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Surgical Management of Intra-Articular Distal Humerus Fractures

Surgical Management of Intra-Articular Distal Humerus Fractures. RP Dunbar IOA-AAOS Program Yogyakarta, Indonesia November 2013. Objectives. Overview of Anatomy Evaluation & Classification Treatment Principles Surgical Steps Outcomes & Pitfalls. Functional Anatomy. Anatomy.

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Surgical Management of Intra-Articular Distal Humerus Fractures

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  1. Surgical Management of Intra-Articular Distal Humerus Fractures RP Dunbar IOA-AAOS Program Yogyakarta, Indonesia November 2013

  2. Objectives • Overview of Anatomy • Evaluation & Classification • Treatment Principles • Surgical Steps • Outcomes & Pitfalls

  3. Functional Anatomy

  4. Anatomy • Angulated ant. 15-30° in sagittal plane • 6° valgus of condyles • 3°- 8° internally rotated

  5. Distal humerus strikes proximal ulna Condyles displaced by forearm musculature Mechanism of Injury & Deforming Forces

  6. Distal Humerus/Elbow Anatomy Extra-articular Intra-articular

  7. Three Joints • Ulnohumeral • Radiocapitellar • Proximal Radioulnar

  8. Physical Examination • Open or closed • Neurovascular status • Ulnar n. • Examine shoulder & wrist

  9. Radiographs AP Lateral Traction View

  10. CT Scan Not Commonly ordered! AXIAL CORONAL REFORMAT

  11. Treatment Goals • Articular Congruity • Anatomic Reduction • Early ROM • Functional Recovery

  12. Preop Planning • Patient Position • Surgical Approach • Olecranon Osteotomy • Triceps Split • Paratricipital • Imaging • Implants

  13. Patient Positioning LATERAL PRONE

  14. Imaging AP Lateral

  15. Approach Radially curved posterior incision Identify/Protect Ulnar Nerve

  16. Paratricipital ApproachSchildhauer et al JOT 2003

  17. Olecranon Osteotomy • Intra-articular fractures w/articular comminution • Chevron type osteotomy • Apex distal (bigger piece) • Rotationally stable • Ease of reduction • Consider pre-drilling for later fixation

  18. Olecranon Osteotomy • Oscillating saw: • Cut to level of subchondral bone • Aim for “bare area” • Complete with an osteotome

  19. Coronal Shear Fractures • Can involve capitellum or extend to trochlea • CT scan may be useful • Approach • Lateral vs. osteotomy

  20. Coronal Shear Fracture FixationLag Screws TypicalButtress when Able

  21. Type C FracturesFixation Principles • Fix joint first! • Small articular fragments can be secured with small, countersunk screws • Beware of screw traffic! “Seattle Traffic Jam”

  22. Fixation Principles • Re-attach articular block to diaphysis • Restoring the columns

  23. Fixation Principles • Anatomic fixation of articular segment • Stable fixation of metaphyseal component in anatomic alignment, length, rotation • Important considerations: • Leave fossae unobstructed • Trochlear anatomy/width is critical • Restoration of relationship of columns

  24. Fixation Principles • Anatomic rigid fixation of articular segment • Stable fixation of metaphyseal component in anatomic alignment, length, rotation • Important considerations: • Leave fossae unobstructed • Trochlear anatomy/width is critical • Restoration of relationship of columns

  25. Fixation Principles • Anatomic rigid fixation of articular segment • Stable fixation of metaphyseal component in anatomic alignment, length, rotation • Important considerations: • Leave fossae unobstructed • Trochlear anatomy/width is critical • Restoration of relationship of columns

  26. Fixation Principles • Anatomic rigid fixation of articular segment • Stable fixation of metaphyseal component in anatomic alignment, length, rotation • Important considerations: • Leave fossae unobstructed • Trochlear anatomy/width is critical • Restoration of relationship of columns

  27. Fixation Principles • Anatomic rigid fixation of articular segment • Stable fixation of metaphyseal component in anatomic alignment, length, rotation • Important considerations: • Leave fossae unobstructed • Trochlear anatomy/width is critical • Restoration of relationship of columns

  28. Choice of Implants • Small fragment plates & screws • Pelvic reconstruction plates • Anatomy specific plates (+/- locking capability)

  29. Plate Positioning Lateral-Posterior Medial

  30. Choice of Implants

  31. TENSION BAND CONSTRUCTS Osteotomy Reduction/Fixation WIRE SCREW

  32. Osteotomy Repair- Plate • Pre-drill intramedullary screw • Compression of osteotomy: • IM screw • Shaft screws

  33. CHECK Range of Motion! NOT DONE YET! • Flexion/Extension • Pronation/Supination • Check for impingement • No crepitus

  34. Ulnar Nerve TranspositionChen et al. JOT 2010 • 48 transposed vs. 89 not transposed at time of ORIF • 33% ulnar neuritis with transposition vs 9% without

  35. Postoperative Care • Bulky splint in extension • +/- drain • Start motion @ 48 hrs • No lifting for 6-8 weeks • +/- Removable splint

  36. Complications • Infection • Stiffness • Heterotopic Ossification • Arthrofibrosis • Arthritis • Loss of Fixation • Hardware Failure • Nonunion

  37. Total Elbow Arthroplasty • Indications: Elderly + Poor bone + Highly comminuted + Low fracture • Unable to obtain goals with ORIF • Stable fixation • Early motion

  38. 76 year old female

  39. Summary • Most treated operatively • Olecranon osteotomy when needed • Stable fixation • Protect but don’t tranpose Ulnar n. • Early motion

  40. Thanks

  41. AO/OTA Classification

  42. Extra-articular “A” Fractures • Single plate +/- lag screw • Two plates to support both columns • Relative vs absolute stability

  43. Sufficient Single Plate Fixation

  44. Double Plating

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