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Distal humeruss.pptx
- 1. Distal humerus fractures By Dr Dependra Bhandari JR1 Department of orthopaedics KMCTH
- 2. Epidemiology • Distal humerus fractures comprise approximately 2% of all fractures and 33% of all humerus fracture • Have a bimodal age distribution , between 12 and 19 years in men and 80 years and older in female • In youngs due to high energy injuries, in elderys(>60% of fracture) due to low energy injuries.
- 3. Anatomy • Elbow joint ia a hinge joint and consists of 3 components: 1. Humeroulnar articulation 2. Humeroradial articulation 3. Radioulnar articulation • Humeroulnar – alignment, stability and strength • Others- forarm and hand motion and position
- 5. • Triangular structure with its apex directed anteriorly • Bifurcates into two divergent cortical columns Medial column ends with medial epicondyle Lateral column ends with capitellum Tie arch- trochlea
- 7. • In relation to the long axis of humerus, the distal humerus articular surface has 4 to 8 degree of valgus Angulated 35 to 40 degree anteriorly in sagittal plane Axially , is internally rotated 3 to 8 degrees
- 9. Mechanism of injury • Either low energy falls or high energy trauma • Most common is a simple fall in the forward direction in which elbow either struck directly or axially loaded in a fall on to the outstretched hand
- 10. Clinical evaluation • History • Pain • Swelling • instability • Physical examination • Crepitus • Restricted range of motion • Careful neurovascular examination • Compartment syndrome • Open injuries
- 11. Radiographic evaluation • Elbow AP/ lateral views • Traction views( fracture shortening, rotation and angulation) • CT scan Intraarticular fractures Pre existing deformities To localize fractures in less invasive operative procedure Highy comminuted fractures
- 12. Classification • AO/OTA classification • MILCH classification • JUPITER classification
- 13. AO/OTA classification • Type A : Extraarticular fracture • A1: Apophyseal avulsion • A1.1: lateral epicondyle • A1.2: medial epicondyle • A2:metaphyseal simple • A2.1:oblique inward • A2.2: oblique outward • A2.3 : transverse • A3:metaphyseal multifragmentary • A3.1:intact wedge • A3.2:fragmentary wedge • A3.3:complex
- 16. • Type B: Partial articular • B1: lateral saggital • B1.1:transcapitellum • B1.2:transtrochlear simple • B1.3:transtrochlear multifragmentary • B2: medial saggital • B2.1:transtrochlear simple(medial side) • B2.2:transtrochlear simple(through groove) • B2.3:transtrochlear multifragmentary • B3:frontal/coronal • B3.1:capitellum • B3.2:trochlea • B3.3:capitellum and trochlea
- 19. • Type C: Complete articular • C1:Articular simple, metaphyseal simple • C1.2:slight displacement • C1.2:marked displacement • C1.3: T shaped epiphyseal • C2:Articular simple , metaphyseal multifragmentary • C2.1:intact wedge • C2.2:fragmentary wedge • C2.3:complex • C2:Articular , metaphyseal multifragmentary • C3.1:metaphyseal simple • C3.2:metaphyseal wedge • C3.3:metaphyseal complex
- 22. Jupiter and Mehne classification • Grade I : Intraarticular fractures( single and bi column) • Grade II: Extra articular and intracapsular fractures • Grade III: Extra capsular fractures
- 26. Milch Classification • Condylar fractures • Type I: lateral trochlear ridge left intact • Type II: lateral trochlear ridge part of condylar fragment(medial or lateral)
- 28. Capitellum fracture classification • Type I : Hanhn-steinthal fragment : large osseous component of capitellum, sometimes with trochlear involvement • Type II: Kocher-Lorenz fragment: articular cartilage with minimal subchondral bone attached “ uncapping of the condyle” • Type III: Markedly communited( Morrey) • Type IV: Extension into the trochlea(Mckee)
- 31. Outcome measures for distal humerus fractures • Scoring systems • MEPS( mayo elbow performance score) • PREE( patient –related elbow evaluation) • DASH ( disabilities of the arm , shoulder and hand) • Range of motion • Strength • Rate of secondary surgeries • complications
- 33. General treatment principles • Anatomic articular reduction • Stable internal fixation of the articular surface • Restoration of articular axial alignment • Stable internal fixation of the articular segment to the metaphysis and diaphysis • Early range of elow motion
- 34. Non operative treatment( extraarticular and complete articular) • Indications • Nondisplaced fracture • Eldery patients with significant comorbid conditions • Patients medically unfit to undergo surgery • Milch type 1 fractures
- 35. Techniques • Posterior long arm splint • At least 90 degree elbow flexion, with forearm in neutral • Immobilization for 1/2 weeks then ROM exercises are initiated • Above elbow cast • Olecranon traction • Transolecranon traction pin • Traction for 3-4 weeks • Collar and cuff treatment( Bag of bones)
- 36. • Closed reduction followed by application of collar and cuff • Elbow between 90 and 120 degrees • of flexion • Elbow hung freely to allow gravity assisted reduction • Shoulder motion and elbow flexion initiated at 2 weeks and progressed
- 37. Operative treatment • Indications Displaced fractures Vascular injury Open fractures Inability to maintain acceptable reduction
- 38. Timing of surgery • Medically fit and stabilized patients with non compromised soft tissue with early surgery within 48 to 72 hours • In case with injured soft tissues , delay of surgery be most appropriate • Surgery should be conducted with in 2 or 3 weeks
- 39. Positioning Supine on a radiolucent table with arm over chest • Quick and easy set up • Requires assistant to hold arm during procedure Lateral • Allows good access to posterior arm and elbow without need for additional assistant Prone • In rare condition, bilateral fractures
- 41. Surgical approaches • Anterior approach • Posterior approach • Medial approach • Lateral approach
- 42. Posterior approach • Most orthopaedic procedures in and around distal humerus • Safer- less damage to vital structures • Easier – posterior structures are aponeurotic and dissection is easier with less bleeding • Clearer – better visualization of articular surface
- 44. Triceps splitting approach • Midline tongue splitting( Campbell) • Triceps tongue splitting Osteotomy approach • Olecranon osteotomy Triceps reflecting approach • triceps reflecting approach( Bryan – moore) • TRAP(triceps reflecting Anconeus pedicle) approach Triceps preserving approach • Paratricipital approach(triceps –on)
- 46. • Advantages • Technical ease • Ability to convert from ORIF to TEA • No need of additional hardware to reattach olecranon • Disadvantages • Limited visualization of anterior articular surfaces • Risk of triceps insufficiency
- 47. Olecranon osteotomy (Macausland and Muller)
- 49. • Used for AO/OTA type B and C • Advantages • Most extensile approach • Best visualization of articular surface for reduction and fixation • Disadvantages • Non union, malunion and hardware prominence related to osteotomy • Avoided if possibility of TEA
- 50. Triceps reflecting approach(Bryan- Morrey)
- 51. Triceps reflecting approach(Bryan- Morrey) • Subperiosteal reflection of the triceps insertion from medial to lateral in continuity with the forearm fascia and anconeus muscle • Although triceps tendon insertion is detached , the extensor mechanism maintains its continuity as a single sleeve through its soft tissue attachments • Used primarily for arthoplasty
- 53. Triceps reflecting anconeus pedicle (TRAP) approach • Complete detaching the triceps from proximal ulna with the anconeus muscle • Anconeus flap is elevated and reflected proximally to expose the triceps insertion which is also released
- 54. • Indications • ORIF intra articular fractures • TEA • Advantages • Avoids complications associated with olecranon osteotomy • Disadvantages • Risk of triceps dehiscence and extensor weakness
- 55. Paratricipital approach(triceps-on) • Involves the creation of surgical windows along the medial and lateral sides of the triceps muscle and tendon withoit disipting its insertion on the olecranon
- 57. • Indications • ORIF extra articular and simple intraarticular fractures (AO types C1 and C2) • Advantages • Avoids disruption of the extensor mechanism • No post operative restrictions related to approach • Disadvantages • Limited visualization of articular surfaces
- 58. Lateral approach to distal humerus
- 59. • Kocher approach • Interval between extensor carpi ulnaris ECU and anconeus • EDC split • Creation of lateral elbow arthrotomy at the equator of the radiocapitellar joint • Kaplan approach • Interval between ECRL and EDC
- 60. • Indications • Lateral column fractures • Lateral epicondyle fractures • Coronal shear fractures of capitellum or trochlea • Advantages • Good acess to capitellum and lateral column structures • Disadvantages • No acess to medial column
- 61. Medial approach to distal humerus
- 62. • Indications • Medial epicondyle and medial column fractures • Isolated trochlear fractures( very rare)
- 63. Fixation of distal humerus fractures • For AO/OTA type A and C fractures • Reconstruction can be done according to two strategies 1. Reduction and fixation of the articular surfaces followed by attachment to the humeral shaft 2. Reduction and fixation of the medial or lateral condyle to the shaft , then reconstruction of the articular surface, followed by reduction and fixation of the contralateral condyle
- 64. AO/OTA type C fractures • Fracture hematoa is evacuated • Raw fracture surfaces are cleaned of loose debris • Fracture fragments can be manipulated manually or with small diameter k wires
- 67. • Definitive fixation of articular segment done with one or two centrally placed screws along the capitellar-trochlear axis. • Screws is usually inserted medial to lateral with its starting point located in the centre of trochlea.
- 68. AO/OTA type A and C • Rigid attachment to the medial and latral columns or distal humerus shaft • Can be done by precontoured plates and screws • Plating can be orthogonal, parallel or triple
- 69. • Orthogonal plating • Placement of plates on both column at approximately 90-degree angle • End of lateral plate should lie just proximal to the posterior articular surface of capitellum • Medial plate is usually applied on the medial supracondylar ridge • Parallel plating • Plates placed relatively parallel to each other.
- 71. • Ideally the lateral plate should be a 3.5mm dynamic compression plate or equivalent • Medial plate is typically a 3.5mm reconstruction plate to allow easier bending or 3.5mm DCP
- 72. • Ideally, the longest possible screws should be inserted through the plate and engage as many articular fragments as possible • Screws should not be placed through the olecranon fossa as they may lead to impingement
- 77. • For AO/OTA type B fractures • For type B1 and B2 (single column ) fractures Fixed with multiple screws or with single column plating
- 79. • For AO/OTA type B3.1 fractures of capitellum with or without involvement of the lateral ridge of trochlea After an acess to fractured capitellum fragment anatomically reduced by elbow extension , forearm supination and application of gentle varus force. Permanent rigid fixation obtained by headless compression screws
- 82. Post operative care • Patients placed in a well padded plaster splint and arm is elevated to minimize swelling • Elbow range of motion is started between days 2 and 7 postoperatively depending on status of incision • Plaster splint is used for the first 6 weeks
- 83. Complications • Non unioun • Malunioun • Elbow stiffness • Heterotopic ossification • Wound complication and infection • Ulnar neuropathy • Volkmann ischemic contracture(rare)
- 85. •THANK YOU
Notas del editor
- Low energy like fall from standing height
- Neurovascular ma- bcoz the sharp fracture end of the proximal fragment may impale or contuse the brachial artery , median nerve or radial nerve
- Partial articular- fracture involving one part of the articular surface yet the rest of the joint is still attached to the metaphysis and diaphysis
- Complete articular- the fracture is distributing the joint surface and separated from the diaphysis
- Less than 1 % of elbow fractures
- Double arc sign (1 arc subchondran bone of capetellum & other for lateral edge of trohclea)
- Elbow flexion if.. Swelling and neurovascular status permits
- Assisted reduction via a ligamnetotaxis –type effect
- Early surgery decreased complications- such as HO and stiffness Injured soft tissues such as excessive swelling , bruising , or abrasions Although , no literature exists to define a suitable delay surgery..
- Supine- for multiple injured patients with multiple extremity involvement Bilateral fractures when second surgical team available
- Classified based on direction.. And further subclassified based on their anatomic intervals The ideal approach to a specific fracture pattern should provide sufficient exposure to allow anatomic reconstruction of the fracture and the application of the required internal fixation with minimal soft tissue or bony disruption, to allow early mobilization
- Longitudinal midline skin incision over the post aspect of the elbow Raising of subcutaneous flaps on either side to expose the tricipital aponeurosis Isolation of ulnar nerve
- The triceps split approach described by Campbell involves a midline split through the triceps tendon and medial head (A). The approach can be extended distally by splitting the triceps insertion on the olecranon and raising medial and lateral full-thickness fasciotendinous flaps (B, C).
- Olecranon.. Ie avoids complication a/w olecranon osteotomy Articular surface.. Usually used for extra articular fractures Insufficiency.. Dispruption of extensor mechanism
- An osteotomy should aim for the bare area of the greater sigmoid notch to avoid cartilage damage. The bare area is a region within the articular surface that is devoid of cartilage. Its size and orientation vary between individuals, but it is commonly identified by the narrowest part of the greater sigmoid notch. Incision beginning 5cm distal to the tip of olecranon and exten ding proximally medial to the midline of the arm to 10-12cm above olecranon tip
- Initaited with an oscillating saw and completed with an osteotome The olecranon osteotomy should be fixed according to surgeon’s preference. The three main options are: Tension band fixation Intramedullary fixation Plate fixation
- Extensile posterior approach Incision in the midline of limb extending from 7cm distal to the olecranon to 9cm proximal to it
- Make an incision centered on the junction of the middle and distal thirds of the humeral shaft. Avoid placing the incision over the tip of the olecranon
- Detach the triceps insertion subperiosteally from the proximal ulna towards the radial side. incise the posterior capsule proximal to the olecranon Release the extensor muscles from the lateral epicondyle of the humerus and the anconeus from the posterolateral humerus and ulna. Now the entire extensor apparatus flap can be retracted to the radial side.
- Advantage is preservation of the neurovascular supply to the anconeus
- Alonso-lames- in 1972.. For management of supracondylar fractures
- Ulnar and radial window
- So not for c3
- The skin incision is centered over the lateral epicondyle. Proximally it can be extended along the lateral supracondylar ridge up until the radial nerve. Distally it is extended in the line of the radial head along the common extensor muscles
- EDC-extensor digitorum comminis
- enter the incision over the medial epicondyle and extend it proximally over the medial supracondylar ridge and distally in the line of the flexor/pronator mass as required. Note: The incision is usually crossed by the posterior branch of the medial antebrachial cutaneous nerve. Take care of this nerve branch during the dissection of the subcutaneous tissue; if it is divided, neuroma formation can be troublesome.
- ORIF is the goal standard treatment Articular surface( advantageous when the articular surface is comminuted)
- Open reduction and internal fixation of an intra-articular distal humerus fracture via an olecranon osteotomy (A). K-wires are used as joysticks to manipulate the fracture fragments in to an anatomic reduction (B)
- A large tenaculum is used to stabilize the reduction (C) while the K-wires are drilled into the opposite articular fragment (D) to provisionally fixate the segment. A small-diameter screw is then inserted from medial to lateral (E). This provides provisional fixation of the articular segment.
- placement of the plate further distal may lead to impingement of the radial head against the plate in extension, resulting in pain and limited range of motion. - Supracondylar ridge with contouring to curve arounfd the medial epicondyle.
- 1- distal humerus fracture with intraarticular extension 2- supracondylar fracture with intraarticular extension 3-comminuted intraarticular distal humerus fractures type c3
- r the articular segment is fixated, it is reduced to the shaft and provisionally stabilized with long bicortical K-wires inserted up each column (F). Definitive articular segment to shaft fixation is obtained with bicolumn plating in a parallel or orthogonal fashion (G–I)
- . Definitive articular segment to shaft fixation is obtained with bicolumn plating in a parallel or orthogonal fashion (G–I). Ideally, as many screws as possible are inserted through the plates into the articular segment; the screws should be as long as possible and they should engage as many articular fragments as possible. Screws should not be placed through the olecranon fossa as they may lead to impingement and decreased range of motion -- once ORIF of the distal humerus is complete the elbow is placed through a range of motion to ensure there is no impingement
- Orif with 7hole recon plate for lateral condyle and 6 hole stp for medial condyle with 1 ccs with washer for intercondylar fracture
- single column plating has the advantage of providing an anti-glide construct at the proximal fracture line between the column and humeral shaft (Fig. 35-14).
- IGURE 35-14 A 73-year-old woman with a comminuted intra-articular fracture of the medial column (AO/OTA type B1.3) treated with ORIF via an olecranon osteotomy (A–C).
- placed anterior to posterior through the articular surface (Fig. 35-26), or by screws placed into the capitellum in a retrograde fashion from he posterior aspect of the lateral column, or by a combined method (Fig. 35-27). The placement of posterior to anterior screws has been shown to be biomechanically more stable and has the added clinical benefit of not violating the articular surface.
- IGURE 35-26 Fracture of the capitellum and the lateral ridge of the trochlea (A).The double arc sign126 is evident on the lateral radiograph (arrow). One arc represents the subchondral bone of the capitellum and the other arc represents the lateral ridge of the trochlea. This patient underwent open reduction and internal fixation with three headless compression screws inserted anterior to posterior
- At 6 weeks post operation, passive stretching and static progressive splinting are used if required. Strengthening may begin at 12 weeks, provided there is evidence of radiographic union.