.
• Medial condyle fractures include trochleaMedial condyle fractures include trochlea
and medial epicondyle fractures.and medial epicondyle fractures.
• Lateral condyle fractures includeLateral condyle fractures include
capitellum and lateral epicondylecapitellum and lateral epicondyle
fractures.fractures.
• Lateral fractures are more common thanLateral fractures are more common than
medial.medial.
• MOI-abduction or adduction of the forearmMOI-abduction or adduction of the forearm
with elbow extension.with elbow extension.

38. Condylar # classificationCondylar # classification
Milch ClassificationMilch Classification
• Type I:Type I: Trochlear ridge Trochlear ridge
remains intact.remains intact.
• Type IIType II: Trochlear ridge: Trochlear ridge
part of the condylarpart of the condylar
fragment(medial orfragment(medial or
lateral).lateral).
• Explanation-Explanation- condylarcondylar
fracture (medial orfracture (medial or
lateral) involving thelateral) involving the
Trochlear ridgeTrochlear ridge
significantlysignificantly
compromised the stabilitycompromised the stability
of the elbow joint.of the elbow joint.

39. Condylar # classification
Jupiter classification
 Classified as low or
high based on
proximal extension
of fracture line to
supracondylar
region.
 Jupiter low
equivalent to milch
type I.
 Jupiter high
equivalent to type II.

40. Condylar fracturesCondylar fractures
TreatmentTreatment
• Non operative for nondisplaced or minimallyNon operative for nondisplaced or minimally
displaced fractures by posterior splintng withdisplaced fractures by posterior splintng with
the elbow flexed to 90* and the forearm inthe elbow flexed to 90* and the forearm in
supination for lateral condylar # or insupination for lateral condylar # or in
pronation for medial condylar #.pronation for medial condylar #.
• Operative is indicated in open or displaced #Operative is indicated in open or displaced #
by screw fixation with or without collateralby screw fixation with or without collateral
ligament repair.ligament repair.
• Range of motion exercises should be startedRange of motion exercises should be started
as soon as the patient can tolerate therapyas soon as the patient can tolerate therapy
usually after 4 weeks.usually after 4 weeks.

41. Condylar fracturesCondylar fractures
ComplicationsComplications
• Lateral condyle #- Improper reduction orLateral condyle #- Improper reduction or
failure of fixation may result in cubitusfailure of fixation may result in cubitus
valgus and tardy ulnar nerve palsy.valgus and tardy ulnar nerve palsy.
• Medial condyle #-Medial condyle #-
--posttraumatic arthritis,--posttraumatic arthritis,
--ulnar nerve symptoms with excess callus--ulnar nerve symptoms with excess callus
formation,formation,
--cubitus varus with Improper reduction or--cubitus varus with Improper reduction or
failure of fixation.failure of fixation.

42. Posterior Approaches to DistalPosterior Approaches to Distal
HumerusHumerus
• A posterior approach to the elbow can be madeA posterior approach to the elbow can be made
with the patient in the lateral decubitus position,with the patient in the lateral decubitus position,
with the arm supported by a padded post.with the arm supported by a padded post.
• All posterior approaches use a longitudinalAll posterior approaches use a longitudinal
midline incision over the posterior aspect of themidline incision over the posterior aspect of the
elbow beginning at the junction of the middleelbow beginning at the junction of the middle
and distal thirds of the humeral shaft.and distal thirds of the humeral shaft.
• Some surgeons make a straight incision,Some surgeons make a straight incision,
whereas others prefer to curve the incisionwhereas others prefer to curve the incision
around the olecranon to the radial side.around the olecranon to the radial side.
• The incision ends over the ulnarThe incision ends over the ulnar
diaphysis,approximately 5 cm distal to the tip ofdiaphysis,approximately 5 cm distal to the tip of
the olecranon.the olecranon.

43. • The ulnar nerve should be routinelyThe ulnar nerve should be routinely
identified behind the medial epicondyle,identified behind the medial epicondyle,
and protected in all posterior approachesand protected in all posterior approaches
to the elbow.to the elbow.
• Extensive dissection of the nerve isExtensive dissection of the nerve is
inadvisable, as this increases the risk ofinadvisable, as this increases the risk of
tethering and damage to its vascularity.tethering and damage to its vascularity.
• However, adequate exposure of the nerveHowever, adequate exposure of the nerve
is required to reduce the risk of its injury ifis required to reduce the risk of its injury if
olecranon osteotomy or insertion ofolecranon osteotomy or insertion of
hardware is required.hardware is required.

45. • There are several variations of approach toThere are several variations of approach to
gain access to the posterior aspect of the distalgain access to the posterior aspect of the distal
humerus,there are four main types of posteriorhumerus,there are four main types of posterior
approach:-approach:-
• Olecranon Osteotomy,Olecranon Osteotomy,
• Triceps-sparing Approach,Triceps-sparing Approach,
• Triceps-Splitting Approach,Triceps-Splitting Approach,
• Triceps-Reflecting Approach.Triceps-Reflecting Approach.

46. Olecranon OsteotomyOlecranon Osteotomy
MACAUSLAND & MULLER’SMACAUSLAND & MULLER’S
APPROACHAPPROACH
• Reflection of the triceps tendon and its bony insertion, byReflection of the triceps tendon and its bony insertion, by
use of an olecranon osteotomy, most widely useduse of an olecranon osteotomy, most widely used
approach to the elbow.approach to the elbow.
• The triceps insertion is isolated and the joint surfaces onThe triceps insertion is isolated and the joint surfaces on
either side of the trochlear notch are identified byeither side of the trochlear notch are identified by
opening joint capsule.opening joint capsule.
• An elevator or gauze swab is then inserted from medialAn elevator or gauze swab is then inserted from medial
to lateral through the joint across the notch.to lateral through the joint across the notch.
• This serves to protect the articular surfaces during theThis serves to protect the articular surfaces during the
subsequent osteotomy, and also facilitates the accuratesubsequent osteotomy, and also facilitates the accurate
placement of the osteotomyplacement of the osteotomy..

47. --The approach initially recommended by the AO
group was an extra-articular oblique osteotomy of
the olecranon, although the approach more
commonly used is an intra-articular osteotomy,
through the mid-portion of the greater sigmoid
notch.
--The osteotomy must be proximal to the coronoid
process, to provide a balance between an
osteotomy that is too small, which may
compromise the exposure of the articular
surfaces, and one that is too large, which may
cause an inadvertent osteotomy at the level of the
coronoid and destabilize the elbow.
--Predrilling and tapping of the olecranon should
be performed if screw fixation of the osteotomy is
planned.

50. --The osteotomy should be performed as a chevron,
with its apex directed distally, perpendicular to the
long axis of the shaft of the ulna.
--The chevron facilitates reduction and fixation of the
osteotomy and also provides a greater surface area
of cancellous bone over which healing can occur.
--The osteotomy is performed using a narrow saw
and completed using an osteotome, to “crack”
through the articular surface.
--This maneuver facilitates subsequent anatomic
reconstruction of the osteotomy fragments.
--At the completion of surgery, the osteotomy can be
secured either with an intramedullary 6.5-mm,
partially threaded cancellous screw, or using two K-
wires and a tension-banding technique.

52. • The approach has the advantage of providingThe approach has the advantage of providing
excellent access to the whole of the distalexcellent access to the whole of the distal
humerus, especially to view the distal posteriorhumerus, especially to view the distal posterior
articular surfaces.articular surfaces.
• It provides only limited exposure of theIt provides only limited exposure of the
capitellum, but its major drawback is thecapitellum, but its major drawback is the
postoperative morbidity, which is associatedpostoperative morbidity, which is associated
with the internal fixation of the osteotomy.with the internal fixation of the osteotomy.

53. Triceps-Sparing approachTriceps-Sparing approach
Bryan-Morrey approachBryan-Morrey approach
– Posterior Midline incision,Posterior Midline incision,
– Ulnar nerve identified and mobilized,Ulnar nerve identified and mobilized,
– Medial edge of triceps and distal forearm fasciaMedial edge of triceps and distal forearm fascia
elevated as single unit off olecranon and reflectedelevated as single unit off olecranon and reflected
laterally,laterally,
– Resection of extra-articular tip of olecranon.Resection of extra-articular tip of olecranon.

55. • Incise the fascia over the flexor carpi ulnaris muscle atIncise the fascia over the flexor carpi ulnaris muscle at
the border of the ulnar bone, as the first step inthe border of the ulnar bone, as the first step in
the preparation of the extensor apparatus flap.the preparation of the extensor apparatus flap.
• The fascia is detached subperiosteally from the ulnaThe fascia is detached subperiosteally from the ulna
towards the radial side.towards the radial side.
• At the level of the olecranon the extensor apparatus isAt the level of the olecranon the extensor apparatus is
detached together with a sliver of bone using a finedetached together with a sliver of bone using a fine
chisel.chisel.
• Proximal to the olecranon the posterior capsule isProximal to the olecranon the posterior capsule is
incised.incised.
• At the level of the humerus the extensor muscles areAt the level of the humerus the extensor muscles are
freed from the bone.freed from the bone.
• Now the entire extensor apparatus flap can be retractedNow the entire extensor apparatus flap can be retracted
to the radial side.to the radial side.
• To enhance visualization of the articular surface, theTo enhance visualization of the articular surface, the
elbow should be flexed beyond 100 degrees.elbow should be flexed beyond 100 degrees.

56. • For closure, the extensor apparatus is pulledFor closure, the extensor apparatus is pulled
into place using a clamp.into place using a clamp.
• Some surgeons place the ulnar nerve back inSome surgeons place the ulnar nerve back in
the cubital tunnel, whereas other surgeonsthe cubital tunnel, whereas other surgeons
perform an anterior subcutaneousperform an anterior subcutaneous
transposition.transposition.
• The bone sliver is reattached to theThe bone sliver is reattached to the
olecranon with transosseous sutures.olecranon with transosseous sutures.
• Distally, the incision of the flexor carpi ulnarisDistally, the incision of the flexor carpi ulnaris
fascia is closed.fascia is closed.

58. Triceps-Splitting ApproachesTriceps-Splitting Approaches
Campbell approachCampbell approach
• The triceps-splitting approach has beenThe triceps-splitting approach has been
developed to attempt to overcome the morbiditydeveloped to attempt to overcome the morbidity
associated with the use of olecranon osteotomy.associated with the use of olecranon osteotomy.
• It is made by fashioning a direct midlineIt is made by fashioning a direct midline
posterior split in the triceps.posterior split in the triceps.
• Distally sharp dissection is used to reflect theDistally sharp dissection is used to reflect the
triceps insertion off the olecranon and proximaltriceps insertion off the olecranon and proximal
ulna medially and laterally .ulna medially and laterally .
• A thin wafer of bone may be detached from theA thin wafer of bone may be detached from the
olecranon at the level of the triceps insertion.olecranon at the level of the triceps insertion.
• The triceps may also be detached as a distallyThe triceps may also be detached as a distally
based “tongue” muscle flap with splitting of onlybased “tongue” muscle flap with splitting of only
its deeper portion.its deeper portion.

59. • The limited access to the joint surfacesThe limited access to the joint surfaces
can be improved by flexing the elbow andcan be improved by flexing the elbow and
grasping and posteriorly retracting thegrasping and posteriorly retracting the
olecranon with reduction forceps.olecranon with reduction forceps.
• Meticulous repair of the tendon throughMeticulous repair of the tendon through
drill holes in the olecranon must bedrill holes in the olecranon must be
performed at the conclusion of surgery, toperformed at the conclusion of surgery, to
minimize the risk of triceps tendon pull-off.minimize the risk of triceps tendon pull-off.

60. • This approach does not appear to be detrimentalThis approach does not appear to be detrimental
to elbow function and reduces the risk of laterto elbow function and reduces the risk of later
hardware complications, encountered with thehardware complications, encountered with the
use of an olecranon osteotomy.use of an olecranon osteotomy.
• Another major advantage of this approach is thatAnother major advantage of this approach is that
it allows greater intraoperative flexibility,it allows greater intraoperative flexibility,
because either internal fixation or total elbowbecause either internal fixation or total elbow
arthroplasty (TER) can be performed.arthroplasty (TER) can be performed.
• This is particularly useful if there is uncertaintyThis is particularly useful if there is uncertainty
as to whether reduction and internal fixation ofas to whether reduction and internal fixation of
the fracture will be technically feasible, and TERthe fracture will be technically feasible, and TER
might be required.might be required.

61. -->The major drawback of the triceps-splitting approach is the-->The major drawback of the triceps-splitting approach is the
risk of postoperative detachment of the tendon from therisk of postoperative detachment of the tendon from the
proximal ulna.proximal ulna.

62. Triceps-ReflectingTriceps-Reflecting
ApproachesApproaches
• The approach has been used less frequently forThe approach has been used less frequently for
open reduction with internal fixation (ORIF),open reduction with internal fixation (ORIF),
because of the limited exposure of the lateralbecause of the limited exposure of the lateral
column that it provides,and it should only becolumn that it provides,and it should only be
used if the surgeon is convinced that a TER willused if the surgeon is convinced that a TER will
be required.be required.
• The whole of the triceps is reflected as aThe whole of the triceps is reflected as a
continuous cuff of tissue, from medial to lateral.continuous cuff of tissue, from medial to lateral.
• The medial aspect of the triceps is sharplyThe medial aspect of the triceps is sharply
reflected off the proximal ulna at its insertion,reflected off the proximal ulna at its insertion,
taking care to only continue dissection untiltaking care to only continue dissection until
adequate exposure of the joint has beenadequate exposure of the joint has been
obtained.obtained.

63. • Several variations of this approach have beenSeveral variations of this approach have been
described:-described:-
--As originally described there is a risk of ulnar--As originally described there is a risk of ulnar
nerve palsy from retraction during surgery. Tonerve palsy from retraction during surgery. To
protect against this the triceps may be split soprotect against this the triceps may be split so
that 75% of the muscle lies laterally and 25%that 75% of the muscle lies laterally and 25%
medially .medially .
The triceps is then reflected laterally as for theThe triceps is then reflected laterally as for the
standard technique. The ulnar nerve and itsstandard technique. The ulnar nerve and its
blood supply are protected from traction injuryblood supply are protected from traction injury
by the medial triceps during surgery.by the medial triceps during surgery.
--A wafer of bone carrying the triceps insertion--A wafer of bone carrying the triceps insertion
may be detached, to facilitate later closure. Themay be detached, to facilitate later closure. The
triceps is then reflected laterally as an “osteo-triceps is then reflected laterally as an “osteo-
anconeus flap” to provide exposure of the lateralanconeus flap” to provide exposure of the lateral
column.column.

65. ORIF WITH PLATINGORIF WITH PLATING
PRINCIPLESPRINCIPLES
• Triangle ofTriangle of
stability-conceptstability-concept
• The mechanicalThe mechanical
properties of the distalproperties of the distal
humerus are based onhumerus are based on
a triangle of stability,a triangle of stability,
comprising the medialcomprising the medial
and lateral columns,and lateral columns,
and the articularand the articular
surface.surface.
In C-type fractures, allIn C-type fractures, all
3 columns have to be3 columns have to be
restored.restored.

66. Opening the jointOpening the joint
--Cleaning of the--Cleaning of the
fracture sitefracture site
• Clean out theClean out the
fracture byfracture by
removing bloodremoving blood
clots, loose piecesclots, loose pieces
of bone, and anyof bone, and any
interposed tissue.interposed tissue.

67. Reconstruction of theReconstruction of the
articular surfacearticular surface
• Condylar reassemblyCondylar reassembly
• Reduce the articular fragments.Reduce the articular fragments.
In good quality bone, useIn good quality bone, use
pointed reduction forceps.pointed reduction forceps.
• In poor quality bone, useIn poor quality bone, use
temporary fixation with a K-wire.temporary fixation with a K-wire.
• Definitive fixationDefinitive fixation
• Use a lag screw (a partiallyUse a lag screw (a partially
threaded screw, or a fullythreaded screw, or a fully
threaded screw with overdrillingthreaded screw with overdrilling
the near fragment) to obtainthe near fragment) to obtain
interfragmentary compression.interfragmentary compression.
In osteoporotic bone, use aIn osteoporotic bone, use a
position screw.position screw.
• Try to use two screws to avoidTry to use two screws to avoid
rotational instability.rotational instability.
• In very distal fractures, generallyIn very distal fractures, generally
only one screw can be inserted.only one screw can be inserted.
An additional K-wire can be usedAn additional K-wire can be used
to obtain rotational stabilityto obtain rotational stability

68. Condylar reattachmentCondylar reattachment
• Temporary fixationTemporary fixation
• Reduce the reconstitutedReduce the reconstituted
articular (condylar) blockarticular (condylar) block
to the metaphysis andto the metaphysis and
use K-wires foruse K-wires for
preliminary fixation.preliminary fixation.
• Plate preparationPlate preparation
• Place the lateral columnPlace the lateral column
plate dorsally and theplate dorsally and the
medial column platemedial column plate
medially. In this positionmedially. In this position
they form an angle ofthey form an angle of
approximately 90approximately 90
degrees to each other.degrees to each other.

69. • Definitive fixationDefinitive fixation
• First place a 3.5 mmFirst place a 3.5 mm
reconstruction platereconstruction plate
posterolaterally. It may curveposterolaterally. It may curve
around the capitellum which isaround the capitellum which is
non-articular posteriorly.non-articular posteriorly.
• The more bone is covered byThe more bone is covered by
the plate, the more the stabilitythe plate, the more the stability
that can be achieved.that can be achieved.
• Placement of the lateralPlacement of the lateral
plateplate
Place a K-wire through thePlace a K-wire through the
distal hole. Now insert thedistal hole. Now insert the
proximal screw as a loadproximal screw as a load
screw. As the plate is pulledscrew. As the plate is pulled
proximally, stable contact withproximally, stable contact with
the bone is obtained.the bone is obtained.
• Fix the plate to the bone byFix the plate to the bone by
inserting the remaining screws.inserting the remaining screws.

70. • Medial plateMedial plate
• Place another platePlace another plate
medially on the crest ofmedially on the crest of
the medialthe medial
supracondylar ridge, atsupracondylar ridge, at
a right angle to thea right angle to the
plane of the lateralplane of the lateral
plate to increaseplate to increase
stability.stability.
• It is recommended toIt is recommended to
insert the distal screwinsert the distal screw
into the trochlea belowinto the trochlea below

71. • Contoured 3.5-millimeterContoured 3.5-millimeter
reconstruction plates, orreconstruction plates, or
precontoured plates, areprecontoured plates, are
selected for direct lateralselected for direct lateral
positioning on the lateralpositioning on the lateral
column and direct medialcolumn and direct medial
positioning on the medialpositioning on the medial
column.column.
• These are usually placedThese are usually placed
slightly posteriorly and areslightly posteriorly and are
always placed on top ofalways placed on top of
the soft tissues—do NOTthe soft tissues—do NOT
strip the medial and lateralstrip the medial and lateral
columns.columns.

72. Osteosynthesis of theOsteosynthesis of the
olecranon osteotomyolecranon osteotomy
• Drill hole for wire-Drill hole for wire- Using a 2.5 mm drill, make aUsing a 2.5 mm drill, make a
coronal hole in the proximal ulna from ulnar tocoronal hole in the proximal ulna from ulnar to
radial side, to pass the figure-of-eight wire.radial side, to pass the figure-of-eight wire.
• Insert wire-Insert wire-Prepare a 0.8 mm wire by making aPrepare a 0.8 mm wire by making a
loop approximately one third along its length.loop approximately one third along its length.
Insert the shorter segment of the wire through thisInsert the shorter segment of the wire through this
drill hole.drill hole.
• Reduction of the olecranon-Reduction of the olecranon- Reduce theReduce the
olecranon osteotomy with pointed reductionolecranon osteotomy with pointed reduction
forceps.forceps.
• K-wire location-K-wire location- Use the figure-of-eight tensionUse the figure-of-eight tension
band wiring technique to obtain stable fixation.band wiring technique to obtain stable fixation.
Two K-wires are drilled parallel across theTwo K-wires are drilled parallel across the
osteotomy.osteotomy.
• Obtain correct K-wire tensionObtain correct K-wire tension
• The wire loop has to go underneath the triceps tendon.The wire loop has to go underneath the triceps tendon.
• Double twist the wire loop to obtain equal tension onDouble twist the wire loop to obtain equal tension on
both sides. The cut wire loops are then impacted firmlyboth sides. The cut wire loops are then impacted firmly
onto the bony cortex of the ulna.onto the bony cortex of the ulna.
• Cut the wires to the appropriate length and bend them.Cut the wires to the appropriate length and bend them.
Impact the bend K-wire tip into the olecranon, being sureImpact the bend K-wire tip into the olecranon, being sure
to bury them beneath the triceps tendon.to bury them beneath the triceps tendon.

73. Osteotomy FixationOsteotomy Fixation
• Single screwSingle screw
techniquetechnique
– Long screw may beLong screw may be
beneficial for adequatebeneficial for adequate
fixation.fixation.
• Short screw mayShort screw may
loosen or toggle withloosen or toggle with
contraction of tricepscontraction of triceps
against olecranonagainst olecranon
segment.segment.
Hak and Golladay, JAAOS, 8:266-75, 2000

74. Osteotomy FixationOsteotomy Fixation
• Dorsal platingDorsal plating
– Low profile periarticularLow profile periarticular
implants now available.implants now available.
– Axial screw through plate.Axial screw through plate.
– Good results after plateGood results after plate
fixation.fixation.
• Hewin et al (2007)Hewin et al (2007) J OrthopJ Orthop
TraumaTrauma 21:5821:58
• Tejwani et al (2002)Tejwani et al (2002) BullBull
Hosp Jt DisHosp Jt Dis 61:2761:27

76. THANK YOU…..!!!!!THANK YOU…..!!!!!