Distal Humerus Technque

Surgical Techniques

Distal Humerus Fractures

Jeffrey Anglen, MD

The video that accompanies this article is “Open Reduction and Internal Fixation,” available on the Orthopaedic Knowledge Online website, at http://www5.aaos.org/oko/trauma/jaaos.

Dr. Anglen is Professor and Chairman, Department of Orthopaedics, Indiana University School of Medicine, Indianapolis, IN. Neither Dr. Anglen nor the department with which he is affiliated has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of this article. Reprint requests: Dr. Anglen, Indiana University School of Medicine, Suite 600, 540 Clinical Drive, Indianapolis IN 46202. J Am Acad Orthop Surg 2005;13:291297 Copyright 2005 by the American Academy of Orthopaedic Surgeons. Volume 13, Number 5, September 2005

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ractures of the elbow constitute about 7% of adult fractures; distal humerus fractures account for less than half of all elbow fractures. There is evidence, however, that incidence is increasing. Investigators in Finland performed a retrospective review of hospital admission records between 1970 and 1995 and found that the age-adjusted increase in incidence in women older than 60 years had more than doubled.1 The Orthopaedic Trauma Association (OTA)/AO classification system divides distal humerus fractures into type A, nonarticular; type B, partial articular; and type C, complete articular2 (Fig. 1). Additional levels of classification are based on position and orientation of the fracture line and degree of comminution. The partial articular fractures can be described as “unicolumnar” fractures; they are rare in adults (2% to 3%) and are more common in children and adolescents. Fractures of the lateral column are more common than those of the medial column. Capitellar fractures are a special instance of partial articular fractures (OTA/AO B3.1) representing a shearing injury with very little soft-tissue attachment to the anterior fragment. Three types of lateral column fractures have been described by Bryan and Morrey.3

Indications Nonsurgical treatment is appropriate for stable, nondisplaced fractures and in patients with neurologic impairment or otherwise nonfunctional extremities. Hinged or static external fixation can be used for either temporary or definitive treatment in patients with severely contaminated open wounds or extensive soft-tissue defects. In older patients with os-

teopenia and/or comminution of the joint surface in which stable reconstruction cannot be achieved, total elbow arthroplasty using a semiconstrained linked prosthesis may be preferable to other options.4 For most displaced unstable fractures in patients with functional arms, open reduction and internal fixation (ORIF) is indicated to restore optimal elbow function.

Contraindications Contraindications to ORIF of distal humerus fractures include inability to tolerate surgery because of health status, inability to benefit from surgery because of neurologic impairment of the limb, and inability to achieve stability because of severe osteopenia or deficient bone. In addition, ORIF is contraindicated in patients with excessively high risk for local complications because of infected or deficient soft tissues.

Surgical Technique The surgical approach and implant strategy for ORIF of a distal humerus fracture are guided by the classification of the fracture. Nonarticular fractures (type A): These usually can be fixed through a triceps-splitting approach (Fig. 2) or triceps-sparing approach (Fig. 3) with restoration of alignment and bicolumnar fixation. Isolated epicondylar fractures in many cases can be fixed with lag screws alone. Partial articular fractures (type B): In the uncommon adult unicolumnar fracture, lag screws alone may be adequate fixation when the bone quality is good. Otherwise, a buttress or antiglide plate should be used. Some capitellar fractures can be fixed through a lateral or posterior approach with lag screws placed 291

Distal Humerus Fractures

Figure 1

The OTA/AO classification of fractures of the distal humerus. A, nonarticular. B, partial articular. C, complete articular. (Reproduced with permission from Müller ME, Nazareon S, Koch P, Schaftsker J: Comprehensive Classification of Fractures of Long Bones. Berlin, Germany: Springer-Verlag, 1990, p 330.)

Figure 2

The Campbell posterior approach. A, A straight (solid line) or curvilinear (dashed line) incision is made over the posterior aspect of the elbow. B, The triceps muscle is split distally over the olecranon insertion and peeled subperiosteally. C, The triceps muscle is split along the central tendon from distal to proximal direction 6 to 8 cm to expose the distal humerus. (Reproduced with permission from Anson BJ, Maddock WG: Callander’s Surgical Anatomy, ed 4. Philadelphia, PA: W.B. Saunders, 1958.) 292

from posterior to anterior, while small or comminuted capitellar fragments are usually excised. Complete articular fractures (type C): ORIF can be performed through several approaches;5-9 the most common are the extensile medial approach (Bryan and Morrey),5 the extensile lateral approach (Kocher), or the posterior transolecranon approach. The plating construct that provides the greatest sagittal plane stiffness without loss of coronal or torsional stiffness is a medially positioned reconstruction plate and a small-fragment compression plate on the posterolateral surface.10-12 The principles of the procedure are similar to those of any articular fracture. Anatomic restoration of the articular surface is the first priority (and usually, but not always, the first goal completed). The next goal is restoration of joint shaft alignment, then stable fixation of the joint fragments to the shaft, and finally, early, active rehabilitation (Fig. 4). As with any complex fracture procedure, ORIF of distal humerus fractures is best undertaken during daylight hours, after adequate planning, and with a rested, experienced surgical team and staff. The first step is preoperative planning. Using good traction films of the distal humerus in two planes, tracings are made of the injured extremity, carefully noting fracture lines and outlining major fragments. Then, laying this drawing over a tracing of the intact, uninjured side, the fracture fragments are pieced back together and the anatomy of the humerus is reconstructed, showing on the tracing the position of the reduced fragments and fracture lines. Appropriate implants are then traced in position, planning the size and location of plates and the number and position of screws. Finally, the surgical tactic is written out, detailing the steps of the procedure in order, noting any anticipated difficulties or potential barriers and options.

Journal of the American Academy of Orthopaedic Surgeons

Jeffrey Anglen, MD

The following list of instruments and implants should be available: • Small-fragment plates and screws (including long screws up to 100 mm length) • Minifragment plates and screws • Malleable reconstruction plates and plate benders (or anatomically preshaped plates) • Herbert screws • Kirschner wires (K-wires) and, if desired, bioabsorbable pins • Small oscillating saw and osteotomes • Wire set • Bone graft harvesting set C-arm fluoroscopy should be available, but it is not routinely used because the reduction and fixation is primarily performed under direct vision. The patient is positioned prone with the arm at 90° abduction and the elbow at 90° flexion over a radiovideo step 1). lucent arm board ( Care is taken to pad and protect all bony prominence areas. When the patient cannot be placed prone, the procedure can be done from the lateral position with the arm supported across the field. The arm is prepared and draped proximally at least as far as the deltoid insertion. For distal fractures in thinner patients, a pneumatic tourniquet may be applied before preparation and draping; for more extensive fractures or larger arms, it is better to have a sterile tourniquet available and not compromise on the size of the prepared field. The posterior iliac crest should be prepared and draped. A midline posterior incision is made curving around the tip of the olecranon to avoid making a scar directly upon it—usually to the lateral side to avoid having a scar directvideo ly over the ulnar nerve ( step 2). Prior to incision, the skin and subcutaneous tissues can be injected with bupivacaine and epinephrine to decrease bleeding from this very vascular area. The ulnar nerve is identified medial to the huVolume 13, Number 5, September 2005

Figure 3

The Bryan approach. A, A straight or curvilinear incision ulnarly directed exposes the proximal ulna, medial epicondyle, ulnar nerve, and triceps. B, The ulnar nerve is translocated anteriorly. C, The triceps insertion is elevated subperiosteally ulnar to radial off the olecranon. D, With the triceps reflected laterally, the anconeus is released subperiosteally. One can expose the radial head; the most proximal tip of the olecranon is now removed providing full exposure of the distal humerus. E, For full exposure, one can partially release the lateral collateral ligament (LCL) and medial collateral ligament (MCL). F, Repair of the triceps aponeurosis is made back to the proximal ulna through drill holes with a heavy no. 3 or no. 5 Mersilene suture. (Reproduced with permission from Bryan RS, Morrey BF: Extensive posterior exposure of the elbow: A triceps-sparing approach. Clin Orthop 1982;116:188.)

merus and proximal to the zone of injury, and it is carefully exposed.

The cubital tunnel is released and the nerve is freed for anterior trans293

Distal Humerus Fractures

Figure 4

Techniques for internal fixation of the distal humerus. A, T-condylar fracture of the distal humerus. B, Reduction of both condyles with K-wire fixation. The intra-articular fragments are reduced first. C, Compression screw fixation of the condyles and medial and lateral condyle to the distal humerus. Cannulated screws are helpful here. D, Medial and lateral condylar plate fixation of the condyle to the distal shaft of the humerus. E, Y-plate fixation of the humeral shaft to the condyles of the humerus. (By permission of Mayo Foundation for Medical Education and Research. All rights reserved.)

position at the end of the case. The nerve is protected throughout the duration of the procedure, but it is handled gently and should never be forcefully retracted. A chevron-shaped (apex distal) osteotomy is made in the olecranon (Fig. 5, G). Soft tissue is dissected along both sides of the proximal olecranon to identify the joint surface. A Kelly or right-angle clamp is gently passed around the articular surface of the olecranon between the ulna and the humerus and is used to pass a wide Penrose drain, which will show the level of the joint as well as protect the humeral surface. The V-shaped cut or similar cut (Fig. 5D/ 5G) should be located about 3 cm from the tip, to enter the joint at the bottom of the curve, and should be marked in the soft tissues with electrocautery. It is then cut most of the 294

way through the bone with a small, handheld oscillating saw. The final cut into the joint surface is made with a sharp, narrow osteotome, to avoid taking a curf (the width of the saw blade) of the joint surface. Patience, gentleness, and control are important in making the osteotomy to avoid surface damage or fracture. The olecranon is then reflected proximally by dividing the joint capsule. The triceps is split loose medially and laterally parallel to the humerus, taking care to protect the ulnar nerve medially and the radial nerve laterally. The radial nerve lies against the lateral humerus about 14 cm from the joint surface; however, the position is variable, so vigilance is required. The triceps is lifted off the posterior surface of the bone. The olecranon tip is wrapped in a wet sponge, and the reflected triceps

can be retracted by sewing it to the skin of the upper arm with a stitch in the undersurface of the triceps tendon. Fracture fragments are then gently cleaned of clot and debris, taking care to note the orientation and position of any free fragments before removvideo ing them from the field ( step 3-4). The distal humeral articular surface is reassembled based on the preoperative plan and tactics, and stabilized with K-wires (Fig. 4, A-B). The joint surface is restored first, and then the joint attached to the shaft, although occasionally one begins by attaching one articular condyle to the appropriate column, building across the joint and onto the opposite column. Fragments can be manipulated by joystick K-wires, reduction clamps, or instruments. Care is taken not to damage the articular surface itself. The deforming forces of muscles and gravity must be acknowledged and converted into helpful forces by correct positioning and support. Although usually the reduction can be directly and accurately seen, occasionally C-arm fluoroscopy is helpful. The final construct based on the preoperative plan is assembled, usually beginning with the transverse lag screws (Fig. 4, C) or position screws when there is intercondylar comminution or bone loss. When bone is missing from the trochlea, care should be taken not to narrow it; this may require placement of a piece of structural graft, usually obtained from the iliac crest. Plates are applied (Figs. 4, D and E, and 6), usually beginning with one in the posterolateral position along the straight lateral column. This is usually a small fragment (3.5-mm) compression plate or congruent elbow plate. The medial plate is frequently a 3.5mm pelvic reconstruction plate contoured to lie directly medial over the medial epicondyle. Anatomically precontoured plates are available and may be helpful, particularly on the medial side. One should have available minifragment plates, 2.7-

Journal of the American Academy of Orthopaedic Surgeons

Jeffrey Anglen, MD

mm reconstruction plates, and Herbert screws or bioabsorbable pins for the smaller articular fragments. The olecranon osteotomy should be repaired with a tension band convideo step 5-6) or struct (Fig. 6) ( compression screw (Fig. 5, F). Two 1.6- or 2.0-mm K-wires are inserted into the olecranon tip and advanced to the osteotomy site. The osteotomy is then closed and the wires driven in. Engagement of the anterior cortex is not required or especially desirable. The wires should be inserted at least 1 cm deeper than necessary and then backed out that amount, to allow complete seating of the wires later. A figure-of-8 loop of 1.5-mm wire is positioned through a drill hole located distally at approximately the same distance from the osteotomy apex as is the tip of the olecranon. It is then passed behind the K-wires directly on the bone. This may be facilitated with a 14-gauge angiocatheter. The wire is tightened by twisting in two places on opposite arms of the “X” portion of the figure-of-8. The K-wires are bent over 180° and cut off (they should be bent before cutting) and seated firmly in the bone using an impactor. The ulnar nerve is transposed to an anterior subcutaneous position and secured in place with a stitch between the fascia and subcutaneous tissue that restrains the position of the nerve. Care should be taken to ensure that there is no tethering or pressure on the nerve in its new home. Subcutaneous tissue and skin are closed in layers. Stability and range-of-motion testing is done intraoperatively. Portable radiographs are obtained with the patient in the operating room and still in the prone position. Then the patient can be turned and awakened. Gentle active-assisted and passive motion is started early, within the first few days. The patient can be instructed to support the wrist with the opposite hand and gently flex and extend the elbow, gradually inVolume 13, Number 5, September 2005

Figure 5

Osteotomy of the olecranon. Three different types of olecranon osteotomy can be used. A and B, Intra-articular transverse. C through F, Extra-articular oblique. G, Intra-articular chevron. The chevron enhances stability and union. (Panels A-F reproduced with permission from Müller ME, et al: Manual of Internal Fixation: Technique Recommended by the AO-Group. New York, NY: Springer-Verlag, 1970. Panel G by permission of Mayo Foundation for Medical Education and Research. All rights reserved.). 295

Distal Humerus Fractures

Figure 6

A, A distal humerus, intra-articular T-bicondylar fracture with comminution. B, Exposure by an olecranon osteotomy repaired later with tension band wire technique. Internal fixation with transcondylar screws and medial and lateral contoured condylar plates. (By permission of Mayo Foundation for Medical Education and Research. All rights reserved.).

creasing the range of motion. When a sling is used, the patient should be instructed to take the arm out several times daily for these exercises and to let gravity work on extending the elbow. Active motion against resistance should be delayed until some healing has occurred, usually at 6 to 8 weeks. When stability of fixation is marginal, a hinged fracture brace may be used to provide additional support.

Pearls • Despite careful handling, transient postoperative ulnar nerve palsy is not rare. Telling patients about the possibility beforehand is easier than explain296

ing it afterward. • Prepare the posterior iliac crest for bone graft. Again, mention the possibility to the patient before the operation. • Provide good support of the arm so that gravity is not constantly fighting your reduction. • Preoperative planning can save great amounts of time. A sterile tourniquet can be helpful. • Intraoperative radiographs at the end of the procedure are essential; make sure the lateral view is adequate. Repeat if necessary.

Pitfalls Common mistakes include the following:

• Inadequate reduction of the joint surface: – residual step or gap – unrecognized bone loss with resultant narrowing of the trochlea – malrotation between the condyles • Inadequate stability of fixation: – reliance on smooth or threaded pins rather than screw fixation – reliance on a single plate instead of two-column plate fixation – using plates that are too short – using plates of inadequate stiffness (one-third tubular) – plating in distraction at the diaphysis or diaphysismetaphysis junction • Poor hardware placement: – avoid placing screws in the thin bone above the trochlea or into the olecranon fossa – posterior-to-anterior screws may penetrate the capitellum and damage the joint – screws or wires in the epicondyles or olecranon can be quite prominent under the skin and annoying – excessive retraction or rough handling of the ulnar nerve, poor transposition technique (kinking or tethering the nerve) • Tension band problems: – failure to drive the K-wires in and then back them out, so that at the final seating they will not advance with the impactor and stay prominent or back out early – drilling the transverse distal hole in the ulna too shallow, leading to cutout of the wire – not getting the wire behind the K-wires right down on the bone, leading to loosening and loss of function – leaving knots or twists prominent under thin skin

Journal of the American Academy of Orthopaedic Surgeons

Jeffrey Anglen, MD

Outcomes An outcome scale for distal humerus fractures was presented by Bickel and Perry.13 An excellent result is considered a stable, pain-free elbow with nearly normal range of motion of 120° or more. A good result is a stable fracture with no deformity, 60° or more of flexion-extension in a usable range, and rotation 50% of normal. A fair result is a stable fracture construct with mild pain with normal use and <60° of motion associated with moderate deformity. A poor result is defined as pain, deformity, and greatly restricted range of motion.3 O’Driscoll et al14 reported that elbow flexion and extension strength are decreased to about 75% of contralateral strength following apparently successful treatment of comminuted distal humerus fractures, although the average patient will have a functional and relatively pain-free arc of motion of 105°.

Volume 13, Number 5, September 2005

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Palvanen M, Kannus P, Niemi S, Parkkari J: Secular trends in the osteoporotic fractures of the distal humerus in elderly women. Eur J Epidemiol 1998;14:159-164. Fracture and dislocation compendium: Orthopaedic Trauma Association Committee for Coding and Classification. J Orthop Trauma 1996;10(suppl 1):1-154. Bryan RS, Morrey BF: Fractures of the distal humerus, in Morrey BF (ed): The Elbow and Its Disorders, ed 2. Philadelphia, PA: WB Saunders, 1993, pp 328-366. Cobb TK, Morrey BF: Total elbow arthroplasty as primary treatment for distal humeral fractures in elderly patients. J Bone Joint Surg Am 1997;79: 826-832. Bryan RS, Morrey BF: Extensive posterior exposure of the elbow: A tricepssparing approach. Clin Orthop 1982; 166:188-192. Gerwin M, Hotchkiss RN, Weiland AJ: Alternative operative exposures of the posterior aspect of the humeral diaphysis with reference to the radial nerve. J Bone Joint Surg Am 1996;78: 1690-1695. Mills WJ, Hanel DP, Smith DG: Lateral

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approach to the humeral shaft: An alternative approach for fracture treatment. J Orthop Trauma 1996;10:81-86. Olson SA, Hertel R, Jakob RP: The trans-tricipital approach for intraarticular fractures of the distal humerus: A report of two cases. Injury 1994; 25:193-198. Moran MC: Modified lateral approach to the distal humerus for internal fixation. Clin Orthop 1997;340:190-197. Helfet DL, Hotchkiss RN: Internal fixation of the distal humerus: A biomechanical comparison of methods. J Orthop Trauma 1990;4:260-264. Schemitsch EH, Tencer AF, Henley MB: Biomechanical evaluation of methods of internal fixation of the distal humerus. J Orthop Trauma 1994;8:468-475. Jacobson SR, Glisson RR, Urbaniak JR: Comparison of distal humerus fracture fixation: A biomechanical study. J South Orthop Assoc 1997;6: 241-249. Bickel WE, Perry RE: Comminuted fractures of the distal humerus. JAMA 1963;184:553-557. O’Driscoll SW, Jupiter JB, Cohen MS, Ring D, McKee MD: Difficult elbow fractures: Pearls and pitfalls. Instr Course Lect 2003;52:113-134.

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