Distal humeral fracture

Simplifying fracture of the distal humerus. All information have been taken from authentic sources.

1. Distal humeral fracture Dr. Ashiqur Rahman Resident Orthopedics Dhaka Medical college Hospital

2. Introduction In adult fracture around elbow, especially those of the distal humerus , are often high-energy injuries. Fractures of the distal humerus remain a challenging problem despite advances in technique and implants. These injuries often involve articular comminution, and many occur in older patients with osteoporotic bone. But outcomes have been improved with advances in implant technology , surgical approaches, and rehabilitation protocols, with good to excellent results reported in approximately 87 %.

3. Triangle of stability :

4. The goal of treatment is: - Anatomical restoration of the joint surface - Stable internal fixation. - Allows early motion.

5. Imagin g X-ray : - It may be difficult to tell whether one or both condyles are involved, especially with an un-displaced condylar fracture. CT scan: - Can help in planning the surgical approach but the surgeon should be prepared for the worst case.

6. Approaches to internal fixation(Posterior): ( i ) A posterior approach with an olecranon osteotomy but concerns about healing and symptomatic implants (ii) Triceps-reflecting (Bryan-Morrey ) (iii) Triceps-reflecting anconeus pedicle approach/TRAP (iv) Triceps-splitting (Campbell) approach The best fracture exposure is provided by an olecranon osteotomy approach. As more familiarity is gained with fracture patterns and reduction techniques, a triceps-reflecting or triceps-splitting approach may be selected to reduce complications.

7. Posterior Campbell approach Begin the incision 10cm proximal to the elbow on postero -lateral aspect of the arm & continue it distally for 13cm. Deepen the dissection through the fascia & expose the aponeurosis of the triceps as far distally as its insertion on the olecranon. If triceps muscle has been contracted by fixed extension of the elbow, free the aponeurosis proximally & distally in a tounge -shaped flap @ it’s musculo -tendinous junction & retract it distally to it’s insertion; incise the remaining muscle fibres to the bone in the midline.

8. If triceps muscle has not been contracted, divide the muscle & aponeurosis longitudinally in the midline & continue dissection through the periosteum of the humerus , through the joint capsule and along the lateral border of the olecranon. Elevate the periosteum together with triceps muscle from the posterior surface of the distal humerus for 5cm. For wider exposure, continue the subperiosteal stripping on each side, releasing the muscular & capsular attachment to the condyles & exposing the anterion surface, taking care not to injure the ulnar nerve.

9. Strip the periosteum as conservatively as possible because serious damage to the blood supply of the bone causes osteonecrosis. The head of the radius lie in the distal end of the wound. Elbow should be flexed @ right angle for closure of the wound. Fill the distal part of the defect in the triceps tendon with the inverted-V shaped part of the triceps fascia & close the proximal part by suturing the remaining two margins of the triceps.

10. Platting: Plates to be placed at orthogonal angles (90-90 plating) ( i ) Direct medial and lateral patting ( 180) o Biomechanically sound o Confirmed stable fixation on clinical report. o Higher rates of union. (ii) Small Osteochondral fragments can be fixed with o Headless screw o Countersunk mini-fragment screw o Absorbable screw

11. Plates Used: - Pre-contoured 3.5 mm compression plate - 3.5 mm reconstruction plate. - 1/3rd tubular plate ( less preferable) - Mini fragment plate ( for low type fracture) - Locking plate ( Distal humeral Locking plate)

12. Treatment Type-A Supra-condylar fracture: Closed reduction unlikely to be stable & K-wire fixation is not strong enough to permit early mobilization. ORIF is therefore the Rx of choice. A simple transverse or oblique # can usually be reduced & fixed with medial & lateral contoured plate & screw.

13. Type B & C – Intra-articular fracture: Undisplaced fracture: - These can be treated by applying a posterior slab with the elbow flexed almost 90°; movements are commenced after 02 weeks. -However, great care must be taken to avoid dual pitfalls of underdiagnosis (Displacement & comminution are not always obvious on initial x-ray).

14. Displaced type B & C fractures: - If appropriate expertise & facilities are available, ORIF is the Rx of choice for displaced # & most of the undisplaced # in adults. - Minor displacement & comminution may be under appreciated & can lead to displacement. - The danger with conservative Rx is the strong tendency to stiffening the elbow & persistent pain. - Bridging ex-fix can be used for the for the initial Mx of open fractures with soft tissue contamination.

15. - If articular surface involvement is minimal, a triceps preserving approach can be used to access the humerus . - For more comminuted # a good exposure is needed, this may require olecranon osteotomy. - The ulnar nerve should be identified, decompressed & protected throughout; some favor transposition in all cases. - The fragments are reduced & held temporarily by K-wire. - In adults the use of plates & screws is preferred over lag screw or cannulated screws, even for uni -condylar #.

16. - Parallel or orthogonal plates are used depending on the # configuration of lateral column. - Pre-contoured locking plates are available that help maintain position in osteoporotic bone. - Independent lag screw or headless compression screws may be required for coronal plane # but otherwise it is preferable for transverse screws to pass through a plate to engage fragments of the opposite side.

17. 90 – 90 plating in distal humeral fracture

18. Alternative method of treatment Elbow hemi-arthroplasty: - Replacement of the distal humerus alone is finding an increasing role for the Rx of very comminuted # in elderly osteoporotic pt. Total elbow replacement: - Total elbow replacement is an option for un- reconstructable distal humerus distal humerus # & in particular those with pre- existing joint disease.

19. The bag of bone technique: Non-operative treatment with the “bag of bones” technique in an elderly patient with significant medical comorbidities. The elbow should be placed in a cast at 90° of flexion or collar & cuff if tolerated for 2-3 weeks to allow initial healing and for the pain to settle. Active range movements exercises are started as soon as tolerated & continued until gains in full range.

20. Post-operative management The pt. is provided with a sling for comfort but immediate active mobilization is initiated. The use of splint or a cast is not recommended & passive stretch should be avoided. Fracture healing usually occurs by 12 weeks.

21. Complications: EARLY: ( i ) Vascular injury: Rare in closed distal humerous fracture. (ii) Nerve injury: This is most commonly to the ulnar nerve but the radial nerve may be injured by a long lateral plate and median nerve injury has been reported. LATE: ( i ) Stiffness : Stiffness is the most common complication of distal humerus fracture.