Operative Treatment of Intra-Articular Distal Humerus Fractures Charalampos G. Zalavras, MD, PhD, Elizabeth T. Medllister, MD, Anshuman Singh, MD, and John M. Itamura, MD Abstract Intra-articular distal humerus fractures can bo among the most challenging injuries treated by orthopedic surgeons. The goals of surgical treatment are anatomi- coal restoration of the articular surface and stable fixa- tion of the fracture fragments to allow for early motion, However, the bone stock of the distal humerus is limited, and stable fixation may be difficult to achieve in the case ‘of a low fracture pattern, comminution, or osteoporosis. In this article, we provide practical recommendations for ‘surgical management of these complex fractures. nira-articular distel humerus fractures can be among the most challenging injuries, treated by orthopedic surgeons. The goals of surgical treatment are anatomi- cal restoration of the articular surface and stable fixa- tion ofthe fracture fragments to allow for early motion." However, the bone stock of the distal humerus is limited, and stable fixation may be difficult to achieve in the, case of a low fracture pattem, cornminution, or ésteopoross. In this article, we provide practical recommendations for surgical management of these complex fractures. PREOPERATIVE EVALUATION ‘A focused history should assess prior trauma and fane- tion of the extremity, functional demands of the patient, ‘and medical comorbidities. Physical examination should start with a thorough evaluation of the neurovascular sta- tus of the extremity, Vascular examination may reveal a diminished or absent pulse, which may de restored with fracture reduction. If, after teduction, the perfusion of the cxtromity is compromised, then angiography or explors- tion is warranted. Neurologic examinstion may reveal an associated nerve injury. Inspection ofthe extremity should focus on assessment of the soft-tissue envelope to detect any open fracture wourids, Radiographic assessment includes standard antero- posterior and lateral plain films, We have found traction anteroposterior views to be helpful for assessing fracture ‘morphology. Computed tomography provides more details a Dr. Zalavras Is Associate Professor Or. Modlister is Resident, Dr Singh fs Resident, and Or. tamura is Associate Professor, Los ‘Angolos County + USC Medica Center, Keck School of Medicine, University of Southom Calfomia, Los Angeles, California: ‘Am J Orthop. 2007;96(12 suppl:8-12, Copyright Quadrant HealthGom Ine, 2007. Al rights reserved. 8 A Supplement to The American Journal of Orthopedics ‘about the fracture patter, especially with 3-D reconstrac- tions with subtraction of the proximal ulne. However, irec, intraoperative visuaization ofthe fracture ste may reveal a fracture line not well visualized during preopere- tive evaluation, especially in gunshot injuries, Intrearticular fractures of the distal humerus are clas- sified with the Mehne and Matta system as I-cohmn fractures (medial or lateral column), 2-column fractures (L.¥. Hl, or lambda), or fractures involving the cepitellum or trochlea (not covered in this article), SURGICAL TREATMENT: OPEN REDUCTION AND INTERNAL FIXATION Indications Intra-articular distal humerus fractures should be treated ‘surgically. The treatment of choice is open reduction and internal fixation (ORIE); restoration of articular surface congruency minimizes development of arthrosis, and stable fixation allows early motion and maximizes the functional outcome. Total elbow arthroplasty is reliable for elderly patients who have severely comminuted frac- tures not amenable to stable osteosynthesis? Kamineni and Morrey* retrospectively reviewed 43 fractures in 43, patients (mean age, 69 years) who were followed for at least 2 years (mean follow-up, 7 years). At the latest fol- Jow-up, mean flexion are was 24° to 131°, and mean Mayo Elbow Performance Score was 93 (meximuim, 100 points). Fractures in high-risk surgical candidates may be treated rnonoperatively. Anesthesia, Positioning, Preparation General endotracheal anesthesia with muscle relaxation is, preferred. The patient can be in supine, lateral, or prone position based on surgeon preference. The s with the. arm positioned over the chest, which is safe for polytrauma patients with chest or spinal injuries, allows hyperflexion of the elbow and improved visualization of the anterior part of the trochlea. However, this is a more difficult epprozch, and an assistant is needed to hold the extremity because gravity tends to malatign the fracture On the other hand, the lateral position does not require an assistant, end gravity helps maintain the reduction. ‘The entice upper extremity is prepared and draped, ‘and a sterile tourniquet may be applied according to sur- ‘goon preference. Use of a nonsterile tourniquet limits the proximal extension of the surgical approach and is not recommended, The contralateral iliac crest should be pre-Figure 2. Fixation of olecranon asteotomy with a 6.6mm ‘cannulated screw and a washor. As nated in both the “nteroposterior (A) and lateral views (B), tho treadod part of the screw engages the isthmus of the ulna, resulting in ‘compression of the osteotomy site and stable fixation. pared and draped so that, if bone grat is needed, a second ‘surgeon can harvest the graft simultaneously. Surgical Approach "The surgical approach may be performed through an olec- ramon osteotomy or reflection of the riceps (Bryan-Morrey or triceps-reflecting anconeus pedicle approach).’* The C.G, Zalavras otal Figure 3, A voy low int-atioular fracture of he cistal humerus 2 ‘seen in the preoperalve anteroposterior (A) and lateral raclographs (Bs an especialy challenging ijury beoausa of the Tinted distal bone stock avaleble for iaton. The bone fregmonts ‘ro reduced and provsionaly stablized using rection Camps anc ‘Krechner wits (ties), Note that posttoning of the K-wies does ‘ot interfere with plate appication, (6) The implants shouts be ‘Sppfod eo as to maria fxaton ofthe distal fragments to tho tmetaphysi/eaphysis of tre humerus. As many sores a POS {Sle shouid be placed though tho plats int the distal fragments {6 such sorovesin this cas) anc each sal screw should belong find engage 2s many articular ragmenis as possible (D). Both patos ‘hould bo applied wit compression atthe supracondyar ove. Note the lth ft ofthe screw used for tation ofthe osteotomy a rated inte lateral view ().Fotowing tese pencples wit (sur thatthe fracture sit is stabilzed enough to afow early ‘mote of the elbon, and uncompromised fracture hoakng (F) ‘ha safilactory outcome. December 2007 9Operative Treatment of Intra-Anticular Distal Humerus Fractures olecranon osteotomy provides excellent visualization of the fracture (Figore 1), but there are conceras regarding nonunion of the osteotomy site and prominence of the hardware placed at the olecranon. If elbow arthroplasty is considered, the olecranon should not be osteotomnized ‘Triceps reflection avoids the complications of the olec- anon osteotomy (but may result in triceps rupture) and provides satisfactory exposure but not to the same extents the osteotomy. Most osteotomy nonuniohs are attributable to inadequate fixation of the osteotomy site and thus can be prevented with stable fixation. Also, treating a nonunion of the olecranon is easier then trealing an intre-articular malunion of the distal humerus. Incision After perioperative antibiotics ate administered, a posterior | midline skin incision is made. This incision allows wide fexposore, protects cutaneous nerves, and can be reused for | revision procedures. The incision extends from ‘approxi- tnutely 15 em proximal to 7 cm distal to the tip of the ‘leeranon an is placed slightly lateral or media ote ip. Fall thiclnesssuboutancous flaps ae raised bos medially and laterally Ulnar Nerve Dissection ‘The uliar nerve is identified and carefully dissected and mobilized. Te is important to release the ulnar nerve from the arcade of Struthers proximally to the first motor branch to the Mlexor carpi ulnaris distally to allow anterior trans- position of the nerve without tension, For the same reason, the medial intermuscular septum is cxcised. Mobilization of the ulnar nerve protects it during the ease and facilitates plate application along the medial cpicondyle. Depending ‘on how proximally fixation is needed on the lateral column, the radial nerve may also need to be identified | ‘and mobilized. | Olecranon Osteotomy | fa serew and washer will be used t0 fix the oleranon oxteotomy, thea the olecranon and proximal ulna should be dilled and tapped beforehand to facilitate anatomicel rocuction of the osteotomy «ite, Preoperative templating help in selecting the diameter and length ofthe olesranon Sere that wil provide the best Bt in the isthmas ofthe tina (Figures 2A, 2B). In most cases, a 65- or 7.3-mm cannulated seew is appropriate, Based on templating, the Sorrect-diameter guide pin, oil, aud tap are used. The stating point shouldbe slighty radial tothe midline ofthe Glecranon so that a Tong sew can negotiate the varus how ofthe proximal ula, gain purchase atthe narrowest part the diaphyel, and compress the osteotomy sit, Thereby fncreasing stability of the fixation and preventing the com- plication of nonunion, i "The olecranon osteotomy is performed atthe bare spot_| ofthe olecranon, which i leated a the center ofthe oles ‘anon suleus and is identified by elevating the anconeus muscle. A sponge is placed transversely underneath the ‘olecranon to protect the articular cartilage and to allow an assistant to provide countertraction while the osteotomy is made. An apex distal chevron-type osteotomy helps with anatomical reduction and improves stability. A. thin oscillating saw is used initially, but the final portion of the osteotomy is made with an osteotome to facilitate interdigitation of the bone ends and reduction of the oste- tomy, After the osteotomy, the olecranon tip is reflected proximally with the triceps, and the articular surface of the distal humerus can now be directly visualized. An olecra- non osteotomy should be avoided if primary arthroplasty is being considered, Fracture Reduction ‘The hematoma is removed by irrigating the fracture site, and the fracture fragments arc identified, The surgeon and assistants should preserve all existing soft-tissue attach- ments of bone fragments and should be careful at this ‘point to avoid inadvertently dropping an articular fragment completely devoid of soft-tissue attachments. After direct visualization of the fracture site, preoperative assessment of the fracture is confirmed, oF new fracture lines may be discovered, thus changing the preoperative plan. Fracture reduction may start at 1 of the 2 columns or at the ertcular surface. The order an method of reduction must be tailored to the individual fracture pattern. When & column is not comminnted, we prefer to start the reduction ‘there to use the accurate read present. When there is com- tminution atthe metaphyseal level, we reduce the articular surface frst and then attach itt the diaphysis, aiming to restore rotetion and valgus orientation of the joint. Bone- torbone contact across the columns is essential, and any {gaps must be filled, preferably with autogenous bone graft Alternatively, synthetic bone graft may be used 2s a void filler to avoid donor site complications from harvesting iliec crest bone graft. In eases of severe comminution and bone loss, supracondylar shortening, which maximizes ‘bone contact and improves stability at the fracture site, is ‘a viable option.” Any defect in the articular surface should be filled wit autogenous bone graft, because shortening of the trochlea will ead to incongrucney and arthrosis of the ‘nlnohumeral joint. Also, «fully threaded screw should be ‘used so as not to lag the condyles together and shorten the distal humerus articular segment, "The reduced bone fragments are held in place with fracture reduction clamps and are provisionelly fixed using Kirschner wires (K-wires) with a diameter of 1.2 to 2.0 mm, depending on fragment size (Figures 3A~3C). The K-wires are positioned so they do not interfere with plate application, ‘The reduction is then checked both visually and fluoroscopicaly. Fixation Technique Unicolumnar fractures may be stabilized with 1 plate, but inra-articular distal humerus fractures involving both colurnns require 2 plates. Although there is universal agree- tment on the necessity of stable fixation, the optimal tech- 40. A Supplement to The American journal of Orthopedics:Figure 4, Hardware fallure atthe supracondylar level, nique for stable fixation remains controversial. One fixa- tion technique uses 2 plates applied ata right angle to each other (je, a medial plate on the medial column combined with a posterior plate on the lateral column of the distal humerus). An alternative technique uses 2 parallel plates (Ge, « medial plate on the medial column combined with a lateral plate on the lateral colurnn).®9'To our knowledge, ro clinical studies have compared these 2 techniques, and biomechanical studies of distal humerus fixation have lad conflicting results Orthopedic surgeons should have several technical ‘objectives. They should: apply plates so compression is achieved atthe supracondyler level for both columns, place ‘as many screws as possible through the platcs into the tal fragments, use the longest distal screws possible, and rake them engage as many articular fragments as possible Gigures 3D-38)."” Achieving these objectives maximizes fixation ofthe distal fragments fo the metephysis/diaphysis of the humenss, which is critival because most failures ‘occur at the supracondylar level (Figure 4), A free intra-articular 3.5-mm cortical serew or 4,0-mm ceancellous screw can also be used to stabilize a sagittal split of the articular surface. In such @ case, the screw €.G. Zalavras et al should be strtegically placed so it will not block applica- tion of distal screws through the plates, and, if ther ‘couniminution inthe sagittal plane, the screw should not be inserted in compressive mode, s0 as to avoid shortening of the distal humerus articular segment. Free articular fragments, usually secondary to coronal frac- tures, should be fixed with compression screws countersunk tundemeath the articolar cartilage. Headless screws, such as Herbert CZinumer, Warssw, Ind.) and Acutrak (Acumed, Hillsborough, Ore.) screws, arc helpful. Very small articular ‘ragments can be fixed definitively with threaded 0.9- de 1.2- ‘mm K-wires placed in the subchondral bone. A vaciety of plates can be used, depending on fracture configuration and surgeon preference. The 3.5-mm LC- DCP plates provide sulficient strength, but their ability 10 be contoured is limited. They can be placed on the poste- rior aspect ofthe lateral column. The 3.5-mm reconstruc- tion plates can be easily contoured so that they are placed ‘more distally around the medial epicondyle or around the posterior surfece of the capitellum to improve fixation in Tow fracture patterns, Lack of articular cartilage at the posterior distal surface of the lateral column facilitates distal positioning of the plate, A 3.5-nun reconstruction, plate can also be bent in a -shape ang placed on the later- al surface of the lateral column. Precontoured snatomical clbow plates are easily and accurately applied, decrease ‘operative time, and fecilitate insertion of a maximum number of screws in the distal fragments. Our prefer- ence is to use parallel precontoured plates, placed on the medial and leteral columns (Figures 3C-3E), Locking plates, both standard and precontoured, are available. Application of locking screws distally increases stability in the presence of osteoporotic bone, commninution, and short distal segments ‘On completion ofthe Fixation, the joint should be carefully evaluated both visually and Buoroscopically 1o ensure that there i no protrusion of hardware through the articular casti- lage, oleeranon fossa, or coronoid fosse. The elbow is ranged, ‘and the stability ofthe fixation i assessed, ‘The olecranon is then reduced, and the osteotomy is fixed according to the surgeon's preferred technique (sees, ten- sion band, or plate). We prefer to use-a screw, as already described (Figures 2A, 2B, 3D, 3B). In the widely used tension band technique, two 1.2-mm parallel K-wires go through the osteotomy site and engage the anterior cortex of the proximal ulna just distal to the coronoid. Two wires of sinall diameter (20 to 22 gauge) are used to minimize hardware prominence. Ulnar Nerve Transposition and Wound Closure The ulnar nerve is anteriorly transposed into a subcutane- ‘ous location to avoid impingement from hardware over the medial epicondyle or entrapment into scar tissue at the fracture site. TF a tourniquet was used, it is deflated ‘and hemostasis obtained, One or 2 large suction drains are placed, and the wound is closed in layers. A bulky elbow ‘dressing is placed with the arm in extension, December 2007 14‘Operative Treatment of Intra-Anticular Distal Humerus Fractures Postoperative Management Hand and wrist range-of-motion exercises. are begun immediately after surgery, and, along with elevation of Wound healing complications developed in 2 patients, deep infection in I, nonunion in 1, heterotopic ossification requiring excision in 5, arthrosis in 2, and permanent ulnar the extremity, they help limit softtisue swelling in the | neuropathy in 2. carly postoperative period. Heterotopic ossification pro- | — Doornberg and colleagues, who evaluated a series of 30 Phylaxis is not routinely used, 50 a5 10 avoid interfering. | patients et a mean of 19 years after ORIF of inte-aticalar ‘with bone and soft-tissue healing. Prophylaxis (with either indomethacin or inradiation) may be considered for @ patient with head injury. Barly elbow mobilization, which is essential, stars 24 (0 48 hours after surgery with active and actve-ssisted exercises. A night splint is epplied to keep the elbow extended, If fractre healing progresses satisfactorily, mascle-suengthening exercises are slated 12 weeks afer surgery. Rehabilitation should continue for at least 6 months, bectuse improvement in elbow range of motion may oocur for upto 6 or even 12 months. Range of motion of 30° 10.130" is considered sufficient for activities of daily living." be Open Fractures ‘Treatment of open intra-articular distal humerus fractures starts with early antibiotic administration in the emergency department, followed by surgical débridement and irrige- tion of the open fracture. Primary internal fixation can usually be performned at the same time. However in cases ‘of severe contamination or soft-tissue damage, the fracture can be provisionally stabilized in a splint Gf gross align- ment can be maintained) or external fixator, and a repeat débridement should be performed at 24 to 48 hours. Tf a repeat procedure is planned, antibiotic beads are placed at the fracture site to enhance local antibiotic delivery. o of Outcome A satisfactory outcome can be achieved in most patients when anatomical ORIF is performed according to the principles described in this article. However, complications may occur, and reoperations may be required. ‘ Jupiter and colleagues reported on a series of 34 patients with int-articular distal humerus fractures followed up for | 5 ‘a mean of 5.8 years, Twenty-seven (79%) of the 34 patients hhad a good or excellent outcome. Slight to moderate nar- rowing of the joint space developed in 19 patients (56%) and extensive arthrosis in 4 (12%). Complications included | 2 nomunions ofthe fracture site, 1 nonunion of the olecranon osteotomy, I deep infection, 1 clinically significant hetero- topic ossification, and 4 cases of ulnar nerve compression. ‘In a series reported by Sanchez-Sotelo and colleagues,! 4 good or excellent outcome was achieved in 27 (84%) of 32 patients followed up for a mean of 2 years. Mean elbow extension and flexion were 26° and 125°, respectively. | 12. A Supplement to The American Journal of Orthopedics? fractures ofthe dis fragments to allow for early motion. Careful preoperat planning, surgical expertise, and aggressive postoperative rehabititation are essential for optimizing outcome, tal humerus, found that durable results can achieved: There were 26 good or excellent results (87%); mean ASES (American Shoulder and Elbow Surgeons) score was 96 points; and mean DASH (Disabilities of the ‘Arm, Shoulder, and Hand) score was 7 points. Mean elbow extension and flexion were 23° and 129°, respectively. ‘Twenty-four patients (80%) developed arthrosi hhad slight joint-space narrowing, TI had moderate narrow- ing, and 2 had severe arthrosis. However, artrosis did not correlate with impairment or disability of these, 11 CONCLUSIONS ‘The principles of surgical management of intra-articular fractures of the distal humerus are anatomical restoration the articular surface and stable fixation of the fracture AutHors’ DiscLosure STATEMENT ‘The authors report no actual or potential conflicts of inter- cst in relation to this article, REFERENCES: ‘Sano. 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