Distal intraarticular
humerus fractures
Cimerman Matej
Dpt. for Traumatology
Univ. Clinical Centre Ljubljana, Slovenia
KC LJUBLJANA
Dpt. Of Traumatology
facts
• distal humerus fractures remain one of the
most demanding challenges in orthopedic
and trauma surgery (Korner, J Orthop Trauma
2004, Soon, Injury 2004)
• distal humerus fractures in adults are rare
(2-6% of all fractures)
• unsatisfactory results in 20% (Jupiter and
Morrey, 1993)
KC LJUBLJANA
Dpt. Of Traumatology
solution...
• every senior trauma and orthopedic
surgeon should know to treat basics of
these fractures
• and should know and respect his limits
• every big trauma center needs some
monomaniacs
KC LJUBLJANA
Dpt. Of Traumatology
• † dr.Korošec Branko
KC LJUBLJANA
Dpt. Of Traumatology
treatment of articular fractures
(we know everything)
• ...anatomical reduction and stable fixation
• metaphyseal defects should be grafted to
prevent articular displacement
• metaphyseal and diaphyseal displacement
should be reduced to prevent joint
overloading
• immediate motion (AO, Shatzker 1987)
KC LJUBLJANA
Dpt. Of Traumatology
easy to say, difficult to realize
• small bone fragments
• a lot of elderly people with osteopenic
bone
• difficult approach
• elbow joint hates even short
immobilization
• long lever arms
KC LJUBLJANA
Dpt. Of Traumatology
classification: AO Mueller
B: “partial articular” (like partial pregnant)
B3
KC LJUBLJANA
B1
Dpt. Of Traumatology
B2
classification: AO Mueller
C: complete articular
C1
KC LJUBLJANA
Dpt. Of Traumatology
C2
C3
imaging
• AP standard views
• CT and 3D
KC LJUBLJANA
Dpt. Of Traumatology
imaging
KC LJUBLJANA
Dpt. Of Traumatology
surgical anatomy
A
M
L
A
P
P
KC LJUBLJANA
Dpt. Of Traumatology
15°
positioning
KC LJUBLJANA
Dpt. Of Traumatology
lateral decubitus
prone
KC LJUBLJANA
Dpt. Of Traumatology
approach
• posterior with olecranon osteotomy
(with identification or transposition of ulnar nerve)
• posterior triceps splitting
• “V” triceps aponeurosis flap
• paratricipital posterior approach
• anconaeus flap extensile approach
• lateral approach
• medial approach
KC LJUBLJANA
Dpt. Of Traumatology
olecranon osteotomy
Chevron osteotomy, Korošec chissel, oscilating saw and chissel
KC LJUBLJANA
Dpt. Of Traumatology
KC LJUBLJANA
Dpt. Of Traumatology
KC LJUBLJANA
Dpt. Of Traumatology
triceps splitting
KC LJUBLJANA
Dpt. Of Traumatology
KC LJUBLJANA
Dpt. Of Traumatology
KC LJUBLJANA
Dpt. Of Traumatology
reduction and fixation strategy
• reducing and fixation of joint components
• coupling to methaphisys
KC LJUBLJANA
Dpt. Of Traumatology
implants
•
•
•
•
•
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DCP 3,5mm plates are golden standard
1/3 small tubular plates for radial column
LC DCP 3,5mm plates
precontoured plates
both plates posterior
right angle config
KC LJUBLJANA
Dpt. Of Traumatology
KC LJUBLJANA
Dpt. Of Traumatology
KC LJUBLJANA
Dpt. Of Traumatology
KC LJUBLJANA
Dpt. Of Traumatology
KC LJUBLJANA
Dpt. Of Traumatology
KC LJUBLJANA
Dpt. Of Traumatology
KC LJUBLJANA
Dpt. Of Traumatology
do not be afraid of ulnar nerve
KC LJUBLJANA
Dpt. Of Traumatology
ulnar nerve
• identification is necessary
• complete visualization and transposition
only if necessary
KC LJUBLJANA
Dpt. Of Traumatology
postop
• active exercise under the control a soon as
possible
KC LJUBLJANA
Dpt. Of Traumatology
complications
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stiffness: arthrolysis, salvage procedures
non union: refixation, TEP
infection
ulnar nerve paresis: revisions
KC LJUBLJANA
Dpt. Of Traumatology
conclusions
•
•
•
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respect the fracture and your limits
olecranon osteotomy for C type fractures
3.5 mm reco plates golden standard
LC 3.5mm reco plates, 1/3 tubular plates
and precontoured plates
• identify ulnar nerve
• stable fixation mandatory
• endoprosthesis as an option
KC LJUBLJANA
Dpt. Of Traumatology