DISTAL HUMERUS

FRACTURES
DR. NISHAN PATRA
JUNIOR RESIDENT
DEPARTMEMNT OF ORTHOPAEDICS
LMCH
INTRODUCTION

2% OF ALL ADULT FRACTURES

BIMODAL DISTRIBUTION

YOUNG - HIGH VELOCITY

ELDERLY - SIMPLE FALL

ANATOMY
ANTERIOR-POSTERIOR

TRIANGULAR STRUCTURE

TIE ROD - THIN BONY ELEMENT AT THE CENTRE

MEDIAL COLUMN

LATERAL COLUMN

TROCHLEA
ANATOMY

TROCHLEA IS CENTRE POINT

ELBOW JOINT - HINGE JOINT WITH SINGLE AXIS OF

ROTATION (TROCHLEAR AXIS)

DISTALLY 5 DEGREE OF VALGUS

ANATOMY
END ON

TROCHLEA IS CENTRE POINT

ELBOW JOINT - HINGE JOINT WITH SINGLE AXIS OF

ROTATION (TROCHLEAR AXIS)

DISTALLY 5 DEGREE OF VALGUS

ANATOMY
LATERAL VIEW

FORWARD BENDING
OF 30 DEGREES
EVALUATION

PHYSICAL EXAMINATION

SOFT TISSUE ENVELOPE

VASCULAR STATUS

RADIAL & ULNAR PULSES

NEUROLOGICAL STATUS

RADIAL NERVE

ULNAR NERVE

MEDIAN NERVE (RARE)

RADIOLOGICAL
XRAY

TRUE
ANTERO-
POSTERIOR

TRUE
LATERAL

TRACTION
VIEW

CT SCAN
RADIOLOGICAL
ROLE OF CT SCAN

INTRA-ARTICULAR
FRACTURES

CORONAL FRACTURES

SEVERE OSTEOPORISIS

PREEXSITING
DEFORMITIES

COMMINUTION
CLASSIFICATION
AO
HUMERUS , DISTAL HUMERUS - 13

TYPE A - EXTRA-ARTICULAR

A1 - AVULSION FRACTURE

A2 - SIMPLE FRACTURE

A3 - MULTIFRAGMENTORY
CLASSIFICATION
AO
HUMERUS , DISTAL HUMERUS - 13

TYPE B- PARTIAL-ARTICULAR

B1 - LATERAL CONDYL FRACTURE

B2 - MEDIAL CONDYL FRACTURE

B3 - CORONAL FRACTURE
(TROCHLEAR/CAPITULAR)
CLASSIFICATION
AO

HUMERUS , DISTAL HUMERUS - 13

TYPE C- COMPLETE ARTICULAR

C1 - ARTICULAR SIMPLE, METAPHYSEAL SIMPLE

C2 - ARTICULAR SIMPLE, METAPHYSEAL

MULTIFRAGMENTORY

C3 - ARTICULAR MULTIFRAGMENTORY
GOALS OF TREATMENT

RESTORATION OF ARTICULAR CONGRUITY / BONY ALIGNMENT

STABLE FIXATION

EARLY ROM

RESTORING ELBOW FUNTION

ROM: 30-130 DEGREE

STABLE

PAINLESS
TREATMENT
CONSERVATIVE

UNDISPLACED FRACTURE

MORBID / UNFIT PATIENTS

TREATMENT
SURGICAL

ORIF WITH PLATE OSTEOSYNTHESIS

OTHER OPTIONS-

TOTAL ELBOW ARTHROPLASTY

RESERVED IN ELDERLY OSTEOPOROTIC FRACTURES WITH

SIGNIFICANT COMMINUTION

PROMOTES IMMEDIATE ROM

LIMITED BY POOR REMAINING BONE STOCK

TREATMENT
SURGICAL CHALLANGES

COMPLEX ANATOMY AND ANGULATION (VALGUS ANGULATION OF

5 DEG & ANTEROPOSTERIOR ANGULATION OF 30 DEG)

COMMINUTION

OSTEOPOROSIS
SURGERY
POSITION
SURGERY
ANATOMY - BLOOD SUPPLY
3 ARTERIAL ARCADES - MEDIAL, LATERAL AND POSTERIOR

WATERSHED LINE

TROCHLEO-CAPITULAR JUNCTION

FRACTURES OF THIS AREA CAN CAUSE AVASCULAR

NECROSIS LEADING TO TROCHLEAR STENOSIS
SURGERY
APPROACH - POSTERIOR

OLECRANON OSTEOTOMY - MacAusland

TRICEPS SPLITTING - Campbell

TRICEPS ELEVATING / SPARING / PARATRICIPITAL - Alonso Lames

TRICEPS REFLECTING - Brain Morrey

TRICEPS REFLECTING ANCONEUS PEDICLE (TRAP) - O’Driscoll

SURGERY

IDENTIFY & PRESERVE ULNAR NERVE

DISSECT TO DEEPER BONE

Campbell
Alonso Lames
REDUCTION
MacAusland UNDER VISION

FIXATION

Brain Morrey
O’Driscoll
 SURGERY
STEPS

IDENTIFY & PRESERVE

ULNAR NERVE

DISSECT TO DEEPER BONE

REDUCTION UNDER
VISION

FIXATION
SURGERY
REDUCTION

IDENTIFY & PRESERVE ULNAR NERVE

DISSECT TO DEEPER BONE

REDUCTION VISION

FIXATION
SURGERY
TEMPORARY FIXATION

IDENTIFY & PRESERVE ULNAR NERVE

DISSECT TO DEEPER BONE

REDUCTION UNDER VISION

FIXATION
SURGERY
FINAL FIXATION

IDENTIFY & PRESERVE ULNAR NERVE

DISSECT TO DEEPER BONE

REDUCTION UNDER VISION

FIXATION
SURGERY
OSTEOTOMY FIXATION

IDENTIFY & PRESERVE ULNAR NERVE

DISSECT TO DEEPER BONE

REDUCTION UNDER VISION

FIXATION
SURGERY
PLATE CONFIGERATION

a. PERPENDICULAR

b. PARALLEL
SURGERY
AO TECHNIQUE OF FIXATION
INTER CONDYLAR
SCREW (LAG SCREW)

THROUGH /
OUTSIDE THE
PLATE

MEDIAL COLUMN PLATE

DORSOLATERAL PLATE

90 DEGREE
CONFIGURATION
SURGERY

INTERCONDYLAR SCREW

THROUGH/OUTSIDE THE PLATE

MEDIAL COLUM PLATE

DORSOLATERAL PLATE

90 DEG CONFIGERATION
SURGERY
RATIONALE OF O’DRISCOLL

SCREW PURCHASE IN THE DISTAL FRAGMENTS IS

LIMITED

COMMINUTION / OSTEOPOROSIS

STABLE ARCHITECTURE TO BE CREATED WITH THE

PLATES AND SCREWS

AROUND WHICH SOFT COMMINUTED BONES CAN BE

ASSEMBLED
SURGERY
RATIONALE OF O’DRISCOLL
TO ACHIEVE THIS -

2 PARALLEL
PLATES

RIGIDLY FIXED TO
SHAFT

LOCKED DISTALLY

INTERDIGITATION
OF SCREWS
SURGERY
O’DRISCOLL TECHINQUE

2 PRINCLIPLES

1. MAXIMISING FIXATION IN DISTAL FRAGMENTS

2. ENSURING ALL FIXATION IN DISTAL SEGMENT

CONTRIBUTE TO STABILITY AT SUPRACONDYLAR
LEVEL
SURGERY
O’DRISCOLL TECHINQUE

8 OBJECTIVES

1. MAXIMISING FIXATION
IN DISTAL FRAGMENTS
1.

1.

EVERY SCREW IN
THE DISTAL
FRAGMENT
SHOULD PASS
THROUGH THE
PLATE
SURGERY
O’DRISCOLL TECHINQUE

8 OBJECTIVES

1. EVERY SCREW IN DISTAL

FRAGMENT SHOULD BE
ANCHORED IN A FRAGMENT
OF THE OPPOSITE SIDE
THAT IS FIXED BY A PLATE
SURGERY
O’DRISCOLL TECHINQUE

8 OBJECTIVES

1. AS MANY SCREWS AS
POSSIBLE IN THE DISTAL
FRAGMENT
SURGERY
O’DRISCOLL TECHINQUE

8 OBJECTIVES

1. EACH SCREW SHOULD

BE AS LONG AS
POSSIBLE
SURGERY
O’DRISCOLL TECHINQUE

8 OBJECTIVES

1. EVERY SCREW IN THE

DISTAL FRAGMENT
SHOULD ENGAGE AS
MANY ARTICULAR
FRAGMENTS AS POSSIBLE
SURGERY
O’DRISCOLL TECHINQUE

8 OBJECTIVES

1. SCRES IN THE DISTAL

FRAGMENT SHOULD BE
LOCKED TOGETHER BY
INTERDIGITATION,
CREATING A FIXED-ANGLE
STRUCTURE, THEREBY
COMPLETING THE ARC OR
CLOSING THE SCREW
SURGERY
O’DRISCOLL TECHINQUE

8 OBJECTIVES

1. PLATES SHOULD BE
APPLIED WITH
COMPRESSION AT
THE SUPRA
CONDYLAR LEVEL
SURGERY
O’DRISCOLL TECHINQUE

8 OBJECTIVES

1. PLATES SHOULD
BE STRONG
ENOUGH & STIFF
ENOUGH TO
RESIST BENDING
OR BREAKAGE
SURGERY
ROLE OF VA-LCP

BEST OF BOTH WORLDS

AO PRINCIPLE - 90
DEG PLATING

O’DRISCOLL
PRINCIPLE - ALL
OBJECTIVES MET

ESPECIALLY HEPFUL IN

COMMINUTED

OSTEOPOROTIC
FRACTURES
CORONAL SHEAR FRACTURES

OFTEN MISSED

HIGH INTEX OF SUSPICION

AS HIGH AS 20%

CT IS MANDATORY
CORONAL SHEAR FRACTURES
SURGICAL APPROACH

POSTERIOR- WITH OLECRANON OSTEOTOMY

LATERAL

MEDICAL

ANTEROLATERAL

ANTERIOR
CORONAL SHEAR FRACTURES
SURGICAL APPROACH

ISOLATED
CAPITULUM
FRACTURE

LATERAL
APPROACH
CORONAL SHEAR FRACTURES
SURGICAL APPROACH

REDUCED WITH
K WIRES

FIXED WITH
PLATE
(NEUTRALISATIO
N PLATE)
COMPLICATIONS

35% COMPLICATIONS

STIFFNESS 15%

MALUNION / NONUNION

HETEROTROPHIC OSSISFICATION

HARDWARE FAILURES - IF PLATES ENDING AT SAME LEVEL

ULNAR NEURITIS

INFECTION

PERI-IMPLANT FRACTURES
TAKE HOME MESSAGE

DISTAL HUMERUS FRACTURES ARE CHALLENGING BUT

REWARDING

SHEAR FRACTURES - INDIVIDUAL APPROACH BASED ON

CONFIGURATION

AO PRINCIPLES

O’DRISCOLL (HELPFUL IN OSTEOPOROTIC / COMMINUTED #)

EARLY POST-OP REHAB IS KEY

ADVANCED PLATE DESIGN - VA-LCP

THANK YOU