Distal Humerus Fractures

Distal humerusCT distal humerus fracture

 

Epidemiology

 

2 groups

- young patient with high velocity injury

- older patient with low velocity injuries, and comminuted, osteoporotic fractures

 

Anatomy

 

Humeroulnar - Hinged Joint

- trochlea axis is centre of rotation

- 40o anterior angulation in sagittal plane

- trochlea 3-8o externally rotated

- 4 - 8o valgus

 

Radiocapitellar - pivot joint

 

Medial and lateral columns

 

Elbow Lateral NormalElbow Lateral Normal 40 degree anterior angulation

 

Elbow AP NormalElbow Normal AP 4 degrees valgus

 

OTA / AO Classification

 

Type A: Extra-articular fracture

 

Distal Humerus Fracture

 

Type B: Partial articular fractures

 

Elbow Lateral Condyle FractureDistal humerus medial condyle

Lateral condyle                                                       Medial condyle

 

Type C: Complete articular fractures

 

Distal Humeral Fracture APDistal Humeral Fracture BicondylarDistal Humeral Fracture

 

CT scan

 

CT dis hum 1CT dis hum 2

 

Operative Management

 

Options

 

1.  ORIF

 

2.  Distal humeral replacement

 

Osteoporotic and highly comminuted fractures

- difficult to ORIF

 

3.  "Bag of bones" treatment

 

Patient elderly and not operative candidate

- initial rest in plaster

- then mobilisation

 

Prescribed commonly, but limited high quality evidence

 

Aitken et al J Bone Join 2015

- 40 "elderly and low demand" patients treated non-op

- 5 year mortality 40%

- 50% non union

- DASH score 38/100

- modest function, but avoids risks

 

Distal Humerus Non Operative

 

ORIF

 

Approaches

 

1.  Paratricipital

- mobilise triceps either side of humerus

 

2.  Triceps reflecting / Bryan-Morrey

- elevate triceps aponeurosis medial to lateral off ulna

 

3.  Triceps splitting

 

4.  Olecranon osteotomy

- indicated for complex intra-articular fractures

 

Paratricipital Approach

 

Technique

 

AO foundation paratricipital approach

 

Posterior incision

- medially identify and protect ulna nerve

- laterally mobilize triceps from lateral intermuscular septum

- identify and protect radial nerve proximally

 

Medial triceps flipLateral triceps flip

Medial approach with ulna nerve protected           Lateral approach

 

Olecranon Osteotomy

 

Chevron OsteotomyChevron 1Chevron 2

 

Technique

 

AO foundation surgery reference Chevron osteotomy

 

Vumedi Chevron osteotomy

 

Chevron

- distally based V shaped

- through bare area of olecranon

- 3 cm from tip

 

Fixation

- TBW v plate v intramedullary screw

 

Results

 

Jeong et al Medicine 2022

- systematic review of olecranon osteotomy and paratricipital approach

- longer operative time and higher incidence of infection with osteotomy

- no difference in outcome / ROM / hetertopic ossification / ulnar nerve injury

 

Coles et al J Orthop Trauma 2006

- 67 intra-articular fractures treated with olecranon osteotomy

- no nonunions

 

Somerson et al Should Elbow 2022

- 63 patients

- 14% wound dehiscence or infection

- 10% symptomatic hardware

- olecranon osteotomy increased re-operation rate

 

Fixation techniques

 

Vumedi surgical fixation distal humerus fracture

 

Options

 

Precontoured anatomical plates

Parallel plates v perpendicular plates

Locking v non locking screws

 

Precontoured anatomical plates

 

Synthes distal humerus plates website

 

Synthes parallel platesSynthes perpendicular plates

 

Parallel v perpendicular plates

 

Elbow Parallel plates 1Elbow parallel plates 2

Parallel plates - medial plate on medial column and lateral plate on lateral column

 

Elbow orthogonal plates 1Elbow orthogonal plates 2

Perpendicular plates - plates at 90 degrees, with lateral plate posterior

 

Zalavras et al JSES 2011

- cadaveric model

- biomechanical superiority of parallel plates versus perpendicular plates

 

Yetter et al JSES 2021

- systematic review of 83 studies and 2362 patients

- parallel plating lower incidence of revision for fixation failure (1% v 6%)

- perpendicular plating reduced overall complication (45% v 54%)

- these complications included lower incidence neuropathy, wound dehiscence, and implant prominence

 

Results ORIF

 

Doornberg et al JBJS Am 2007

- 30 patients at a mean follow up of 19 years

- 87% good or excellent result

- mean flexion / extension arc 106 degrees

- 80% had evidence of OA on xrays

- mostly mild or moderate and not clinically significant

 

Complications ORIF

Han et al J Orthop Surg Res 2022

- multicentered retrospective study of 349 elbows

- postoperative ulna nerve symptoms 15%

- postoperative radial nerve symptoms 2.4%

- nonunion 4%

- deep infection 2%

- heterotrophic ossification 22%

- significant elbow stiffness 46%

- osteoarthritis 24%

 

Heterotopic Ossification

 

Distal humerus HO 1Distal humerus HO 2

 

Ulna nerve injury

 

Chen et al J Orthop Trauma 2010

- patients undergoing ORIF distal humerus

- 48 patients who underwent ulna nerve transposition versus 89 who did not

- 33% ulna neuritis with transposition

- 9% ulna neuritis without transposition

 

Dehghan et al J Orthop Trauma 2021

- RCT of 58 patients undergoing distal humerus ORIF

- Ulnar nerve transposition, vs not

- Overall high rates of abnormality on NCS (62%) but not different between groups

- Significant improvement in both groups over 12 months

 

Stiffness

 

Non union

 

Arthroplasty replacement

 

Indications

 

Elderly

Comminuted, osteoporotic distal humerus fracture

 

Elderly distal humerus 1Elderly distal humerus 2

 

Results

 

Total Elbow Arthroplasty versus ORIF

 

McKee et al JSES 2009

- RCT 42 patients > 65 years of age

- ORIF verus semiconstrained TEA

- 5 ORIF patients converted to TEA intraoperatively

- better elbow score at 2 years

- no difference in DASH score at 2 years

- mean ROM 107 TEA and 95 ORIF

 

Seok et al J Clin Med 2022

- systematic review of ORIF v TEA

- better flexion / extension arc and lower reoperation with TEA

- no difference outcome measures

 

Elbow Hemiarthroplasty versus ORIF

 

Nielsen et al JSES 2022

- systematic review of ORIF versus elbow hemiarthroplasty in patients > 50 years old

- no difference outcome measures

- high rate of complications in both

 

Total Elbow Arthroplasty versus Elbow Hemiarthroplasty

 

Indications hemiarthroplasty

- younger patient < 65 with unreconstructable fracture

- intact collaterals

 

Advantages

- able to lift heavier weight

 

Disadvantage

- instability

- late wear of olecranon cartilage

 

Jonsson et al JSES 2022

- RCT of 40 patients > 60 years of age

- hemiarthroplasty versus TEA

- no difference in outcome at 2 years

 

Technique

 

Distal humerus # TER 1Distal humerus # replacement 2

 

Vumedi Total Elbow Arthroplasty for distal humerus fracture

 

Vumedi Distal humerus replacement via triceps split