Complex fractures of the distal humerus and their complications - - PowerPoint PPT Presentation

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Complex fractures of the distal humerus and their complications - - PowerPoint PPT Presentation

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Complex fractures of the distal humerus and their complications SOTS, Stockholm January 20th 2010 Lars Henrik Frich. MD PhD Distal Humeral Fractures Goals Restoration of articular surface Early motion Union

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Complex fractures of the distal humerus

and their complications

SOTS, Stockholm January 20th 2010 Lars Henrik Frich. MD PhD

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Distal Humeral Fractures

  • Goals

– Restoration of articular surface – Early motion – Union

  • Problems !
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Demographics

Distal humerus fractures – Approx. 2% of all fractures – 15% of all humerus fractures.

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Trauma mechanisms

  • High velocity injury in

younger patients

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Trauma mechanism

  • Low energy fall
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Fracture patterns

  • Shear force
  • Coronal plane

fractures

– Capitellum – Trochlea

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Fracture Patterns (AO)

B A C 1 2 3

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Complex (triplane fractures)

  • +/- comminution
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Outline

  • History
  • Challenges & Problems
  • Treatment options
  • Complications
  • (my) Concept
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Historical overview

  • Pionering operative tactics

Lambotte 1913

  • ”Bag-of- bones”

Eastwood 1937 Brown & Morgan 1971

  • Stabl fixation

» Morrey et al 1981

  • Precontoured plates

Shawn O’Driscol 2002

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Challenges & Problems

  • Complex anatomy and

Biomechanics

  • Limited bonemass
  • Crushed (avital) joint surface
  • Lack of (surgical) experience
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Distal humerus Bone stock

pQCT

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Crushed (low)fractures

  • Imaging

– CT (allways) – 3-D reconstruction – MRI (seldom)

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Treatment Modalities & Techniques

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Non-operative treatment

91 years old lady

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6 months

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Surgical Technique

  • Straight Incision

“around” the

  • lecranon to

avoid flap necrosis

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Surgical technique

  • Identify and

release the Ulnar nerve

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Triceps Sparing/Split

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Olecranon-osteostomy

  • Olecranon
  • steotomy is

seldom nescesary (fix with a plate)

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ORIF Technique

  • K wires
  • Screws
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ORIF Technique

Classical 90 technique (AO)

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ORIF Technique

  • Parallel plates
  • Precontoured

plates

  • Locking screws
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ORIF Technique Double-column fixation

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Difficult fractures to treat

  • Low fractures
  • Tri-plane fractures
  • Comminuted fractures
  • Poor soft tissues
  • Open fractures
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Coronal Shear Fracture type 1-3

Milch type fractures

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Coronal Shear fractures

  • 1% of all elbow fractures
  • Uniquely difficult to repair

Dubberly: 2006

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Type 1 CS Fracture

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Type 1 CS Fracture

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Type 1 CS Fracture

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Type 3 CS Fracture

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Medial Collum Fracture (Milch type II)

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Anglestabl plate

  • steosynthesis
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Results

  • Conservative treatment

– Patients with limited functions manage with limited ROM

  • Surgical treatment

– 75 % can expect good outcome

Ring & Jupiter 1999

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Elbow Kinematics

  • Painfree and stable

function:

  • 100° flexion
  • 100° Supination

/pronation

Morrey et a.l JBJS 63A:1981

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Results (review)

  • Wide range of

injury and treatment are reported

  • Small series
  • Union rates are

excellent (91%

  • 100%)
  • MEPS
  • 84%-100% good to

excellent

  • utcomes
  • Flexion arc 90º-

106º

  • Complication-rate

high

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McKee type 4

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Hemi arthroplasty

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Hemi-Arthroplasty for Acute Distal Humerus Fractures

Indications

  • “Elderly” osteopenic

low demand patients

  • Adequate fixation of

a comminuted distal humeral fracture is unlikely to be achieved with ORIF

LATITUDE ANATOMIC™- Tornier

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Complex fractures

  • 82 Years old

lady

  • Ostepososis
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Total Elbow Replacement

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Arthroplasty for Acute Distal Humerus Fractures

Indications

  • “Elderly”
  • steopenic low

demand patients

  • Supracondylar

fracture with pre- existing arthritis

  • Unstable pseud-

arthroses

DISCOVERY, Biomet

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Full methal jacket

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Open Fractures

60 Years Male - Liver Disease

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Minimal osteosynthesis External Mobile Fixation

Post-OP 6 weeks

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Minimal osteosynthesis External Mobile Fixation

3 months post OP

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Gunshot (low velocity)

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Temporary DJDII

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DJD2 Chronic Instability applications

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Complications

  • Mal-union
  • Pseud-arthroses
  • Stiffness
  • Infection
  • Neuro-vascular
  • Neuropathy
  • Heterotopic bone
  • (Early) Arthrosis
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Review article 30 % Complications

– Inadequate

  • steosynthesis

– Ulnar nerve palsies – Non-union – Malunion – Infection

Ring & Jupiter JSES 1999

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Complications

Early

  • 37 cases AO type C
  • Precontoured

parallel plates

  • 53% complications
  • 16% nerve injuries
  • J Orthop Trauma 2009

Late

  • 30 cases
  • Posttraumatic

arthritis in 80% after 19 years (12-25)

  • Despite optimal

surgical treatment

  • JBJS 2007; 89A:1524
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Approach related Complications

  • Incisional
  • Olecranon
  • steotomy

– Non-union – Malunion – Hardware failure – Pain

  • Triceps split

– Extension defecits – Weekening of the Triceps – Triceps reflecting approach better that division of the tendon – J Shoulder Elbow Surg 2007:849

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Aproach Related Complications

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TriplaneFracture

62 years old lady

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Poor reduction Stable osteotomy?

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26 years old Male, Top-Skier

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Poor reduction Stable osteotomy?

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Double pseud-arthrosis

8 months Post-OP

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Complications Ulna osteotomy

20 years old male

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Ulna osteotomy related complications

  • 25 cases
  • Tension band

wiring.

  • 36% of bad quality
  • 1 pseudarthrosis

– Chirurgie de la Main 28, 2009:

  • 94 cases
  • Different

techniques

  • 19% symptomatic

fixations

– Journalagent.com 2009

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46 years old male (Alcoholic)

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44 years old male Car accident

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Post OP Radial nerve paresis

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10 months Post-OP

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Re-Osteosynthesis

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Neuro-vascular lesions

  • Less frequent
  • Serious
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Heterotopic ossification

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Stiffness/HO

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Heterotopic Bone

  • Gofton et al.

J hand Surg 2003

  • 13% of cases
  • Recommended

prophylaxis with Indomethacin.

  • Leugmair et al.

J Shoulder Elbow Surg 2008

  • 11 % of cases
  • Most impotant

complication that limited ROM

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Entrapment radial nerve

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Radial nerve entrapped under the plate

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Reoperations in 20% of trauma cases

  • Insufficient
  • steosynthesis
  • Poor access
  • Poor reduction
  • Incorrect use of

implants

  • Underestimation of

soft tissue lesions Review 2006

  • Incomplete

understanding of trauma mechanism

  • Not daytime

surgery

  • Surgical

experience !

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SLIDE 77

How to avoid complications

  • Experienced

surgeons

  • Daytime surgery
  • Centralized

Treatment

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Summary Distal Humerus

  • Preoperative planning

– CT scans – Approach (posterior)

  • ORIF successful in the majority of patients

– Reestablish jointsurface anatomally – Stability between distal fragment og Humeral shaft

  • Early Rehabilitation

– Active and passive ROM

  • Severe bone loss (low demand seniors)

– Consider primary elbow arthroplasty !

– TEA or hemiarthropasty

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Don’t do an Olecranon osteotomy unless you have to!

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Princip-based after-treatment

  • Rehabilitation

– Infra-clavicular block/ catheter – Early ROM – (CPM)