You are on page 1of 98

Fractures of the Distal


Dr. Abdul Karim
FCPS-II resident Orthopaedic Surgery
Functional Anatomy
 Hinged joint with single
axis of rotation distal
(trochlear axis) humeral
 Trochlea is center point
with a lateral and
medial column
Functional Anatomy
 The distal humerus
angles forward
 Lateral positioning
during ORIF facilitates
reconstruction of this
Surgical Anatomy
 The trochlear axis
compared to
longitudinal axis is 4-8
degrees in valgus
 The trochlear axis is 3-
8 degrees externally
 The intramedullary
canal ends 2-3 cm
above the olecranon
Surgical Anatomy
 Medial and lateral
columns diverge from
humeral shaft at 45
degree angle
 The columns are the
important structures for
support of the “distal
humeral triangle”
Mechanism of Injury

 The fracture is related
to the position of elbow
flexion when the load is

 Physical exam
 Soft tissue envelope
 Vascular status
 Radial and ulnar pulses
 Neurologic status
 Radial nerve - most commonly injured
 14 cm proximal to the lateral epicondyle
 20 cm proximal to the medial epicondyle
 Median nerve - rarely injured
 Ulnar nerve

 Radiographic exam
 Anterior-posterior and lateral radiographs
 Traction views are necessary to evaluate intra-
articular extension and for pre-operative planning
 Traction removes overlap
 CT scan helpful in selected cases
 Comminuted capitellum or trochlea
OTA Classification
 Humerus, distal segment (13)
 Types

 Extra-articular fracture

 Partial articular fracture

 Complete articular

fracture (13-C)
OTA Classification
 Humerus, distal segment (13)
 Types

 Extra-articular fracture

 Partial articular fracture

 Complete articular

fracture (13-C)
OTA Classification
 Humerus, distal segment (13)
 Types

 Extra-articular fracture

 Partial articular fracture

 Complete articular

fracture (13-C)
Mehne and Matta

 According to pattern
of fracture line in the
distal humerus.
Riseborough and Radin
 Type I - Fractures involving
minimally displaced articular

 Type II - Fractures involving
displaced fragments that are
not rotated

 Type III - Fractures involving
displaced and rotated

 Type IV - Fractures involving
comminuted fracture fragments
Capitellar and trochlear
 Type I - These are isolated capitellar fractures involving a
large portion of cancellous bone; they are known as Hahn-
Steinthal fractures.
 Type II - These are fractures involving the anterior cartilage,
with a thin-sheared layer of subchondral bone; they are known
as Kocher-Lorenz fractures.
 Type III fractures - These are comminuted osteochondral
 Type IV fractures - Classified by McKee and associates,
these involve the capitellum and one half of the trochlea; they
often result in the double-arc sign observed on lateral
Anatomical Classifications

(1) supracondylar fractures
(2) transcondylar fractures
(3) intercondylar fractures
(4) fractures of the condyles (lateral and
(5) fractures of the articular surfaces
(capitellum and trochlea), and
(6) fractures of the epicondyles.
Treatment Principles

1. Anatomic articular reduction
2. Stable internal fixation of the articular
3. Restoration of articular axial alignment
4. Stable internal fixation of the articular
segment to the metaphysis and diaphysis
5. Early range of motion of the elbow
Technical objectives for
fixation of distal humerus
 Every screw should pass through a plate
 Every screw should 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
 Every screw should engage as many articular
fragments as possible
 Plates should be applied such that compression is
achieved at the supracondylar level for both the
 Plates used must be strong enough and stiff enough to
resist breaking or bending before union occurs at
supracondylar level.
*campbell 11th edition
AO Implants

3.5 or 4.5mm 3.5mm LCP
recon plate

3.5mm LCP distal
AO Implants

3.5mm LCP extra 4.5mm can.screw
articular distal humerus

3mm headless LCP 1/3rd tubular
compression screw plate
AO Implants

Ex fix. Modular

Ring fixator

Elbow hinge fixator
 Careful neurovascular examination of the arm is
essential, especially in extension-type (apex
anteriorly angulated) supracondylar fractures.
 The brachial artery may be lacerated by the proximal
fracture fragment, either at the time of injury or during
reduction, and a compartment syndrome may develop.
 All three major nerves that cross the elbow can be injured,
but the radial and median nerves are those most commonly

 Conservative:
 hanging arm cast
 coaptation splint.
 Overhead olecranon skeletal traction
 Open reduction and internal fixation are
used as a rule only
 in the presence of neurovascular damage or
 when a satisfactory position of the fracture is not
obtained by closed methods.
Open reduction and internal
 Crossed screws or
crossed threaded
 The screws or pins
should be placed in the
medial and lateral pillars
and should engage the
posterior cortex of the
 Overdrilling of the distal
fragment to allow
compression when the
screws are tightened.
 When one or both
columns are
comminuted, hand-
contoured plates can
be used to reconstruct
the humeral pillars
 Pre-contoured DuPont plate fixation
 Goal should be stable,
rigid internal fixation.
Olecranon pin traction
 If operative treatment is
postponded because of
 severe swelling,

 traumatized, contused

 or the patient’s overall

condition, displaced
supracondylar fractures
--- side arm or overhead
olecranon pin traction
until operative treatment
can be performed.
 Often grouped with supracondylar fractures
 Rare injury requires special consideration.
 The fracture line usually extends transversely
across the condyles and often is
 Quite unstable and unite slowly when treated
Implant options
 Percutaneous threaded
Steinmann pins
 AO-type lag screws
 Newer cannulated screw
systems allow provisional
percutaneous pin fixation,
followed by screw fixation
without removal of the
provisional pins.
 This injury, especially if
it is intraarticular with
loss of fixation of the
fracture, can be
complicated by
avascular necrosis

 Most difficult challenge of the fractures of the
lower end of the humerus
 Classification
 Mehne and Mehta classification
 Riseborough and Radin classification

 Mehne and Mehta
classification system
Riseborough and Radin Classification of intercondylar fractures of distal
Types 2 and 3 fractures are treated by open reduction and internal fixation.
Most type 4 fractures are treated nonoperatively unless reconstruction is
technically possible
 Type 1 fractures
 plaster splint
immobilization, with
gradual motion being
permitted once sufficient
healing has occurred.
 Types 2 and 3 fractures
 ORIF esp.when pt. is
young and active
 Open fractures upto
Gustilo type II.
 Surgery is best
performed within the first
24 to 48 hours.
Type 4 fractures
‘‘a bag of bones.’’

 Usually treated nonoperatively
 sling and early motion if the patient is elderly
 or with skeletal traction through an olecranon pin if the
patient is younger
 When the patient is young, open reduction and
internal fixation of two or three of the major
articular fragments,followed by skeletal traction
and early motion, may be preferred
 Hinged-type distraction
external fixator that allows
early motion can be a
satisfactory treatment option
for intercondylar fractures
for which total
reconstruction is not
possible (Ciullo and
Melonakos and Bolano)
 More cost effective than
traction and may yield
similar results.

 Exposure affects ability to achieve reduction
 Reduction influences outcome in articular
 Exposure influences outcome!
 Choose the exposure that fits the fracture
 Campbell posterior
 Advantages:

 only approach to the elbow
that affords a clear view of
all the articular surfaces
 good exposure allows more
freedom in the selection of
the type of internal fixation
 after the ulnar nerve has
been identified and
retracted medially, no large
vessels or nerves lie in the
area of the incision.
Olecranon osteotomy
 McConnell cosmetic
extensile approach to
posterior elbow.
Triceps reflecting
 TRAP approach
Triceps-sparing postero-
medial approach (Byran-
Morrey Approach)
 Midline incision
 Ulnar nerve identified and mobilized
 Medial edge of triceps and distal forearm fascia
elevated as single unit off olecranon and reflected
 Resection of extra-articular tip of olecranon
Bryan-Morrey Approach
 A full complement of equipment for internal
fixation, including
 long screws,
 ordinary plates,
 malleable plates,
 fine Kirschner wires, and
 large and small threaded wires or pins should be
Literature (ORIF)

 Henley
 75% good or excellent results in 33 intercondylar humeral
fractures treated with open reduction and internal fixation.
 Letsch et al.
 81% good or very good results in 104 intraarticular distal humeral
 Gabel et al.
 90% good or excellent results in 10 fractures fixed with dual
contoured plates.
 Helfet and Schmeling,
 experienced surgeon can expect 75% good to excellent results.

 Poor results are due to heterotopic ossification, infection, ulnar
nerve palsy,fixation failure, and nonunion.
 Schemitsch, et al, 1994
 Tested 2 different plate designs in 5 different configurations
 Conclusions:
 For stable fixation the plates should be placed on the separate
columns but not necessary 90 degrees to each other
 Jacobson, et al, 1997
 Tested five constructs
 Strongest construct
 medial reconstruction plate with posterolateral dynamic
compression plate

 Korner, et al, 2004
 Biomechanically compared double-plate
osteosynthesis using conventional reconstruction
plates and locking compression plates
 Conclusions
 Biomechanical behavior depends more on plate
configuration than plate type.
 Cobb & Morrey, 1997
 20 patients 100%
 (avg age 72 yrs) 80%
 TEA for distal humeral 60%
fracture 50%
 Conclusion 30%
 TEA is viable treatment 10%
option in elderly patient 0%
with distal humeral Result
Fracture Excellent Good Fair/poor
 Frankle et al, 2003
 Comparision of ORIF vs. TEA for intra-articular distal
humerus fxs (type C2 or C3) in women >65yo
 Retrospective review of 24 patients
 Outcomes
 ORIF: 4 excellent, 4 good, 1 fair, 3 poor
 TEA: 11 excellent, 1 good
 Conclusions:
 TEA is a viable treatment option for distal intra-articular
humerus fxs in women >65yo, particularly true for women
with assoc comorbidities such as osteoporosis, RA, and
conditions requiring the use of systemic steriods
Open reduction and internal
 Prone position with elbow
flexed over arm board
facilitates open reduction
of fractures involving
elbow joint and lower
metaphyseal region of
Other positions
Posterior approach
 Incision
 5 cm distal to the tip of the
olecranon and extending
proximally medial to the midline
of the arm to 10 to 12 cm
above the olecranon tip.
 Reflect the skin and
subcutaneous tissue to either
side carefully to expose the
olecranon and triceps tendon.
 Isolate the ulnar nerve and
gently retract it from its bed
with a Penrose drain or a moist
 Open reduction and internal
fixation of Y fracture of
condyles through posterior
Osteotomy of olecranon.
A, Preparation of hole for 6.5-mm cancellous screw.
B, Incomplete osteotomy made with thin saw or osteotome.
C, Osteotomy completed by cracking bone.
Reduction of fracture
 Assemble the fragments of the distal
humerus in three steps:
(1) Reduce and fix the condyles together,
(2) If it is fractured, replace and fix the medial or
lateral epicondylar ridge to the humeral
metaphysis, and
(3) Fix the reassembled condyles to the humeral
Reduction and fixation of
 Reduce the condyles
and hold them firmly
with a bone-holding
 Fix small fragments
temporarily one at a
time with small
Kirschner wires
inserted with power
 Insert malleolar or cancellous AO
screws across the major
 Then remove as many of the
previously inserted Kirschner wires
as possible and still maintain
 Newer 4-mm cannulated screws
can be inserted over the Kirschner
wires with the wires in place.
 When the bone is osteoporotic,
use special washers to prevent the
screw heads from sinking through
the cortex.
 Ordinarily countersink screw
heads to prevent excessive bulk
outside the bone in and around
the elbow joint.
 Take particular care in reassembling the
condyles that the fixation device does not
encroach on the olecranon or coronoid
 When encroachment occurs, some loss of
flexion or extension of the elbow will result.
Reduction and fixation of
epicondylar ridge
 Reduce the fragment, hold it with a bone-
holding clamp, temporarily secure it with a
Kirschner wire, and then with lag screws
secure it to the metaphysis.
 When the site of the insertion of the screw is
a sharp edge or ridge, nip out a small bit of
the ridge with a rongeur before trying to place
the screw.
 Finally, after the lag screws are inserted,
remove the temporary Kirschner wire.
Reduction and fixation of
reassembled condyles to
 After the reduction of
the condyles, screws,
threaded pins, or plates
may be required to
rigidly attach them to
the metaphysis.
Double tension band wiring Vs
Double plating technique
 Houben, Bongers, and
von den Wildenberg
found that when
bicondylar intraarticular
fractures without severe
comminution were
treated with double
tension band wiring, the
results were equivalent
to those achieved with
a double plating
Comminuted fractures
 If there is comminution
of pillars hand-
contoured, one-third
tubular plate is applied
to the medial edge of
the medial humeral
pillar and a contoured
3.5-mm reconstruction
plate may be applied to
the posterior aspect of
the lateral humeral
Lateral comminution
 If the medial pillar is not
severely comminuted, a
rigid, prebent DuPont
plate can be applied
alone to the lateral pillar
Mini-fragment plates
 Thoroughly irrigate the joint of all debris and
bone graft defects as necessary.
 When using the posterior Campbell
approach, repair the tongue defect in the
triceps tendon with multiple interrupted
Osteotomy Fixation
 When using the
transolecranon approach,
reduce the proximal
fragment and insert a
cancellous screw using the
previously drilled and
tapped hole in the medullary
 Use no.20G wire for tension
band in a figure of eight
Tension band screw

Tension band Wire
Osteotomy Fixation
 Dorsal plating
 Low profile periarticular
implants now available
allowing antishear screw
placement through the
 No clinical or
biomechanical studies
yet published using these
 Light posterior plaster splint is applied from the posterior axillary fold
to the palm of the hand.
 At 7 days, the posterior plaster splint is removed periodically, and
gentle active and active-assisted exercises are carried out.
 By 3 weeks the posterior plaster splint can be removed, and the
arm is supported by a sling with active motion in the elbow as pain
 Vigorous stretching by a therapist, forced motion, whether active or
passive, and manipulation under anesthesia are contraindicated.
 Results in increased periarticular hemorrhage and fibrosis,
heterotrophic calcification, increased joint irritability, and decreased
rather than increased motion.

 Isolated fractures of the
medial or lateral
condyle of the humerus
in adults are
 When the condyle is
displaced, open
reduction and internal
fixation are the best
 Exposed through either
a medial or lateral
incision, depending on
the fracture, and the
fractured condyle is
secured to the
uninvolved condyle with
lag screws

 Usually fixation is sufficiently rigid to permit
early active motion.
 Aftertreatment is similar to that described for
intercondylar fractures, but usually
rehabilitation advances at a more rapid pace.
 Fracture of the capitellum is one of the most
common purely intraarticular fractures that occur
about the elbow.
 It usually is caused by a fall on the outstretched
upper extremity, with the radial head impacting
against the anterior portion of the lateral humeral
condyle (capitellum), resulting in a varying sized
shear fracture
 Fractures of the capitellum involve only the
articulating surface, producing an intraarticular
fragment, but elbow stability is maintained.
Classification of fractures of
the capitellum
 Depends on the size of the
articular fragment and its
 A good quality Lateral view
 Type 1 fracture
 a large fragment of bone

and articular cartilage
 Type 2 fracture
 a small shell of bone and

articular cartilage
 Type 3 fracture
 comminuted fracture
Treatment options
 Closed reduction
 usually not successful
 Open reduction with and without internal
 type I & II (large fragment)
 Excision of the fragments
 type II and most of type III fractures.
 Insertion of a prosthesis
 not proven successful or practical in literature
 Lateral approach
 Detach the extensor muscles from
the lateral epicondyle by sharp
 Carefully replace the large
articular fragment in its normal
 With a small AO lag screw
/Herbert screw, secure the
fragment in place and countersink
the screw head by overdrilling the
posterior cortex.
 Reattach the extensor muscles to
the lateral epicondyle. Apply a
posterior plaster splint.
New implants
 A small osteochondral
fracture is being fixed
with absorbable

 Outcomes based on pain and function
 Flexion is the first to return usually
 Within the first two months
 Extension comes more slowly
 Usually returns 4-6 months
 Supination/pronation usually unaffected
 25 % of patients describe exertional pain
Summary of the Medical Co-Morbidities
Commonly Associated with Increased Risk of

Surgical Complications
Operative Risk
Co-morbidity  Poor compliance with
 Dementia/mental
impairment rehabilitation
 Deep infection
 Diabetes mellitus
 Nonunion/infection
 Immunocompromise
 Parkinson's disease  Fixation failure

 Rheumatoid arthritis  Nonunion/infection
 Disseminated malignancy  Nonunion/infection
 Steroid medication  Nonunion/infection
 Heavy tobacco usage  Nonunion
 Alcohol abuse  Nonunion, poor
compliance with
 Painful retained hardware
 The most common complaint
 Common location
 Olecranon

 Medial hardware

 Hardware removal
 After fracture union

 One plate at a time in bicolumn fractures

 Removal of both plates with a single surgery is a
fracture risk
 Ulnar nerve palsy
 8-20% incidence
 Reasons:
 operative manipulation
 hardware prominence
 inadequate release
 Results of neurolysis (McKee, et al)
 1 excellent result
 17 good results
 2 poor results (secondary to failure of reconstruction)
 Prevention best treatment
 Heterotopic ossification
 Up to 50% of cases after treatment of distal humerus fractures.

 Posterolateral aspect of the elbow,

 Hastings and Graham functional classification system

 Class I –
 These fractures are associated with no functional limitations.

 Class II
 Class IIA - functional limitation of flexion and extension;
 Class IIB - functional limitation of supination and pronation

 Class III –
 These fractures are associated with ankylosis that eliminates elbow ROM.
 Heterotopic ossification
 Preventive measures
 Early operative treatment (24 to 48 hours)
 Nonsteroidal anti-inflammatory drugs (NSAIDs)
 Low-dose radiation therapy
 Continuous passive ROM exercises.
 Treatment
 Indomethacin
 Recommended dose is 75 mg orally B.D for 3 weeks.
 Low-dose radiation therapy
 Single doses of 600-700 cGy
 The timing of the irradiation (preoperative vs postoperative) does
not seem to affect operative outcomes
 Operative excision of heterotopic ossification is recommended
12 months after the injury

 Failure of fixation
 Associated with stability of operative fixation
 K-wires fixation alone is inadequate
 If diagnosed early, revision fixation indicated
 Late fixation failure must be tailored to
radiographic healing and patient symptoms
 Nonunion of distal
 Uncommon
 Usually a failure of
 Symptomatic treatment
 Bone graft with revision

 Non-union of olecranon osteotomy
 Rates as high as 5% or more
 Chevron osteotomy has a lower rate
 Treated with bone graft and revision tension band
 Excision of proximal fragment is salvage
 50% of olecranon must remain for joint stability

 Infection
 Range 0-6%
 Highest for open fractures
 No style of fixation has a higher rate than any
Case Examples
Case 1: 18 y/o H/o fall
Lateral epicondyle and capitellum
Lateral approach
Capitellum: Post to Ant lag screws
Epicondyle: Screw + buttress plate
Loss of 20 degs ext
Case 2:
43 y/o female fell from horse
•Chevron intra-articular approach
•Tension band screw
•ORIF medial column Fx
•Extensile exposure required intra-op
Antegrade IM nail for humeral Fx

Lacks 10 degs elbow extension
Full shoulder motion
Olecranon hardware tender
Case 3: 20 y/o male
Distal, two column Fx
NV intact
Transverse intra-articular approach
Lag screw and bi-column plating
Tension band wire with cable
Lacks 20 degs flex & ext.
Osteotomy healed without complications