Distal Humerus Fractures

Question 1

What is the classification for distal humerus fractures?

Answer 1

Milch (for single column):
I- lateral trochlear ridge is intact
II- fracture through lateral trochlear ridge

Jupiter (for both column):
High T- proximal to olecranon
Low T- through or distal to olecranon
Multiplane T- T with additional coronal plane fx
Y- both column with vertical fx line
H- trochlea is a free fragment (high rate of AVN)
Lateral lambda- proximal fx line exits laterally
Medial lambda- proximal fx line exits medially

Question 2

What are the treatment options for the various distal humerus fracture types?

Answer 2

Non-dispalced Milch I: casting
Displaced Milch I: CRPP
All others ORIF
TEA indicated in highly comminuted both column fxs in the elderly

Question 3

In ORIF of distal humerus using an olecranon ostetomy where is the osteotomy made?

Answer 3

Bare area of the sigmoid notch

Question 4

In a patient with heterotopic ossification leading to decreased ROM of the elbow, what is a good treatment option?

Answer 4

Excision of heterotopic bone and transection of the posterior band of the MCL

Question 5

What is the most common complication of ORIF of distal humerus fractures?

Answer 5

Decreased elbow ROM

Question 6

What approaches can be made for distal humerus fractures?

Answer 6

All use a variation of the posterior approach:
Triceps reflecting- triceps and distal fascia reflected medial to laterally
Triceps splitting- limited proximally by radial n.
Triceps reflecting with aconeous flap
Paratricipital- used for TEA, less exposure; triceps insertion undisturbed
Olecranon ostetomy (exposes 57% of articular surface)- do not use for TEA

Regardless of approach, must find and expose ulnar nerve

Question 7

What things are important during the posterior approach to humerus during ORIF of distal humerus fracture?

Answer 7

1) curve posterior incision laterally
2) Identify and protect the ulnar n.
3) Dissect the triceps from the lateral intermuscular septum, proximally identify and protect the radial n.
4) Reflect the aconeous medially
5) Can convert a paratricipital approach to an olecranon osteotomy

Question 8

What are the important things to keep in mind for ORIF of distal humerus fractures?

Answer 8

Concerning Screws in the Distal Fragment (Articular Segment)
1. Each screw should pass through a plate.
2. Each screw should engage a fragment on the opposite side that is also fixed to a plate.
3. An adequate number of screws should be placed in the distal fragments.
4. Each screw should be as long as possible.
5. Each screw should engage as many articular fragments as possible.
6. The screws should lock together by interdigitation, thereby creating a fixed-angle
structure and linking the columns together.

Concerning the Plates Used for Fixation

7. Plates should be applied such that compression is achieved at the supracondylar level for both columns.
8. Plates used must be strong enough and stiff enough to resist breaking or bending before union occurs at the supracondylar level.