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Distal Humerus Fractures. Outline. Distal Humerus Preop Planning Surgical Technique Olecranon. Demographics. Distal humerus Fx’s 2-3% of all fx’s 2 groups High energy in young Low energy in elderly. Anatomy. Hinged joint with single axis of rotation
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Outline Distal Humerus • Preop Planning • Surgical Technique Olecranon
Demographics Distal humerus Fx’s • 2-3% of all fx’s 2 groups • High energy in young • Low energy in elderly
Anatomy Hinged joint with single axis of rotation 4 deg (males) to 8 deg (females) valgus, 3-8 deg ER Skeletal Trauma, 3rd edition
Anatomy Medial and lateral columns form triangle with trochlea Medial columndiverges45 deg Lat column 20 deg Skeletal Trauma, 3rd edition
Anatomy The distal humerus angles forward Lateral or prone positioning during ORIF facilitates reconstruction of this angle Slide courtesy of Stephany & Schmeling; OTA Resident Library
Fracture Pattern Fracture pattern determined by load direction and position of elbow Skeletal Trauma, 3rd edition
Classification Extraarticular (A) Partial Articular (B) Complete Articular (C) Müller ME, Nazareon S, Koch P, Schaftsker J: Comprehensive Classification of Fractures of Long Bones. Berlin, Germany: Springer-Verlag, 1990, p 330.)
Treatment Principles Anatomic articular reduction Stable internal fixation Preservation of blood supply Early ROM Avoidance of complications
Pre-op Planning Intraarticular vs Extraarticular • Triceps splitting or sparing • Olecranon osteotomy Age and function of patient • ORIF • TEA • “Bag of Bones”
Triceps Splitting Best for extraarticular fx’s No worse than olecranon osteotomy for strength or outcome McKee et al JBJS-Am 2000; 82: 1701-1707
Triceps Sparing Bryan-Morrey • Approach started medially, reflecting triceps off olecranon • Anconeus reflected with flap as it is brought lateral
Triceps-Reflecting Anconeus Pedicle (TRAP) O’Driscoll • Modified Kocher and Bryan-Morrey • Anconeus preserved • Reflect Anconeus and Triceps proximally as you would osteotomy • Extreme flexion needed to see anterior articular surface FCU Anconeus
Extraarticular osteotomy Good for low extraarticular fx’s or “simple” intraarticular fx’s Still has complications associated with hardware (up to 30%) Anglen JAAOS 2005; 13, 291-7
Intraarticular Osteotomy Chevron osteotomy Apex distal Pre-drill for fixation of osteotomy (if using screw) Jupiter Master Techniques
Intraarticular Osteotomy Place Joker or gauze in joint Bare spot, just proximal to coronoid Complete osteotomy with osteotome Jupiter Master Techniques
Intraarticular Osteotomy Triceps reflected Place olecranon and muscle in moist gauze Don’t forget the radial nerve! Jupiter Master Techniques
Steps to fixation Articular reduction first Don’t lag trochlea if comminution present Fix articular surface to columns, columns to shaft Jupiter Master Techniques
Fixation 90-90 180 or med/lat 2 plates dorsal
Locked vs. non-locked Korner 2004 • Locked or not, dorsal plates failed vs. 90-90 • Plate configuration more important than locking technology Korner J Orthop Trauma 2004;18:286–293
90-90 vs 180 Jacobsen et al., 1997 • Tested five constructs (direct lateral, posterolateral, medial combo’s) • All were stiffer in the coronal plane than compared to the sagittal plane • Strongest construct medial reconstruction plate with posterolateral dynamic compression plate
Repair osteotomy K-wires and tension band 6.5 screw w/ washer and tension band Parallel small frag screws (lag techique) Jupiter Master Techniques
Complications of Repair Osteotomy Coles 2006 • 70 pts • IM screw and tension band • 30% HWR, 8% due to Sx Ring 2004 • 45 pts • K-wires and tension band • 27% HWR, 13% due to Sx
Ulnar Nerve Transposition? Routine transposition • Plenty of level 5 evidence • Don’t have to worry about it if you go back • Strip blood supply • May do worse?
Post-op Soft dressing vs. splint at 90 vs splint in extension Early ROM (AROM/AAROM) Consider NSAIDs for thermal and head injuries (4% HO), but risking nonunion
Outcomes Most daily activities can be accomplished: • 30 –130 degrees extension-flexion • 50 – 50 degrees pronation-supination Good functional outcome • 15-140 degrees of motion 75% strength to contralateral arm, regardless of approach (osteotomy vs triceps-splitting) Slide courtesy of Stephany & Schmeling; OTA Resident Library McKee et al JBJS-Am 2000; 82: 1701-1707
Complications Non-union of olecranon osteotomy • 5% or more • Chevron osteotomy has a lower rate • Bone graft and revision tension band technique • Excision of proximal fragment is salvage • 50% of olecranon must remain for joint stability Slide courtesy of Stephany & Schmeling; OTA Resident Library
Complications Infection • Range 0-6% • Highest for open fractures • No style of fixation has a higher rate than any other Slide courtesy of Stephany & Schmeling; OTA Resident Library
Complications Ulnar nerve palsy • 8-20% incidence • Reasons: operative manipulation, hardware prominence, inadequate release • Results of neurolysis (McKee, et al) • 1 excellent result • 17 good results • 2 poor results (secondary to failure of reconstruction) • Prevention best treatment Slide courtesy of Stephany & Schmeling; OTA Resident Library
Pearls Learn one extraarticular approach and one intraarticular approach well before trying new ones 90-90 or 180 plating more important than locked plates, but locked plates may be helpful with comminution TEA may be better choice for osteopenic patient than locking plates
Case DM 34 yo M fell 15 feet from roof Open wound posterior distal L arm NVI