Anatomy of elbow and INTERCONDYLAR FRACTURE OF THE HUMERUS

Anatomy of elbow and INTERCONDYLAR FRACTURE OF THE HUMERUS

1. ANATOMY OF ELBOW - Vinaykumar .S. Appannavar

2. Elbow joint is a hinge type of joint, formed by the articulation between the lower end of the humerus with ulna, and with the head of the radius Humeroulnar articulation Humeroradial articulation and Radioulnar articulation The lower end of the humerus is enlarged to form the trochlea medially and capitulum laterally Medial to the trochlea is medial epicondyle and lateral to the capitulum is the lateral epicondyle

3. The two epicondyles are continuation of the medial and lateral supracondylar ridges respectively Humeroulnar articulation is responsible for alignment, stability and strength. The other two joints help in forearm and hand motion and position.

4. Three bony points relationship :

5. Carrying angle :

6. Stability of the elbow :

7. Muscles common flexors (originate from medial epicondyle) pronator teres   flexor carpi radialis   Palmaris longus   Flexor Digitorum Superficialis   Flexor Carpi Ulnaris

8. common extensors (originate from lateral epicondyle) anconeus   Extensor carpi radialis longus Extensor carpi radialis brevis extensor digitorum comminus   Extensor digiti minimi   Extensor carpi ulnaris

9. INTERCONDYLAR FRACTURE OF THE HUMERUS

10. It is a common fracture in adults It results from a fall on the point of the elbow so the olecranon is driven into the distal humerus, splitting the two humeral condyles apart

11. Mechanism of injury : Is by a force directed towards an elbow which is flexed > 90° which causes the ulna to drive against the trochlea The fracture pattern may be related to the position of elbow flexion when the load is applied

12. Riseborough and Radin Classification • Type I: Nondisplaced • Type II: Slight displacement with no rotation between the condylar fragment. • Type III: Displacement with rotation • Type IV: Severe comminution of the articular surface

13. Evaluation Physical exam Soft tissue envelope Vascular status Radial and ulnar pulses Neurologic status Radial nerve - most commonly injured 14 cm proximal to the lateral epicondyle 20 cm proximal to the medial epicondyle Median nerve - rarely injured Ulnar nerve

14. Radiographic exam Anterior-posterior and lateral radiographs Traction views may be helpful to evaluate intra-articular extension and for pre-operative planning (creates a partial reduction via ligamentotaxis ) Traction removes overlap CT scan helpful in selected cases Comminuted capitellum or trochlea Orientation of CT cut planes can be confusing

15. Pathoanatomy The fracture line may take the shape of a T or Y. T he fracture is generally badly comminuted and displaced. Classification of Mehne and Matta : 1. High T. 2. Low T 3. Y-type 4. H-type. 5. Medial. 6. Lateral The Mehne and Matta classification describes the most often encountered fracture patterns intraoperatively .

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

17. Diagnosis : There is generally severe pain, swelling, ecchymosis and crepitus around the elbow X-Rays : Standard AP and lateral views are obtained CT scan is helpful to further delineate the fracture pattern

18. Treatment : It depends upon the displacement. An undisplaced fracture needs support in an above – elbow plaster slab for 3-4 weeks, followed by exercises A displaced fracture is treated generally by open reduction and internal fixation Operative Treatment Open reduction and internal fixation: • Restores articular congruity • Interfragmentary screws and dual-plate fixation: One plate is placed medially and another plate posterolaterally . Reconstruction plate and one-third plate are used commonly. • Total elbow arthroplasty (semi constrained): May be considered in markedly comminuted fractures and in fractures with osteoporotic bone.

19. Outcomes Most daily activities can be accomplished with the following final motion arcs: 30 –130 degrees extension-flexion 50 – 50 degrees pronation-supination Outcomes based on pain and function Patients not necessarily satisfied with above motion arcs

20. Good elbow flexion is often the first to return Extension seems to progress more slowly Supination/pronation usually unaffected Pain- 25 % of patients describe exertional pain What patients may expect, for example: Lose 10-25 degs of flexion and extension Maintain full supination and pronation Decrease in muscle strength Overall: Good/excellent 75% Factors most likely to affect outcome Severity of injury Occurrence of a complication

21. Complications Failure of fixation Associated with stability of operative fixation K-wire fixation alone is inadequate Adult distal humerus is much different from pediatric distal humerus If diagnosed early, revision fixation indicated Late fixation failure must be tailored to radiographic healing and patient symptoms Nonunion of distal humerus Uncommon Usually a failure of fixation Symptomatic treatment Bone graft with revision plating

22. Non-union of olecranon osteotomy Rates as high as 5% or more Chevron osteotomy has a lower rate Treated with bone graft occasionally and revision fixation Excision of proximal fragment is salvage 50% of olecranon must remain for joint stability Infection Range 0-6% Highest for open fractures No style of fixation has a higher rate than any other

23. 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 (although routine transposition is of unknown importance)

24. Painful implants The most common complaint Common location Olecranon Medial implants (over medial epicondyle) Lateral implants (some plates prominent over posterior-lateral aspect of lateral condyle) Implant removal After fracture union Patient may need to restrict activity for 6-12 weeks

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