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Distal humerus fractures
- 1. DISTAL HUMERUS FRACTURE Presentor:DrBalaji VINAYAKA MISSION KIRUBANANDA VARIYAR MEDICAL COLLEGE. SALEM
- 2. • The elbowjoint is a hinge joint and consists of three components. – Humeroulnar articulation – Humeroradial articulation and – Radioulnar articulation. • Humeroulnar articulation is responsible for alignment, stability and strength. • The other two joints help in forearm and hand motion and position.
- 4. Distal humerus isa cylindrical diaphysis that flattens above the elbow and diverges into triangular medial and lateral columns. Each column is bounded on its outer border by supracondylar ridge and an outer non articular surface and inner articular surface.
- 5. The articulating surfaceof the medial condyle is called as trochlea Similarly the articulation surface of the lateral condyle is capitellum. Anterior surface has two fossa the coronoid and radial fossa Posterior surface has olecranon fossa.
- 6. • The carryingangle: a line drawn from the long axis of the arm and forearm forms an angle, with elbow in extension and forearm in supination. • This is normal carrying in males is 7-9 degrees and female it is 9-11 degree.
- 7. • Muscles commonflexors (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. • Ligaments medialcollateral ligament – anterior bundle originates from distal medial epicondyle – inserts on common extensor tendon – primary restraint to valgus stress at the elbow from 30 to 120 deg – tight in pronation
- 10. • lateral collateralligament – originates from distal lateral epicondyle – inserts on supinator crest on the ulna – stabilizer against posterolateral rotational instability – taut in supination
- 11. • ROM: • Flexionis about 0- 180*, it is restricted to 150* due the muscle bulk of the biceps. • The majority of the daily living activites takes place in the functional range of motion, from 40-120*. • During assisted standing the joint force on the elbow is maximum with forces reaching four folds of that of body weight.
- 12. MECHANISM OF INJURY •Most of the injuries are low energy with trivial fall or domestic fall with elbow getting struck directly or axially loaded in a fall with out stretched hand. • RTA
- 13. • Classifications: • AO •MILCH • JUPITER
- 14. AO • Type A:Extraarticular
- 15. • Type B:Intra-articular single column
- 16. • Type C:Intra-articular both column fracture
- 18. • MILCH CLASSIFICATION •Milch type I:lateral trochlear ridge intact • Milch type II: fracture through the lateral trochlear ridge.
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- 21. • Riseborough andRadin Classification. • Type I: Nondisplaced. • Type II: slight displacement with no rotation between the condylar fragment in the frontal plane • Type III: Displacement with rotation. • Type IV: Severe comminution of the articula surface.
- 23. TREATMENT X-ray CT with 3Dreconstruction. Xray with AP and Lateral view(postivie fat pad sign)
- 24. • Conservative management: 1.Cast or splint stabilization 2. Traction 3. Bag of bones technique.
- 25. • Cast orsplint stabilization • It can be used in minimal or non displaced fractures. • Disadvantage is that poor maintenance of fractured fragments and lack of early mobilization.
- 26. The bag ofbone technique • This technique involves placing the arm in a collar and cuff with the elbow in marked flexion. • Elbow motion is initiated after the swelling and pain subsides. • Recommended for surgical unfit patients and elderly whose functional goals are limited.
- 27. • Surgical intervention: •Single column fracture(B1 and B2) • Comprising 15% of all distal humerus fracture. • Lateral column fractures addressed with kocher approach • Medial column fractures are apporached with posterior triceps reflecting or transolecranon approach.
- 28. • Bicolumn fractures •Distal humerus are operated with olecranon osteotomy, triceps-splitting or Triceps Reflecting Anconeus Pedicle approach. • Use of two orthogonal plates is the most stable method of treating these fractures. • 90-90* with medial and posterolateral position. • Medial and lateral position.
- 29. • Total elbowarthroplasty • Semiconstrained hinge design is used to treat unsalvageable nonunions. • All the previous implants are removed and arthroplasty is proceeded. • External fixation with ring or hybrid ring fixators.
- 30. SURGICAL APPROACH POSTERIOR POSITION •Lateral decubitus position also called as swimmer’s position. • Arm hanging over a post • With tourniquet.
- 32. 1) Longitudinal midlineskin incision over the posterior aspect of the elbow
- 33. • Beginning atleast 5cmproximal to the tip of the olecranon, curving slightly laterally at the tip, then returning to the midline and extending 5 cm distal to the tip of the olecranon
- 34. • 2) Raising subcutaneo usflaps on either side
- 35. • Isolation ofthe ulnar nerve.
- 36. Osteotomy Fixation Single screwWITH TBW technique: 1) Expose the tip by sharp dissection of soft tissues to see the bone 2) Pre-drilling & tapping should be done prior to osteotomy 3) cannulated cancellous screw are used 4) A Tension band wiring done before full tightening of the screw
- 38. Osteotomy Fixation Tension bandtechnique with K-wires: • Easy to place • May be less stable than independent lag screw or plate • Implant irritation is a problem
- 39. • Olecranon osteotomy. •There are two types olecranon of two types 1. Transverse osteotomy 2. Chevron osteotomy. • Soft tissue dissection is done to identify the olecranon bone.
- 40. • A lineof osteotomy is marked with the help of a pen or cautery.
- 41. • Small, thinoscillating saw is used to cut about 95 % of the osteotomy along the previously marked line.
- 42. • The osteotomyis completed using the osteotome.
- 43. • The osteotomyfixation must be planned well in advance. • Osteotomy fixation can be done using – Tension band wiring with k-wire fixation. – Cancellous screw fixation
- 44. • Exposure of thedistal humreus especially the intercondylar area is excellent after an osteotomy.
- 45. • Osteotomy approachis best used to visualise the distal humerus. • Most suited for all type Communited fractures • Disadvantages are 1. Nonunion at the osteotomy site 2. Hardware irritation
- 46. complications • Early complications: •Vascular injury • Nerve injury • Malunion • Wound infection
- 47. • Delayed complications •Heterotrophic ossification • Elbow stiffness • osteoarthritis