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Distal Humerus Fractures

Categories
  • Elbow
  • Joint/Tendon
Tags
  • Elbow injury
Elbow
Humerus

Shoulder Anatomy

Anatomy

Shoulder anatomy
Rotator Cuff Muscles

Description

  • The shoulder joint is a multi-axial joint with muscles crossing it to allow shoulder range of motion (ROM)
  • The rotator cuff muscles are important in allowing shoulder ROM
  • The rotator cuff muscles consists of Subscapularis, Supraspinatus, Infraspinatus and Teres Minor
  • Other important shoulder muscles that allow shoulder ROM include long head of Biceps and the Deltoid muscle

Upper Limb Anatomy

Right shoulder and arm, posterior view
Right shoulder and arm, posterior view

Right shoulder and arm, posterior view

Normal Upper Limb Anatomy
Triceps Brachii Muscle
Upper Limb Anatomy (Arm)
Muscles of the Forearm
Muscles of the Forearm
Medial aspect of right forearm

Medial aspect of right forearm

Distal Humerus Posterior View
Structure of Radial NerveStructure of Radial Nerve
Upper Limb Anatomy (Nerve)

Blood supply around the elbow joint

Blood supply and anastomosis

Blood supply and anastomosis around the right elbow. Anterior view

Elbow Joint

Distal Humerus Biomechanics

The triangular structure of distal humerus at elbow joint provides structural strength.

Anterior view right distal humerus bone

Anterior view right distal humerus bone

Rotation around throchlear axis

The elbow joint is a hinge joint with axis of rotation around throchlear axis

Elbow joint structural stability structures

Elbow joint structural stability structures

Distal Humerus Fractures

The mechanism is an axial compression with varying elbow ROM. Flexed elbow < 90° usually results in a transcolumnar fracture while > 90° result in an intercondylar fracture pattern.

Associated injury:

  • Elbow dislocation and instability (exclude Terrible Triad Elbow injury)

Presentation:

  • Pain with supination and pronation
  • Swelling
  • Deformity
  • Block to elbow range of motion

Clinically:

  • Bone tenderness
  • Haemarthrosis
  • Flexion/extension painful
  • Avoid ROM to avoid neurovascular injury
  • Assess neurovascular status and exclude compartment syndrome

Investigations:

  • X-ray: AP & Lateral & Greenspan views.
  • CT: often required especially for intra-articular fracture evaluation and surgical planning.

Classification

  • Supracondylar (AO classification)
  • Distal single column (Milch classification, AO classification)
  • Bicolumnar (Jupiter classification, AO classification)
Classification

AO Classification for Distal Humerus Fractures

AO classification for distal humerus fractures

AO Classification for Distal Humerus Fractures

AO classification for distal humerus fractures

Milch Lateral Condyle Fracture Classification

Milch Lateral condyle fracture classification

Milch Ⅰ: fracture line lateral to capitello-trochlear groove

Milch Ⅱ: fracture passes through the capitello-trochlear groove, unstable elbow

Jupiter & Mehne & Matta Classification Distal Humerus Fracture

Jupiter & Mehne & Matta classification distal humerus fracture

Management

Non operative:

    • Stable and nondisplaced Milch Type Ⅰ fracture
    • Cast: Forearm in supination for lateral condyle fractures while in pronation for medial condyle fractures

Operative treatment:

      • Supracondylar fractures
      • Elbow dislocation with associated displaced fracture
      • Ligamentous disruption with elbow instability with associated fracture
      • Intercondylar
      • Open fracture

Surgery options:

      • ORIF plate and screw fixation: supracondylar and intercondylar
      • External fixator
      • Total elbow joint replacement: elderly with bicolumnar fractures

Plate and Screw Fixation

Osteosynthesis

Elbow external fixator for fractures around the elbow joint area

Indication consideration:

      • Open fracture
      • Unstable fracture or additional support after ORIF
      • Major bone loss
      • Vascular injury
Hinged elbow external fixator

Hinged elbow external fixator

Elbow Joint Replacement

Total joint replacement a consideration for elderly patients with significant comminuted fractures.

Arthroplasty of the elbow joint
Elbow joint replacement

Surgery Technique

Surgery

Posterior Approach to Distal Humerus/Elbow/Proximal Ulnar

Nerves posterior to elbow joint

Posterior view of right elbow

Posterior approach to right distal humerus, Radial nerve at risk

Structure of Radial NerveStructure of Radial Nerve

Radial nerve is responsible for motor elbow and wrist extension. Sensory distribution shown on pic.

Skin Incision Approach to Distal Humerus/Elbow/Proximal Ulnar

Distal humerus to curving around the lateral olecranon

Distal humerus to curving around the lateral olecranon to 2-4cm along ulnar crest

Deep posterior approach to distal humerus/elbow:

Fascia release or olecranon osteotomy

Fascia release or olecranon osteotomy

Medial window: Medial fascia release

Medial window: Medial fascia release
  • Ulnar nerve exploration along medial intermuscular septum and followed to the cubital tunnel, isolate and retract with latex loop
  • Retract triceps laterally
  • Medial attachment of triceps along olecranon is partially released

Lateral window: Lateral fascia release

Lateral window: Lateral fascia release
  • Free triceps on lateral side
  • Split triceps fascia & mobilize from lateral intermuscular septum &
  • partially release triceps tendon on lateral side of olecranon with 1mm sliver of cartilage
  • Retract triceps medially
  • Distally partially release anconeus

Midline Window: Midline fascia release

Midline Window: Midline fascia release
  • Split triceps tendon in midline to to upper limit of olecranon fossa to proximal triceps muscle area with caution to Radial nerve for more proximal muscle splitting
  • Medial incision along medial ulnar border ± cartilage/periosteum sleeve
  • Retract the split triceps

Olecranon Osteotomy Principles

Olecranon osteotomy principles
  • Osteotomy
  • Final bone incision with osteotome
  • Olecranon fixation options: plate & screws/tension band wire

Distal Humerus Fracture Plate and Screw Fixation

Distal humerus fracture plate and screw fixation

Elbow External Fixator

Hinged external fixator can supplement unstable elbow fracture ORIF and ligament repair.

Elbow external fixator

Safe Zones for Pin Sites for External Fixator around Elbow Joint

Safe zones for pin sites

Arc for safe zone for application of external fixator pins of right arm

Elbow Joint Replacement

Elbow joint replacement

Post Operative Rehabilitation

      • Rigid fixation: arm sling for 7-10 days then elbow range of motion, non-weight bearing
      • Suboptimal fixation may require extended splintage
      • Strengthening exercises after fracture union
Arm sling

Arm sling

Hand grip exercises with arm in splint

Hand grip exercises with arm in splint

Download ASSIC Performance Fingerprint or Strength & Conditioning apps for rehab guideline routines or create own under professional supervision

apple app store  google play store

Complications

  • Elbow stiffness
  • Non union
  • Malunion
  • Volkmann contracture due to missed initial compartment syndrome at time of injury

References

  1. A comparative Biomechanical Analysis of 2 Double-Row, Distal Triceps Tendon Repairs. Matthew A Dorweiler, Rufus O Van Dyke, Robert C Siska, Michael A Boin and Mathew J DiPaola. The Orthopaedic Journal of Sports Medicine May 2017, 5(5): 23259671177080.
  2. Traumatic elbow injuries: what the orthopedic surgeon wants to know. Sheehan S.E. Radiographics 33(3(: 869-888.
  3. A follow-up of one hundred cases of fracture of the head of the radius with a review of the literature. Johnston GW. Ulster Med J 31: 51-56.
  4. Management of severely comminuted distal radius fractures. David M Brogan, Marc J Richard, David Ruch, Sanjeev Kakar. J Hand Surg Am. 2015 Sep; 40(9): 1905-14.
  5. Surgical management for olecranon fractures in adults: a systematic review and meta-analysis. Koziarz A, Woolnough T, Oitment C, Nath S, Johal H. Orthopedic. 2019 Mar 1;42(2): 75-82.
  6. Classifications in Brief: Mayo classification of olecranon fractures. Sullivan CW, Desai K. Clin Orthop Relat Res. 2019 Apr;477(4): 908-910.
  7. Elbow fractures. Midtgaard KS, Ruzbarsky JJ, Hackett TR, Viola RW. Clin Sports Med. 2020 Jul;39(3): 623-636.
  8. Comparison of outcome between nonoperative and operative treatment of medial epicondyle fractures. Petra Grahn, Tero Hämäläinen, Yrjänä Nietosvaara, Matti Ahonen. Acta Orthop. 2021 Feb;92(1): 114-119.
  9. A narrative review on avulsion fractures of the upper limb and lower limbs. Christopher Vannabouathong, Olufemi R Ayeni, Mohit Bhandari. Clin Med Insights Arthritis Musculoskelet Disord. 2018;11: 1179544118809050.
  10. Outcome after ORIF of capitellar and trochlear fractures. JH Dubberley, KJ Faber, JC Macdermid, SD Patterson, GH King. J Bone Joint Surg Am. Vol. 88 2006: 46-54.
  11. Coronal plane partial articular fractures of the distal humerus: current concept in management. DE Ruchelsman, NC Tejwani, YW Kwon, KA Egol. J Am Acad Orthop Surg. Vol 16 2008: 716-728.
  12. Complex elbow dislocations and the “terrible triad” injury. Allistair D R Jones, Robert W Jordan. Open Orthop J. 2017 Nov 30;11: 1394-1404.
  13. Articular fractures of the distal humerus. T. Bégué. Orthopaedics & Traumatology: Surgery & Research 100(2014) S55-S63.

Contributor:

Dr N J Kauta

Learn More

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