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Fracture of Distal End Humerus.

Distal humerus fractures, accounting for about 2% of all fractures in adults, involve complex anatomy with critical articular surfaces, requiring careful evaluation via radiographs and potentially CT scans for surgical planning. Supracondylar humerus fractures are the most common in children and predominantly result from falls on outstretched hands, necessitating varying treatment strategies based on fracture types. Complications include nerve injuries and malunion, with nonoperative methods indicated for specific cases, particularly involving elderly patients with significant comorbidities.

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DISTAL END HUMERUS FRACTURES BY:-Dr. Anshu sharma Guide:- Dr.A.K. Mathur
• Fractures of adult distal humerus areFractures of adult distal humerus are relatively uncommon comprisingrelatively uncommon comprising approximately 2%of all fractures and one-approximately 2%of all fractures and one- third of all humerus fractures.third of all humerus fractures.
Anatomy of Distal HumerusAnatomy of Distal Humerus -->The lower end of the humerus forms the condyles-->The lower end of the humerus forms the condyles which is expended from side to side, and has articularwhich is expended from side to side, and has articular and nonarticular parts.and nonarticular parts. -->The articular parts are:--->The articular parts are:- Capitellum articulate with head of radius,Capitellum articulate with head of radius, Trochlea articulate with trochlear notch of ulna.Trochlea articulate with trochlear notch of ulna. -->The non-articular parts are:--->The non-articular parts are:- Medial and lateral supra condylar ridge,Medial and lateral supra condylar ridge, Medial and lateral epicondyles,Medial and lateral epicondyles, Coronoid fossa,Coronoid fossa, Radial fossa,Radial fossa, Olecranon fossa.Olecranon fossa.
Ossification center  There are six epiphysis around the elbow.  Time of their appearance:- C-1 R-3 I-5 “CRITOL” T-7 O-9 L-11. -->These epiphysis generally unite 2 years after they first appear.
Surgical Anatomy  Medial and lateral columns diverge from humeral shaft at 45 degree angle  The columns are the important structures for support of the “distal humeral triangle”.
SurgicalSurgical AnatomyAnatomy The articulating surfaces of capitellum and trochlea projects distally and anteriorly at an angle of 40 to 45 degrees. -The trochlear axis compared to longitudinal axis is 4-8 degrees in valgus. -The trochlear axis is 3-8 degrees externally rotated. -The intramedullary canal ends 2-3 cm above the olecranon fossa.
distal humeral triangle Functional Anatomy  Hinged joint with single axis of rotation (trochlear axis).  Trochlea is center point with a lateral and medial column.
The blood supply of the distal humerus. A. Anterior view. B. Posterior view. SUC, superior ulnar collateral artery; B, brachial artery; IUC, inferior ulnar collateral artery; RR, radial recurrent artery; PUR, posterior ulnar recurrent artery; R, radial artery; RC, radial collateral artery; MC, middle collateral artery; IR, interosseous recurrent artery.
Blood supplyBlood supply • The distal humerus thus has a richThe distal humerus thus has a rich anastomotic blood supply and problemsanastomotic blood supply and problems with healing and osteonecrosis arewith healing and osteonecrosis are therefore relatively uncommon.therefore relatively uncommon. • During reduction and internal fixation ofDuring reduction and internal fixation of complex closed distal humeral fractures,complex closed distal humeral fractures, retention of even completelyretention of even completely devascularized fragments is appropriate ifdevascularized fragments is appropriate if they are large and contributing to thethey are large and contributing to the stability of the reconstruction.stability of the reconstruction.
ImagingImaging • RadiographsRadiographs – recommended viewsrecommended views • obtain AP and lateral of humerus and elbow.obtain AP and lateral of humerus and elbow. • include entire length of humerus and forearm.include entire length of humerus and forearm. – additional viewsadditional views • obtain wrist radiographs if elbow injury present or distal tenderness on examobtain wrist radiographs if elbow injury present or distal tenderness on exam • oblique radiographs may assist in surgical planningoblique radiographs may assist in surgical planning • traction radiographs may assist in surgical planningtraction radiographs may assist in surgical planning – specifically evaluate if there is continuity of the trochlear fragment to medialspecifically evaluate if there is continuity of the trochlear fragment to medial epicondylar fragment, this can influence hardware choiceepicondylar fragment, this can influence hardware choice • CTCT – often obtained for surgical planning.often obtained for surgical planning. – especially helpful when shear fractures of the capitellum and trochleaespecially helpful when shear fractures of the capitellum and trochlea are suspected.are suspected. – 3D CT scan.3D CT scan. • MRIMRI – usually not indicated in acute injury.usually not indicated in acute injury.
Radiograph Anatomy/LandmarksRadiograph Anatomy/Landmarks Fat pad signFat pad sign -Note the non- displaced fracture (Red Arrow). -Note the posterior fat pad (Yellow Arrows).
Radiograph Anatomy/LandmarksRadiograph Anatomy/Landmarks Baumann’s angleBaumann’s angle Baumann’s angle is formed by a line perpendicular to the axis of the humerus, and a line that goes through the physis of the capitellum. A normal angle is approximately 85-9°, and so when reducing paediatric supracondylar humerus fractures, a deviation of more than 5° from the contralateral side should not be accepted.
Radiograph Anatomy/LandmarksRadiograph Anatomy/Landmarks Ant.humeral lineAnt.humeral line • Anterior HumeralAnterior Humeral LineLine – Drawn along theDrawn along the anterior humeralanterior humeral cortexcortex – Should pass throughShould pass through the middle of thethe middle of the capitellumcapitellum – Variable in veryVariable in very young childrenyoung children-Rogers. Plastic bowing, torus and greenstick supracondylar fractures of the humerus: radiographic clues to obscure fractures of the elbow in children. Radiology. 1978;128:145. -Herman. Relationship of the anterior humeral line to the capitellar ossific nucleus: variability with age. J Bone Joint
Radiograph Anatomy/LandmarksRadiograph Anatomy/Landmarks Humerocapitellar angleHumerocapitellar angle • The capitellumThe capitellum is angulatedis angulated anteriorly aboutanteriorly about 30 degrees.30 degrees. • TheThe appearance ofappearance of the distalthe distal humerus ishumerus is similar to asimilar to a hockey stick.hockey stick. 30
Radiograph Anatomy/LandmarksRadiograph Anatomy/Landmarks Radiocapitellar lineRadiocapitellar line • RadiocapitellarRadiocapitellar line shouldline should intersect theintersect the capitellumcapitellum in allin all views.views. • Make it a habitMake it a habit to evaluate thisto evaluate this line on everyline on every pediatric elbowpediatric elbow film.film.
Classification of FracturesClassification of Fractures • The AO-ASIF Group have defined threeThe AO-ASIF Group have defined three types of distal humeral fractures:-types of distal humeral fractures:- -->Type A-An extra articular supracondylar-->Type A-An extra articular supracondylar fractures,fractures, -->Type B-An intracondylar unicondylar-->Type B-An intracondylar unicondylar fractures,fractures, -->type C-Bicondylar fractures with varying-->type C-Bicondylar fractures with varying degree of comminution.degree of comminution.
Supracondylar Humerus FracturesSupracondylar Humerus Fractures • Most common fracture around the elbow inMost common fracture around the elbow in children.children. – 60 percent of elbow fractures.60 percent of elbow fractures. • 95 percent are extension type injuries.95 percent are extension type injuries. – Produces posterior angulation/displacement of theProduces posterior angulation/displacement of the distal fragment.distal fragment. • Occurs from a fall on an outstretched hand.Occurs from a fall on an outstretched hand. – Ligamentous laxity and hyperextension of the elbowLigamentous laxity and hyperextension of the elbow are important mechanical factors.are important mechanical factors. • May be associated with a distal radius orMay be associated with a distal radius or forearm fractures.forearm fractures.
Supracondylar Humerus FracturesSupracondylar Humerus Fractures Associated InjuriesAssociated Injuries • Nerve injury incidence is high, between 7 and 16 %.Nerve injury incidence is high, between 7 and 16 %. – Radial nerve,Radial nerve, – Median nerve,Median nerve, – Ulnar nerve (flexion type).Ulnar nerve (flexion type). • Radial nerve injury is most commonly injured nerve.Radial nerve injury is most commonly injured nerve. • In many cases, assessment of nerve integrity is limitedIn many cases, assessment of nerve integrity is limited because children can not always cooperate.because children can not always cooperate. • 5% have associated distal radius fracture.5% have associated distal radius fracture. Physical exam of distal forearm and Radiographs ifPhysical exam of distal forearm and Radiographs if needed.needed. • Vascular injuries are rare, but pulses should always beVascular injuries are rare, but pulses should always be assessed before and after reduction.assessed before and after reduction. • In the absence of a radial and/or ulnar pulse, theIn the absence of a radial and/or ulnar pulse, the fingers may still be well-perfused, because of thefingers may still be well-perfused, because of the
Supracondylar Humerus Fractures Gartland’s Classification  Type 1  An undisplaced fracture.  Type 2  Angulated/displaced fracture with intact posterior cortex.  2A-a less severe injury with distal fragment merely angulated,  2B-a severe injury with distal fragment is both angulated and malroated.  Type 3  Complete displacement, with no contact between fragments.
Supracondylar Humerus FracturesSupracondylar Humerus Fractures TreatmentTreatment • Type 1 FracturesType 1 Fractures – In most cases, these can be treated withIn most cases, these can be treated with immobilization for approximately 3 weeks, at 90immobilization for approximately 3 weeks, at 90 degrees of flexion.degrees of flexion. – If there is significant swelling, do not flex to 90If there is significant swelling, do not flex to 90 degrees until the swelling subsides.degrees until the swelling subsides. – It is essential to obtain an x ray 5-7 days later toIt is essential to obtain an x ray 5-7 days later to check that there has been no displacement.check that there has been no displacement.
Supracondylar Humerus FracturesSupracondylar Humerus Fractures TreatmentTreatment • Type 2 Fractures: Posterior AngulationType 2 Fractures: Posterior Angulation – If minimally displaced (anterior humeral line hitsIf minimally displaced (anterior humeral line hits part of capitellum)part of capitellum) • Immobilization for 3 weeks.Immobilization for 3 weeks. • Close follow-up is necessary to monitor for loss ofClose follow-up is necessary to monitor for loss of reduction.reduction. – Displaced (anterior humeral line missesDisplaced (anterior humeral line misses capitellum)capitellum) • Reduction may be necessary.Reduction may be necessary.
Type 2 FracturesType 2 Fractures TreatmentTreatment • Reduction of these fractures is usually notReduction of these fractures is usually not difficultdifficult – Maintaining reduction usually requires flexion beyondMaintaining reduction usually requires flexion beyond 90°90° • Excessive flexion may not be toleratedExcessive flexion may not be tolerated because of swellingbecause of swelling – May require percutaneous pinning to maintainMay require percutaneous pinning to maintain reductionreduction • Most authors suggest that percutaneousMost authors suggest that percutaneous pinning is the safest form of treatment forpinning is the safest form of treatment for many of these fracturesmany of these fractures – Pins maintain the reduction and allow the elbow to bePins maintain the reduction and allow the elbow to be immobilized in a less flexed position.immobilized in a less flexed position.
Supracondylar Humerus FracturesSupracondylar Humerus Fractures TreatmentTreatment • Type 3 FracturesType 3 Fractures – These fractures have a high risk of neurologic and/orThese fractures have a high risk of neurologic and/or vascular compromise.vascular compromise. – Can be associated with a significant amount ofCan be associated with a significant amount of swelling.swelling. – Current treatment protocols use percutaneous pinCurrent treatment protocols use percutaneous pin fixation in almost all cases.fixation in almost all cases. – In rare cases, open reduction may be necessary.In rare cases, open reduction may be necessary. • Especially in cases of vascular disruption.Especially in cases of vascular disruption.
Supracondylar Humerus FracturesSupracondylar Humerus Fractures Pin FixationPin Fixation • Different authors have recommendedDifferent authors have recommended different pin fixation methods.different pin fixation methods. • The medial pin can injury the ulnar andThe medial pin can injury the ulnar and median nerve.median nerve. – Some advocate 2 or 3 lateral pins to avoid injuring theSome advocate 2 or 3 lateral pins to avoid injuring the nerve.nerve. • Space pins as widely as possibleSpace pins as widely as possible – If the lateral pins are placed close together at theIf the lateral pins are placed close together at the fracture site, the pins may not provide muchfracture site, the pins may not provide much resistance to rotation and further displacement.resistance to rotation and further displacement. • Some recommend one lateral, and oneSome recommend one lateral, and one medial pinmedial pin
Pin ConfigurationPin Configuration
Supracondylar Humerus Fractures  If pin fixation is used, the pins are usually bent and cut outside the skin.  The arm is immobilized.  The pins are removed in the clinic 3 to 4 weeks later.  In most cases, full recovery of motion can be expected.
Supracondylar Humerus Fractures: Complications  Immediate:- Vascular injury to brachial artery. Nerve injury to radial nerve, median nerve (AIN) and ulnar nerve(in flexion type).  Early:- Volkmann’s ischemia and Compartment syndrome.  Late:- Malunion-Cubitus varus Myositis ossificans, Volkmann’s ischemic
Intercondylar fractureIntercondylar fracture • Most common distal humeral fracture in adults.Most common distal humeral fracture in adults. • Comminution is common.Comminution is common. • Fracture fregments are often displaced byFracture fregments are often displaced by unapposed muscle pull at the medial and lateralunapposed muscle pull at the medial and lateral epicondyles which rotate the articular surfaces.epicondyles which rotate the articular surfaces. Mechanism of injury:Mechanism of injury:   ForceForce is directed against the posterior aspect of is directed against the posterior aspect of an elbow which is flexed > 90° which causesan elbow which is flexed > 90° which causes the ulnathe ulna to driveto drive into the into the trochlea.trochlea.
Clinical FeaturesClinical Features 1. The elbow maybe held in 90° flexion1. The elbow maybe held in 90° flexion and forearm is kept pronated.and forearm is kept pronated. 2. Crepitus may be elicited.2. Crepitus may be elicited. 3. Independent mobility of the medial and3. Independent mobility of the medial and lateral condyle can be elicited.lateral condyle can be elicited. 4. The normal 3 point bony relationship4. The normal 3 point bony relationship between the olecranon, medial epicondylebetween the olecranon, medial epicondyle and lateral epicondyle is lost.and lateral epicondyle is lost.
Riseborough and Radin classification  Type I - Fractures involving minimally displaced articular fragments.  Type II - Fractures involving displaced fragments that are not rotated .  Type III - Fractures involving displaced and rotated fragments.  Type IV - Fractures involving comminuted fracture fragments.
Jupiter, Mehne and Matta classification  According to pattern of fracture line in the distal humerus.  1. High T. 2. Low T 3. Y-type 4. H-type. 5. Medial lambda. 6. Lateral lambda.  The Mehne and Matta classification describes the most often encountered fracture patterns intraoperatively.
Nonoperative TreatmentNonoperative Treatment -->Nonoperative treatment indicated in:--->Nonoperative treatment indicated in:- -Nondisplaced fractures,-Nondisplaced fractures, -Elderly patients with displaced fractures and severe-Elderly patients with displaced fractures and severe osteopenia and comminution,osteopenia and comminution, -Patients with significant co-morbid conditions.-Patients with significant co-morbid conditions. -->Non operative methods are:--->Non operative methods are:- -Cast immobilization:- rarely indicated.-Cast immobilization:- rarely indicated. ““worst of both worlds”worst of both worlds” inadequate reduction and prolonged immobilization.inadequate reduction and prolonged immobilization. -Bag of bones:-arm is placed in a collar and cuff with as-Bag of bones:-arm is placed in a collar and cuff with as much flexion as possible after initial reduction.much flexion as possible after initial reduction. Aim is to obtain a painless pseudoarthrosis byAim is to obtain a painless pseudoarthrosis by gravity traction effect.gravity traction effect.
Operative treatmentOperative treatment • Indicated in displaced reconstructible fracture.Indicated in displaced reconstructible fracture. • Aim is to restore articular congurity and toAim is to restore articular congurity and to secure supracondylar component.secure supracondylar component. • Methods of fixation:-Methods of fixation:- -Interfragmentry screws,-Interfragmentry screws, -Dual plate fixation by olecranon osteotomy-Dual plate fixation by olecranon osteotomy approach or triceps sparing extensile posteriorapproach or triceps sparing extensile posterior approach.approach. -->Total elbow arthroplasty in markedly-->Total elbow arthroplasty in markedly comminuted fractures and with osteoporosis.comminuted fractures and with osteoporosis.
ComplicationsComplications • Elbow stiffness,Elbow stiffness, • Failure of fixation,Failure of fixation, • Nerve injury to ulnar nerve,Nerve injury to ulnar nerve, • Posttrumatic arthritis,Posttrumatic arthritis, • Heterotopic bone formation,Heterotopic bone formation, • Nonunion of osteotomy,Nonunion of osteotomy, • Infection.Infection.
Condylar fracturesCondylar fractures • Rare in adults and more common inRare in adults and more common in pediatric age group.pediatric age group. • Medial condyle fractures include trochleaMedial condyle fractures include trochlea and medial epicondyle fractures.and medial epicondyle fractures. • Lateral condyle fractures includeLateral condyle fractures include capitellum and lateral epicondylecapitellum and lateral epicondyle fractures.fractures. • Lateral fractures are more common thanLateral fractures are more common than medial.medial. • MOI-abduction or adduction of the forearmMOI-abduction or adduction of the forearm with elbow extension.with elbow extension.
Condylar # classificationCondylar # classification Milch ClassificationMilch Classification • Type I:Type I: Trochlear ridge Trochlear ridge remains intact.remains intact. • Type IIType II:  Trochlear ridge:  Trochlear ridge part of the condylarpart of the condylar fragment(medial orfragment(medial or lateral).lateral). • Explanation-Explanation- condylarcondylar fracture (medial orfracture (medial or lateral) involving thelateral) involving the Trochlear ridgeTrochlear ridge significantlysignificantly compromised the stabilitycompromised the stability of the elbow joint.of the elbow joint.
Condylar # classification Jupiter classification  Classified as low or high based on proximal extension of fracture line to supracondylar region.  Jupiter low equivalent to milch type I.  Jupiter high equivalent to type II.
Condylar fracturesCondylar fractures TreatmentTreatment • Non operative for nondisplaced or minimallyNon operative for nondisplaced or minimally displaced fractures by posterior splintng withdisplaced fractures by posterior splintng with the elbow flexed to 90* and the forearm inthe elbow flexed to 90* and the forearm in supination for lateral condylar # or insupination for lateral condylar # or in pronation for medial condylar #.pronation for medial condylar #. • Operative is indicated in open or displaced #Operative is indicated in open or displaced # by screw fixation with or without collateralby screw fixation with or without collateral ligament repair.ligament repair. • Range of motion exercises should be startedRange of motion exercises should be started as soon as the patient can tolerate therapyas soon as the patient can tolerate therapy usually after 4 weeks.usually after 4 weeks.
Condylar fracturesCondylar fractures ComplicationsComplications • Lateral condyle #- Improper reduction orLateral condyle #- Improper reduction or failure of fixation may result in cubitusfailure of fixation may result in cubitus valgus and tardy ulnar nerve palsy.valgus and tardy ulnar nerve palsy. • Medial condyle #-Medial condyle #- --posttraumatic arthritis,--posttraumatic arthritis, --ulnar nerve symptoms with excess callus--ulnar nerve symptoms with excess callus formation,formation, --cubitus varus with Improper reduction or--cubitus varus with Improper reduction or failure of fixation.failure of fixation.
Posterior Approaches to DistalPosterior Approaches to Distal HumerusHumerus • A posterior approach to the elbow can be madeA posterior approach to the elbow can be made with the patient in the lateral decubitus position,with the patient in the lateral decubitus position, with the arm supported by a padded post.with the arm supported by a padded post. • All posterior approaches use a longitudinalAll posterior approaches use a longitudinal midline incision over the posterior aspect of themidline incision over the posterior aspect of the elbow beginning at the junction of the middleelbow beginning at the junction of the middle and distal thirds of the humeral shaft.and distal thirds of the humeral shaft. • Some surgeons make a straight incision,Some surgeons make a straight incision, whereas others prefer to curve the incisionwhereas others prefer to curve the incision around the olecranon to the radial side.around the olecranon to the radial side. • The incision ends over the ulnarThe incision ends over the ulnar diaphysis,approximately 5 cm distal to the tip ofdiaphysis,approximately 5 cm distal to the tip of the olecranon.the olecranon.
• The ulnar nerve should be routinelyThe ulnar nerve should be routinely identified behind the medial epicondyle,identified behind the medial epicondyle, and protected in all posterior approachesand protected in all posterior approaches to the elbow.to the elbow. • Extensive dissection of the nerve isExtensive dissection of the nerve is inadvisable, as this increases the risk ofinadvisable, as this increases the risk of tethering and damage to its vascularity.tethering and damage to its vascularity. • However, adequate exposure of the nerveHowever, adequate exposure of the nerve is required to reduce the risk of its injury ifis required to reduce the risk of its injury if olecranon osteotomy or insertion ofolecranon osteotomy or insertion of hardware is required.hardware is required.
• There are several variations of approach toThere are several variations of approach to gain access to the posterior aspect of the distalgain access to the posterior aspect of the distal humerus,there are four main types of posteriorhumerus,there are four main types of posterior approach:-approach:- • Olecranon Osteotomy,Olecranon Osteotomy, • Triceps-sparing Approach,Triceps-sparing Approach, • Triceps-Splitting Approach,Triceps-Splitting Approach, • Triceps-Reflecting Approach.Triceps-Reflecting Approach.
Olecranon OsteotomyOlecranon Osteotomy MACAUSLAND & MULLER’SMACAUSLAND & MULLER’S APPROACHAPPROACH • Reflection of the triceps tendon and its bony insertion, byReflection of the triceps tendon and its bony insertion, by use of an olecranon osteotomy, most widely useduse of an olecranon osteotomy, most widely used approach to the elbow.approach to the elbow. • The triceps insertion is isolated and the joint surfaces onThe triceps insertion is isolated and the joint surfaces on either side of the trochlear notch are identified byeither side of the trochlear notch are identified by opening joint capsule.opening joint capsule. • An elevator or gauze swab is then inserted from medialAn elevator or gauze swab is then inserted from medial to lateral through the joint across the notch.to lateral through the joint across the notch. • This serves to protect the articular surfaces during theThis serves to protect the articular surfaces during the subsequent osteotomy, and also facilitates the accuratesubsequent osteotomy, and also facilitates the accurate placement of the osteotomyplacement of the osteotomy..
--The approach initially recommended by the AO group was an extra-articular oblique osteotomy of the olecranon, although the approach more commonly used is an intra-articular osteotomy, through the mid-portion of the greater sigmoid notch. --The osteotomy must be proximal to the coronoid process, to provide a balance between an osteotomy that is too small, which may compromise the exposure of the articular surfaces, and one that is too large, which may cause an inadvertent osteotomy at the level of the coronoid and destabilize the elbow. --Predrilling and tapping of the olecranon should be performed if screw fixation of the osteotomy is planned.
--The osteotomy should be performed as a chevron, with its apex directed distally, perpendicular to the long axis of the shaft of the ulna. --The chevron facilitates reduction and fixation of the osteotomy and also provides a greater surface area of cancellous bone over which healing can occur. --The osteotomy is performed using a narrow saw and completed using an osteotome, to “crack” through the articular surface. --This maneuver facilitates subsequent anatomic reconstruction of the osteotomy fragments. --At the completion of surgery, the osteotomy can be secured either with an intramedullary 6.5-mm, partially threaded cancellous screw, or using two K- wires and a tension-banding technique.
• The approach has the advantage of providingThe approach has the advantage of providing excellent access to the whole of the distalexcellent access to the whole of the distal humerus, especially to view the distal posteriorhumerus, especially to view the distal posterior articular surfaces.articular surfaces. • It provides only limited exposure of theIt provides only limited exposure of the capitellum, but its major drawback is thecapitellum, but its major drawback is the postoperative morbidity, which is associatedpostoperative morbidity, which is associated with the internal fixation of the osteotomy.with the internal fixation of the osteotomy.
Triceps-Sparing approachTriceps-Sparing approach Bryan-Morrey approachBryan-Morrey approach – Posterior Midline incision,Posterior Midline incision, – Ulnar nerve identified and mobilized,Ulnar nerve identified and mobilized, – Medial edge of triceps and distal forearm fasciaMedial edge of triceps and distal forearm fascia elevated as single unit off olecranon and reflectedelevated as single unit off olecranon and reflected laterally,laterally, – Resection of extra-articular tip of olecranon.Resection of extra-articular tip of olecranon.
• Incise the fascia over the flexor carpi ulnaris muscle atIncise the fascia over the flexor carpi ulnaris muscle at the border of the ulnar bone, as the first step inthe border of the ulnar bone, as the first step in the preparation of the extensor apparatus flap.the preparation of the extensor apparatus flap. • The fascia is detached subperiosteally from the ulnaThe fascia is detached subperiosteally from the ulna towards the radial side.towards the radial side. • At the level of the olecranon the extensor apparatus isAt the level of the olecranon the extensor apparatus is detached together with a sliver of bone using a finedetached together with a sliver of bone using a fine chisel.chisel. • Proximal to the olecranon the posterior capsule isProximal to the olecranon the posterior capsule is incised.incised. • At the level of the humerus the extensor muscles areAt the level of the humerus the extensor muscles are freed from the bone.freed from the bone. • Now the entire extensor apparatus flap can be retractedNow the entire extensor apparatus flap can be retracted to the radial side.to the radial side. • To enhance visualization of the articular surface, theTo enhance visualization of the articular surface, the elbow should be flexed beyond 100 degrees.elbow should be flexed beyond 100 degrees.
• For closure, the extensor apparatus is pulledFor closure, the extensor apparatus is pulled into place using a clamp.into place using a clamp. • Some surgeons place the ulnar nerve back inSome surgeons place the ulnar nerve back in the cubital tunnel, whereas other surgeonsthe cubital tunnel, whereas other surgeons perform an anterior subcutaneousperform an anterior subcutaneous transposition.transposition. • The bone sliver is reattached to theThe bone sliver is reattached to the olecranon with transosseous sutures.olecranon with transosseous sutures. • Distally, the incision of the flexor carpi ulnarisDistally, the incision of the flexor carpi ulnaris fascia is closed.fascia is closed.
Triceps-Splitting ApproachesTriceps-Splitting Approaches Campbell approachCampbell approach • The triceps-splitting approach has beenThe triceps-splitting approach has been developed to attempt to overcome the morbiditydeveloped to attempt to overcome the morbidity associated with the use of olecranon osteotomy.associated with the use of olecranon osteotomy. • It is made by fashioning a direct midlineIt is made by fashioning a direct midline posterior split in the triceps.posterior split in the triceps. • Distally sharp dissection is used to reflect theDistally sharp dissection is used to reflect the triceps insertion off the olecranon and proximaltriceps insertion off the olecranon and proximal ulna medially and laterally .ulna medially and laterally . • A thin wafer of bone may be detached from theA thin wafer of bone may be detached from the olecranon at the level of the triceps insertion.olecranon at the level of the triceps insertion. • The triceps may also be detached as a distallyThe triceps may also be detached as a distally based “tongue” muscle flap with splitting of onlybased “tongue” muscle flap with splitting of only its deeper portion.its deeper portion.
• The limited access to the joint surfacesThe limited access to the joint surfaces can be improved by flexing the elbow andcan be improved by flexing the elbow and grasping and posteriorly retracting thegrasping and posteriorly retracting the olecranon with reduction forceps.olecranon with reduction forceps. • Meticulous repair of the tendon throughMeticulous repair of the tendon through drill holes in the olecranon must bedrill holes in the olecranon must be performed at the conclusion of surgery, toperformed at the conclusion of surgery, to minimize the risk of triceps tendon pull-off.minimize the risk of triceps tendon pull-off.
• This approach does not appear to be detrimentalThis approach does not appear to be detrimental to elbow function and reduces the risk of laterto elbow function and reduces the risk of later hardware complications, encountered with thehardware complications, encountered with the use of an olecranon osteotomy.use of an olecranon osteotomy. • Another major advantage of this approach is thatAnother major advantage of this approach is that it allows greater intraoperative flexibility,it allows greater intraoperative flexibility, because either internal fixation or total elbowbecause either internal fixation or total elbow arthroplasty (TER) can be performed.arthroplasty (TER) can be performed. • This is particularly useful if there is uncertaintyThis is particularly useful if there is uncertainty as to whether reduction and internal fixation ofas to whether reduction and internal fixation of the fracture will be technically feasible, and TERthe fracture will be technically feasible, and TER might be required.might be required.
-->The major drawback of the triceps-splitting approach is the-->The major drawback of the triceps-splitting approach is the risk of postoperative detachment of the tendon from therisk of postoperative detachment of the tendon from the proximal ulna.proximal ulna.
Triceps-ReflectingTriceps-Reflecting ApproachesApproaches • The approach has been used less frequently forThe approach has been used less frequently for open reduction with internal fixation (ORIF),open reduction with internal fixation (ORIF), because of the limited exposure of the lateralbecause of the limited exposure of the lateral column that it provides,and it should only becolumn that it provides,and it should only be used if the surgeon is convinced that a TER willused if the surgeon is convinced that a TER will be required.be required. • The whole of the triceps is reflected as aThe whole of the triceps is reflected as a continuous cuff of tissue, from medial to lateral.continuous cuff of tissue, from medial to lateral. • The medial aspect of the triceps is sharplyThe medial aspect of the triceps is sharply reflected off the proximal ulna at its insertion,reflected off the proximal ulna at its insertion, taking care to only continue dissection untiltaking care to only continue dissection until adequate exposure of the joint has beenadequate exposure of the joint has been obtained.obtained.
• Several variations of this approach have beenSeveral variations of this approach have been described:-described:- --As originally described there is a risk of ulnar--As originally described there is a risk of ulnar nerve palsy from retraction during surgery. Tonerve palsy from retraction during surgery. To protect against this the triceps may be split soprotect against this the triceps may be split so that 75% of the muscle lies laterally and 25%that 75% of the muscle lies laterally and 25% medially .medially . The triceps is then reflected laterally as for theThe triceps is then reflected laterally as for the standard technique. The ulnar nerve and itsstandard technique. The ulnar nerve and its blood supply are protected from traction injuryblood supply are protected from traction injury by the medial triceps during surgery.by the medial triceps during surgery. --A wafer of bone carrying the triceps insertion--A wafer of bone carrying the triceps insertion may be detached, to facilitate later closure. Themay be detached, to facilitate later closure. The triceps is then reflected laterally as an “osteo-triceps is then reflected laterally as an “osteo- anconeus flap” to provide exposure of the lateralanconeus flap” to provide exposure of the lateral column.column.
ORIF WITH PLATINGORIF WITH PLATING PRINCIPLESPRINCIPLES • Triangle ofTriangle of stability-conceptstability-concept • The mechanicalThe mechanical properties of the distalproperties of the distal humerus are based onhumerus are based on a triangle of stability,a triangle of stability, comprising the medialcomprising the medial and lateral columns,and lateral columns, and the articularand the articular surface.surface. In C-type fractures, allIn C-type fractures, all 3 columns have to be3 columns have to be restored.restored.
Opening the jointOpening the joint --Cleaning of the--Cleaning of the fracture sitefracture site • Clean out theClean out the fracture byfracture by removing bloodremoving blood clots, loose piecesclots, loose pieces of bone, and anyof bone, and any interposed tissue.interposed tissue.
Reconstruction of theReconstruction of the articular surfacearticular surface • Condylar reassemblyCondylar reassembly • Reduce the articular fragments.Reduce the articular fragments. In good quality bone, useIn good quality bone, use pointed reduction forceps.pointed reduction forceps. • In poor quality bone, useIn poor quality bone, use temporary fixation with a K-wire.temporary fixation with a K-wire. • Definitive fixationDefinitive fixation • Use a lag screw (a partiallyUse a lag screw (a partially threaded screw, or a fullythreaded screw, or a fully threaded screw with overdrillingthreaded screw with overdrilling the near fragment) to obtainthe near fragment) to obtain interfragmentary compression.interfragmentary compression. In osteoporotic bone, use aIn osteoporotic bone, use a position screw.position screw. • Try to use two screws to avoidTry to use two screws to avoid rotational instability.rotational instability. • In very distal fractures, generallyIn very distal fractures, generally only one screw can be inserted.only one screw can be inserted. An additional K-wire can be usedAn additional K-wire can be used to obtain rotational stabilityto obtain rotational stability
Condylar reattachmentCondylar reattachment • Temporary fixationTemporary fixation • Reduce the reconstitutedReduce the reconstituted articular (condylar) blockarticular (condylar) block to the metaphysis andto the metaphysis and use K-wires foruse K-wires for preliminary fixation.preliminary fixation. • Plate preparationPlate preparation • Place the lateral columnPlace the lateral column plate dorsally and theplate dorsally and the medial column platemedial column plate medially. In this positionmedially. In this position they form an angle ofthey form an angle of approximately 90approximately 90 degrees to each other.degrees to each other.
• Definitive fixationDefinitive fixation • First place a 3.5 mmFirst place a 3.5 mm reconstruction platereconstruction plate posterolaterally. It may curveposterolaterally. It may curve around the capitellum which isaround the capitellum which is non-articular posteriorly.non-articular posteriorly. • The more bone is covered byThe more bone is covered by the plate, the more the stabilitythe plate, the more the stability that can be achieved.that can be achieved. • Placement of the lateralPlacement of the lateral plateplate Place a K-wire through thePlace a K-wire through the distal hole. Now insert thedistal hole. Now insert the proximal screw as a loadproximal screw as a load screw. As the plate is pulledscrew. As the plate is pulled proximally, stable contact withproximally, stable contact with the bone is obtained.the bone is obtained. • Fix the plate to the bone byFix the plate to the bone by inserting the remaining screws.inserting the remaining screws.
• Medial plateMedial plate • Place another platePlace another plate medially on the crest ofmedially on the crest of the medialthe medial supracondylar ridge, atsupracondylar ridge, at a right angle to thea right angle to the plane of the lateralplane of the lateral plate to increaseplate to increase stability.stability. • It is recommended toIt is recommended to insert the distal screwinsert the distal screw into the trochlea belowinto the trochlea below
• Contoured 3.5-millimeterContoured 3.5-millimeter reconstruction plates, orreconstruction plates, or precontoured plates, areprecontoured plates, are selected for direct lateralselected for direct lateral positioning on the lateralpositioning on the lateral column and direct medialcolumn and direct medial positioning on the medialpositioning on the medial column.column. • These are usually placedThese are usually placed slightly posteriorly and areslightly posteriorly and are always placed on top ofalways placed on top of the soft tissues—do NOTthe soft tissues—do NOT strip the medial and lateralstrip the medial and lateral columns.columns.
Osteosynthesis of theOsteosynthesis of the olecranon osteotomyolecranon osteotomy • Drill hole for wire-Drill hole for wire- Using a 2.5 mm drill, make aUsing a 2.5 mm drill, make a coronal hole in the proximal ulna from ulnar tocoronal hole in the proximal ulna from ulnar to radial side, to pass the figure-of-eight wire.radial side, to pass the figure-of-eight wire. • Insert wire-Insert wire-Prepare a 0.8 mm  wire by making aPrepare a 0.8 mm  wire by making a loop approximately one third along its length.loop approximately one third along its length. Insert the shorter segment of the wire through thisInsert the shorter segment of the wire through this drill hole.drill hole. • Reduction of the olecranon-Reduction of the olecranon- Reduce theReduce the olecranon osteotomy with pointed reductionolecranon osteotomy with pointed reduction forceps.forceps. • K-wire location-K-wire location- Use the figure-of-eight tensionUse the figure-of-eight tension band wiring technique to obtain stable fixation.band wiring technique to obtain stable fixation. Two K-wires are drilled parallel across theTwo K-wires are drilled parallel across the osteotomy.osteotomy. • Obtain correct K-wire tensionObtain correct K-wire tension • The wire loop has to go underneath the triceps tendon.The wire loop has to go underneath the triceps tendon. • Double twist the wire loop to obtain equal tension onDouble twist the wire loop to obtain equal tension on both sides. The cut wire loops are then impacted firmlyboth sides. The cut wire loops are then impacted firmly onto the bony cortex of the ulna.onto the bony cortex of the ulna. • Cut the wires to the appropriate length and bend them.Cut the wires to the appropriate length and bend them. Impact the bend K-wire tip into the olecranon, being sureImpact the bend K-wire tip into the olecranon, being sure to bury them beneath the triceps tendon.to bury them beneath the triceps tendon.
Osteotomy FixationOsteotomy Fixation • Single screwSingle screw techniquetechnique – Long screw may beLong screw may be beneficial for adequatebeneficial for adequate fixation.fixation. • Short screw mayShort screw may loosen or toggle withloosen or toggle with contraction of tricepscontraction of triceps against olecranonagainst olecranon segment.segment. Hak and Golladay, JAAOS, 8:266-75, 2000
Osteotomy FixationOsteotomy Fixation • Dorsal platingDorsal plating – Low profile periarticularLow profile periarticular implants now available.implants now available. – Axial screw through plate.Axial screw through plate. – Good results after plateGood results after plate fixation.fixation. • Hewin et al (2007)Hewin et al (2007) J OrthopJ Orthop TraumaTrauma 21:5821:58 • Tejwani et al (2002)Tejwani et al (2002) BullBull Hosp Jt DisHosp Jt Dis 61:2761:27
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