Introduction Consists of supracondylar fractures single column (condyle) fractures bicolumn fractures coronal shear fractures Epidemiology incidence distal intercondylar fractures are the most common fracture pattern demographics most common in young males and older females Pathophysiology mechanism low energy falls in elderly high energy impact in younger population pathoanatomy elbow position affects fracture type elbow flexed < 90 degrees axial load leads to transcolumnar fracture direct posterior blow leads to olecranon fracture with or without distal humerus involvement elbow flexed > 90 degrees may lead to intercondylar fracture Associated injuries elbow dislocation terrible triad injury floating elbow Volkmann contracture result of a missed forearm compartment syndrome Prognosis 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% treatment of these fractures is complex due to: low fx line of one or both columns metaphyseal fragmentation of one or both columns articular comminution poor bone quality Anatomy Osteology elbow is a hinged joint trochlea articulates with sigmoid notch allows for flexion and extension capitellum articulates with proximal radius allows for forearm rotation Muscles common flexors (originate from medial epicondyle) pronator teres flexor carpi radialis palmaris longus FDS FCU common extensors (originate from lateral epicondyle) anconeus ECRL ECRB extensor digitorum comminus EDM ECU Ligaments medial collateral ligament anterior bundle originates from distal medial epicondyle inserts on sublime tubercle primary restraint to valgus stress at the elbow from 30 to 120 deg tight in pronation lateral collateral ligament originates from distal lateral epicondyle inserts on crista supinatorus stabilizer against posterolateral rotational instability taut in supination Nerves ulnar nerve resides in cubital tunnel in a subcutaneous position below the medial condyle radial nerve resides in spiral groove 15cm proximal to distal humeral articular surface between brachioradialis and brachialis proximal to elbow divides into PIN and superficial radial nerve at level of radial head Classification Can be classified as supracondylar fractures distal single column fractures subclassified using Milch classification system (see table) lateral condyle more common than medial distal bicolumnar fractures classified using Jupiter classification system (see table) 5 major articular fragments have been identified capitellum/lateral trochlea lateral epicondyle posterolateral epicondyle posterior trochlea medial trochlea/epicondyle AO/OTA Classification of Distal Humerus Fractures Type A Extraarticular (supracondylar fracture),80% are extension type; epicondyle Type B Intraarticular-Single column (partial articular-isolated condylar, coronal shear, epicondyle with articular extension) Type C Intraarticular-Both columns fractured and no portion of the joint contiguous with the shaft (complete articular) Each type further divided by degree and location of fracture comminution Milch Classification of Single Column Condyle Fractures Milch Type I Lateral trochlear ridge intact Milch Type II Fracture through lateral trochlear ridge Jupiter Classification of Two-Column Distal Humerus Fractures High-T Transverse fx proximal to or at upper olecranon fossa Low-T Transverse fx just proximal to trochlea (common) Y Oblique fx line through both columns with distal vertical fx line H Trochlea is a free fragment (risk of AVN) Medial lambda Proximal fx line exists medially Lateral lambda Proximal fx line exists laterally Multiplane T T type with additional fracture in coronal plane Presentation Symptoms elbow pain and swelling Physical exam gross instability often present avoid ROM due to risk of neurovascular damage neurovascular exam check function of radial, ulnar, and median nerve check distal pulses brachial artery may be injured if pulse decreased, obtain noninvasive vascular studies; consult vascular surgery if abnormal monitor carefully for forearm compartment syndrome Imaging Radiographs recommended views obtain AP and lateral of humerus and elbow include entire length of humerus and forearm additional views obtain wrist radiographs if elbow injury present or distal tenderness on exam oblique radiographs may assist in surgical planning traction radiographs may assist in surgical planning specifically evaluate if there is continuity of the trochlear fragment to medial epicondylar fragment, this can influence hardware choice CT often obtained for surgical planning especially helpful when shear fractures of the capitellum and trochlea are suspected 3D CT scan improves the intraobserver and interobserver reliability of several classification systems MRI usually not indicated in acute injury Treatment Nonoperative cast immobilization indications nondisplaced Milch Type I fractures technique immobilize in supination for lateral condyle fractures immobilize in pronation for medial condyle fractures Operative 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 arthroplasty indications distal bicolumnar fractures in elderly patients Techniques Open Reduction Internal Fixation positioning 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 obtain test imaging before prepping and draping prep entire arm from shoulder to hand approach articular surface exposure olecranon osteotomy 57% triceps-reflecting 46% triceps-splitting 35% posterior superficial approach raise full thickness medial and lateral soft tissue flaps elevate deep fascia to identify ulnar and radial nerves triceps splitting (Campbell) split triceps tendon in midline down to olecranon tricep sparing (known as paratricipital, Alonso-Llames, medial and lateral windows) indications extra articular fractures or fractures with simple articular split) can be converted to olecranon osteotomy if needed medial side identify ulnar nerve and dissect it 15cm proximal to elbow joint proximally, and distally to first motor branch to FCU elevate triceps from posterior aspect of humerus on medial side and free it from medial intermuscular septum posterior band of MCL is elevated and posterior joint capsule entered to visualize trochlea lateral side identify radial nerve proper proximally if fracture is distal if fracture is distal and does not require long plates, proper radial nerve does not need to be exposed elevate remainder of tricep from posterior aspect of humerus anconeus may be divided or dissected on lateral side to improve exposure olecranon osteotomy indications complex intra articular fragments and/or presence of coronal splint) contraindications total elbow arthroplasty is planned/may be required technique identify bare area of sigmoid notch medially and laterally pre-drill (for 6.5mm screw) or plate prior to making bone cut pass sponge through ulnohumeral joint to protect articular surface while making cut fluoroscopy is used to confirm location of osteotomy shallow chevron (apex distal) is cut down to subchondral bone (95% cut) finish cut (remaining 5%) with osteotome peel olecranon and triceps proximally and wrap with saline soaked sponge fixation screw, K wires and tension band or plate clamp osteotomy from medial and lateral side with large pointed reduction clamps insert 6.5, 7.0 or 7.3mm screw (or plate) in previously drilled hole apply tension band still preferable for posterior trochlea fx and medial epicondyle fx complications AIN nerve injury check ability to flex thumb interphalangeal joint in recovery triceps reflecting (Bryan-Morrey) reflect triceps tendon, forearm fascia and periosteum from medial to lateral off olecranon repair through transosseous drill holes immobilize to protect triceps repair for 4-6wk postop triceps-reflecting anconeous pedicle (O'Driscoll) elevate anconeous subperiosteally from proximal ulna medial exposure is Bryan-Morrey triceps reflecting approach lateral muscles interval is an alternative to visualize the articular elevate ECRB and part of ECRL of supracondylar ridge usually able to work anterior to and sacrifice LCL if fx of lateral column, utilize and mobilize sublux joint to assist in articular visualization fixation principles (O'Driscoll) fixation in the distal fragment must be maximized all fixation in distal fragments should contribute to stability between the distal fragments and the shaft. fixation objectives (O'Driscoll) 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. fixation 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 postoperative 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 Total Elbow Arthroplasty Complications 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
Distal Humerus Fracture ORIF Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Authors: Orthobullets Team Hinged Elbow External Fixator Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Authors: Orthobullets Team
QUESTIONS 1 of 21 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Previous Next (OBQ05.204) An 85-year-old woman falls and injures her elbow in her non-dominant arm. Radiographs are shown in Figure A and B. She also suffers from severe osteoporosis, lives independently, and is a low-level community ambulator. Which of the following is the most appropriate treatment? Review Topic QID: 1090 FIGURES: A B 1 Hinged elbow brace 7% (44/593) 2 Olecranon osteotomy, articular ORIF, locked lateral plating 4% (23/593) 3 Triceps-splitting approach with double plate fixation 6% (33/593) 4 Total elbow arthroplasty 72% (428/593) 5 Casting for 4 weeks then ROM 10% (60/593) Select Answer to see Preferred Response PREFERRED RESPONSE 4 Sorry, this question is for Virtual Curriculum Members Only Click here to purchase Sorry, this question is for Virtual Curriculum Members Only Click here to purchase Sorry, this question is for Virtual Curriculum Members Only Click here to purchase Sorry, this question is for Virtual Curriculum Members Only Click here to purchase Sorry, this question is for Virtual Curriculum Members Only Click here to purchase Sorry, this question is for Virtual Curriculum Members Only Click here to purchase Sorry, this question is for Virtual Curriculum Members Only Click here to purchase Sorry, this question is for Virtual Curriculum Members Only Click here to purchase Sorry, this question is for Virtual Curriculum Members Only Click here to purchase Sorry, this question is for Virtual Curriculum Members Only Click here to purchase Sorry, this question is for Virtual Curriculum Members Only Click here to purchase (OBQ12.227) Which of the following patients is most appropriately treated with a total elbow arthroplasty? Review Topic QID: 4587 1 42-year-old laborer with an open T-type supracondylar distal humerus fracture 1% (51/4234) 2 90-year-old male with a comminuted transolecranon fracture-dislocation of the elbow 11% (480/4234) 3 66-year old female with a coronal shear fracture of the distal humerus 4% (190/4234) 4 50-year-old male with a nonunion of a supracondylar humerus fracture 4% (169/4234) 5 86-year-old female with a comminuted bicolumnar distal humerus fracture 78% (3311/4234) Select Answer to see Preferred Response PREFERRED RESPONSE 5 (OBQ04.157) Which of the following elbow injuries as found in Figures A-E best characterizes the radiographic "double-arc" sign? Review Topic QID: 1262 FIGURES: A B C D E 1 Figure A 2% (9/470) 2 Figure B 2% (9/470) 3 Figure C 88% (412/470) 4 Figure D 3% (15/470) 5 Figure E 5% (25/470) Select Answer to see Preferred Response PREFERRED RESPONSE 3 (OBQ04.239) What is the most common complication of the fracture seen in figure A, if operatively treated as seen in figure B? Review Topic QID: 1344 FIGURES: A B 1 Decreased elbow range of motion 91% (1052/1150) 2 Wound healing complications 1% (12/1150) 3 Iatrogenic ulnar nerve injury 4% (43/1150) 4 Inadvertent intra-articular hardware penetration 2% (23/1150) 5 Nonunion of the distal humerus fracture 2% (19/1150) Select Answer to see Preferred Response PREFERRED RESPONSE 1 Sorry, this question is for Virtual Curriculum Members Only Click here to purchase Sorry, this question is for Virtual Curriculum Members Only Click here to purchase Sorry, this question is for Virtual Curriculum Members Only Click here to purchase Sorry, this question is for Virtual Curriculum Members Only Click here to purchase Sorry, this question is for Virtual Curriculum Members Only Click here to purchase Sorry, this question is for Virtual Curriculum Members Only Click here to purchase
When can I remove the recon plates for an intercondylar humerus fracture with wound problems? Trauma - Treatment Consult I have a patient that I treated with recon plates for an intercondylar hume...
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