• Empiric antibiotic therapy
Fixation Methods: Group 1
• Lag screw fixation • Comminution is supported by small or mini-fragment buttress plate • Bone graft is considered for comminution and required for bone loss
• Hinged joint with single axis of rotation (trochlear axis) • Trochlea is center point with a lateral and medial column
distal humeral triangle
Functional Anatomy
Mechanism of Injury
• The fracture is related to the position of elbow flexion when the load is appPhysical exam
– Soft tissue envelope – Vascular status
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”
– Distal humerus • Extra-articular • Intra-articular
Note: Fixation tactics & implants are based on groups
Treatment Principles
1. Anatomic articular reduction 2. Stable internal fixation of the articular surface 3. Restoration of articular axial alignment 4. Stable internal fixation of the articular segment to the metaphysis and diaphysis 5. Early range of motion of the elbow
– Definitive fixation at repeat evaluation
• Empiric antibiotic therapy • Repeat evaluation in OR until soft tissue closure (2-5 days)
Treatment: Closed Fracture
• Median nerve - rarely injured • Ulnar nerve
Evaluation
• Radiographic exam
– Anterior-posterior and lateral radiographs – Traction views are necessary to evaluate intraarticular extension and for pre-operative planning (“ligamentotaxis”) – Traction removes overlap – CT scan helpful in selected cases
Treatment: Open Fracture
• Emergent I&D • Definitive reduction and internal fixation • Temporary external fixation across elbow if definitive fixation not possible
• The distal humerus angles forward • Lateral positioning during ORIF facilitates reconstruction of this angle
Surgical Anatomy
• The trochlear axis compared to longitudinal axis is 94-98 degrees in valgus • The trochlear axis is 3-8 degrees externally rotated • The intramedullary canal ends 2-3 cm above the olecranon fossa
• Comminuted capitellum or trochlea
OTA Classification
• Follows AO Long Bone System • Humerus, distal segment given # 13 • 3 Main Types
• Extra-articular fracture (13-A) • Partial articular fracture (13-B) • Complete articular fracture (13-C)
• “Bag of bones” technique
– Rarely indicated if at all
• Cast or cast / brace
– Indicated for completely non-displaced, stable fractures
Literature: John, et al, 1994
Summary - Classifications
• Classifications are useful for research! • Classification data may not be reproducible between different surgeons! • Classification data may not be reproduced by the same surgeon at different times!
Literature: Cobb & Morrey, 1997
• 20 patients – (avg age 72 yrs) • TEA for distal humeral fracture • Conclusion
Summary - Classifications
• Meaningful patterns
– Extra-articular distal humerus
• Medial epicondyle • Lateral epicondyle • Distal metaphyseal humerus
– Partial articular distal humerus
• Capitellum • Trochlea
– Complete articular distal humerus
Simplicity
• Group 1
– – – – Lateral epicondyle Medial epicondyle Capitellum Trochlea
• Group 2
Other Potential Options
• Total elbow arthroplasty
– Comminuted intra-articular fracture in the elderly – Promotes immediate ROM – Usually limited by poor remaining bone stock
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Result very good good fair/poor
Literature: Pereles, et al, 1997
• 18 patients (> 60 yrs, avg age: 71 yrs) • SF-36 evaluation • All patients had a good or excellent clinical result • Their general health was comparable to published norms
• 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
• Definitive reduction and internal fixation
– Timing
• Within 24 hours or at 5-7 days – The inflammatory response peaks at 3 days post injury. ORIF during that peak may lead to excessive heterotopic ossification
• Each broad category further subdivided into 9 specific fracture types
OTA Classification
• Humerus, distal segment (13) – Types • Extra-articular fracture (13-A) • Partial articular fracture (13-B) • Complete articular fracture (13-C)