Orthopaedic Trauma Flashcards
What does the distal humerus fracture consist of?
- supracondylar fractures
- single column (condyle) fractures
- bicolumn fractures
- coronal shear fractures
What is the most common fracture pattern ln distal humerus fracture ?
distal intercondylar fractures
What is the mechanism of Injury distal humerus fracture?
- low energy falls in elderly
- high energy impact in younger population
What are the distal humerus fracture associated injuries ?
- elbow dislocation
- terrible triad injury
- floating elbow
- Volkmann contracture ….Result of a missed compartment syndrome
What is the of prognosis of distal humerus fracture?
- majority of patients regain 75% of elbow motion and strength
- goal is to restore elbow ROM 30-130 degrees of flexion
- unsatisfactory outcomes in up to 25%
Why the treatment can be complicated ln distal humerus fracture?
- low fx line of one or both columns
- metaphyseal fragmentation of one or both columns
- articular comminution
- poor bone quality
What is the non-operative treatment ln distal humerus fracture?
Cast immobilization
Discuss the non-operative treatment of distal humerus fracture?
cast immobilization
indications
- nondisplaced Milch Type I fractures
technique
- immobilize in supination for lateral condyle fractures
- immobilize in pronation for medial condyle fractures
What Are the surgical options And the indications for each type for distal humerus fracture?
- *closed reduction and percutaneous pinning**
- indications*
displaced Mich Type I fractures
open reduction internal fixation
indications
supracondylar fractures
intercondylar / bicolumnar fractures
Milch Type II fractures
total elbow arthroplastyindications
distal bicolumnar fractures in elderly patients
Discuss positioning of patient for distal humerus fracture ORIF?
lateral decubitus position
on foam mattress with radiolucent arm board
prone position
useful in patients with spine injuries or contralateral extremity fractures
supine positioning
can be used in a polytrauma situation or with contraindications to other positioning
What is the complications of distal humerus fracture ORIF?
Elbow stiffness
most common
Heterotopic ossification
- reported rate of 8%
- routine prophylaxis is not warranted
- increased rate of nonunion in patients treated with indomethacin
Nonunion
low incidence
avoid excessive soft-tissue stripping
Malunion
avoided by proper surgical technique
- cubitus valgus (lateral column fxs)
- cubitus varus (medial column fxs)
DJD
Ulnar nerve injury
AIN Injury
can be seen with olecranon osteotomy
How do you approach the articular surface exposure into distal humerus fracture?
- olecranon osteotomy 57%
- triceps-reflecting 46%
- triceps-splitting 35%
What are the fixation objectives of (O’Driscoll) In distal humerus fracture ORIF ?
- every screw in the distal fragments should pass through a plate
- engage a fragment on the opposite side that is also fixed to a plate
- as many screws as possible should be placed in the distal fragments
- each screw should be as long as possible
- each screw should engage as many articular fragments as possible
- the screws in the distal fragments should lock together by interdigitation, creating a fixed-angle structure
- this creates the architecural equivalent of an arch, which gives the most biomechanical stability
- plates should be applied such that compression is achieved at the supracondylar level for both columns
- the plates must be strong enough and stiff enough to resist breaking or bending before union occurs at the supracondylar level.
Discuss fixation of distal humerus fracture after articular surface exposure and full dissection?
countersunk / headless screw to fix articular fragments 1st after provisional reduction with k-wires
- if metaphyseal injury is not comminuted, reducing one column to the metaphysis first may be beneficial
- consider using positional screws when reducing trochlea to avoid narrowing it with compression
then address condyles and epitrochlear ridge
- lateral epicondyle may be fix with tension band wire or plate
two plates in orthogonal planes used to fix articular segment to shaft
- place 3.5-mm LCDC plate or one of equivalent strength on lateral side
- place 2.7-mm or 3.5-mm LCDC plate on medial side
- interdigitate screws if possible to increase strength
new literature supports parallel plates
if ulnar nerve contacts medial hardware during flexion/extension, can transpose however literature does not support decreased ulnar n. symptoms with transposition
What is the postoperative protocol of distal humerus fracture?
- place in splint with elbow in approx 70 degrees of flexion
- remove splint at 48 hours post-operatively, initiate ROM exercises
- if osteotomy performed patient may do active and active assisted flexion and extension for 6 weeks; no active extension against gravity or resistance
- if not osteotomy, permitted to do active motion against gravity without restrictions
- no restrictions to rotation
- start gentle strengthening program at 6 weeks, and full strengthening program at 3 months
