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Operative Treatment of Intra-Articular Distal Humerus Fractures Charalampos G

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Operative Treatment of Intra-Articular Distal Humerus Fractures Charalampos G A Review Paper Operative Treatment of Intra-Articular Distal Humerus Fractures Charalampos G. Zalavras, MD, PhD, Elizabeth T. McAllister, MD, Anshuman Singh, MD, and John M. Itamura, MD Abstract about the fracture pattern, especially with 3-D reconstruc- tions with subtraction of the proximal ulna. However, Intra-articular distal humerus fractures can be among the most challenging injuries treated by orthopedic direct, intraoperative visualization of the fracture site may surgeons. The goals of surgical treatment are anatomi- reveal a fracture line not well visualized during preopera- cal restoration of the articular surface and stable fixa- tive evaluation, especially in gunshot injuries. tion of the fracture fragments to allow for early motion. Intra-articular fractures of the distal humerus are clas- However, the bone stock of the distal humerus is limited, sified with the Mehne and Matta system as 1-column and stable fixation may be difficult to achieve in the case fractures (medial or lateral column), 2-column fractures of a low fracture pattern, comminution, or osteoporosis. (T, Y, H, or lambda), or fractures involving the capitellum In this article, we provide practical recommendations for or trochlea (not covered in this article). surgical management of these complex fractures. SURGICAL TREATMENT: OPEN REDUCTION ntra-articular distal humerus fractures can be among AND INTERNAL FIXATION the most challenging injuries treated by orthopedic Indications surgeons. The goals of surgical treatment are anatomi- Intra-articular distal humerus fractures should be treated cal restoration of the articular surface and stable fixa- surgically. The treatment of choice is open reduction and Ition of the fracture fragments to allow for early motion.1-4 internal fixation (ORIF); restoration of articular surface However, the bone stock of the distal humerus is limited, congruency minimizes development of arthrosis, and and stable fixation may be difficult to achieve in the case stable fixation allows early motion and maximizes the of a low fracture pattern, comminution, or osteoporosis. functional outcome. Total elbow arthroplasty is reliable In this article, we provide practical recommendations for for elderly patients who have severely comminuted frac- surgical management of these complex fractures. tures not amenable to stable osteosynthesis.5 Kamineni and Morrey5 retrospectively reviewed 43 fractures in 43 PREOPERATIVE EVALUATION patients (mean age, 69 years) who were followed for at A focused history should assess prior trauma and func- least 2 years (mean follow-up, 7 years). At the latest fol- tion of the extremity, functional demands of the patient, low-up, mean flexion arc was 24° to 131°, and mean Mayo and medical comorbidities. Physical examination should Elbow Performance Score was 93 (maximum, 100 points). start with a thorough evaluation of the neurovascular sta- Fractures in high-risk surgical candidates may be treated tus of the extremity. Vascular examination may reveal a nonoperatively. diminished or absent pulse, which may be restored with fracture reduction. If, after reduction, the perfusion of the Anesthesia, Positioning, Preparation extremity is compromised, then angiography or explora- General endotracheal anesthesia with muscle relaxation is tion is warranted. Neurologic examination may reveal an preferred. The patient can be in supine, lateral, or prone associated nerve injury. Inspection of the extremity should position based on surgeon preference. The supine position focus on assessment of the soft-tissue envelope to detect with the arm positioned over the chest, which is safe for any open fracture wounds. polytrauma patients with chest or spinal injuries, allows Radiographic assessment includes standard antero- hyperflexion of the elbow and improved visualization of posterior and lateral plain films. We have found traction the anterior part of the trochlea. However, this is a more anteroposterior views to be helpful for assessing fracture difficult approach, and an assistant is needed to hold the morphology. Computed tomography provides more details extremity because gravity tends to malalign the fracture. On the other hand, the lateral position does not require an Dr. Zalavras is Associate Professor, Dr. McAllister is Resident, assistant, and gravity helps maintain the reduction. Dr. Singh is Resident, and Dr. Itamura is Associate Professor, Los The entire upper extremity is prepared and draped, Angeles County + USC Medical Center, Keck School of Medicine, and a sterile tourniquet may be applied according to sur- University of Southern California, Los Angeles, California. geon preference. Use of a nonsterile tourniquet limits the Am J Orthop. 2007;36(12 suppl):8-12. Copyright Quadrant proximal extension of the surgical approach and is not HealthCom Inc. 2007. All rights reserved. recommended. The contralateral iliac crest should be pre- 8 A Supplement to The American Journal of Orthopedics® C. G. Zalavras et al A B Figure 1. Exposure of fracture site after olecranon osteotomy. C D E F Figure 3. A very low intra-articular fracture of the distal humerus as seen in the preoperative anteroposterior (A) and lateral A B radiographs (B) is an especially challenging injury because of the limited distal bone stock available for fixation. The bone fragments Figure 2. Fixation of olecranon osteotomy with a 6.5-mm are reduced and provisionally stabilized using reduction clamps and cannulated screw and a washer. As noted in both the Kirschner wires (K-wires). Note that positioning of the K-wires does (A) (B) anteroposterior and lateral views , the treaded part of not interfere with plate application. (C) The implants should be the screw engages the isthmus of the ulna, resulting in applied so as to maximize fixation of the distal fragments to the compression of the osteotomy site and stable fixation. metaphysis/diaphysis of the humerus. As many screws as pos- sible should be placed through the plates into the distal fragments pared and draped so that, if bone graft is needed, a second (6 such screws in this case), and each distal screw should be long surgeon can harvest the graft simultaneously. and engage as many articular fragments as possible (D). Both plates should be applied with compression at the supracondylar level. Note Surgical Approach the isthmic fit of the screw used for fixation of the osteotomy as noted in the lateral view (E). Following these principles will The surgical approach may be performed through an olec- ensure that the fracture site is stabilized enough to allow early ranon osteotomy or reflection of the triceps (Bryan-Morrey motion of the elbow, and uncompromised fracture healing (F) or triceps-reflecting anconeus pedicle approach).3,6 The with a satisfactory outcome. December 2007 9 Operative Treatment of Intra-Articular Distal Humerus Fractures olecranon osteotomy provides excellent visualization of olecranon to protect the articular cartilage and to allow an the fracture (Figure 1), but there are concerns regarding assistant to provide countertraction while the osteotomy nonunion of the osteotomy site and prominence of the is made. An apex distal chevron-type osteotomy helps hardware placed at the olecranon. If elbow arthroplasty with anatomical reduction and improves stability. A thin is considered, the olecranon should not be osteotomized. oscillating saw is used initially, but the final portion of Triceps reflection avoids the complications of the olec- the osteotomy is made with an osteotome to facilitate ranon osteotomy (but may result in triceps rupture) and interdigitation of the bone ends and reduction of the oste- provides satisfactory exposure but not to the same extent as otomy. After the osteotomy, the olecranon tip is reflected the osteotomy. Most osteotomy nonunions are attributable proximally with the triceps, and the articular surface of the to inadequate fixation of the osteotomy site and thus can distal humerus can now be directly visualized. An olecra- be prevented with stable fixation. Also, treating a nonunion non osteotomy should be avoided if primary arthroplasty is of the olecranon is easier than treating an intra-articular being considered. malunion of the distal humerus. Fracture Reduction Incision The hematoma is removed by irrigating the fracture site, After perioperative antibiotics are administered, a posterior and the fracture fragments are identified. The surgeon and midline skin incision is made. This incision allows wide assistants should preserve all existing soft-tissue attach- exposure, protects cutaneous nerves, and can be reused for ments of bone fragments and should be careful at this revision procedures. The incision extends from approxi- point to avoid inadvertently dropping an articular fragment mately 15 cm proximal to 7 cm distal to the tip of the completely devoid of soft-tissue attachments. After direct olecranon and is placed slightly lateral or medial to the tip. visualization of the fracture site, preoperative assessment Full-thickness subcutaneous flaps are raised both medially of the fracture is confirmed, or new fracture lines may be and laterally. discovered, thus changing the preoperative plan. Fracture reduction may start at 1 of the 2 columns or at Ulnar Nerve Dissection the articular surface. The order and method of reduction The ulnar nerve is identified and carefully dissected and must be tailored to the individual fracture pattern. When a mobilized. It is important to release the ulnar nerve from column is not comminuted,
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