anatomy of elbow & fractures around elbow & surgical options in adults

ELBOW ANATOMY, FRACTURES,
AND SURGICAL OPTIONS
By Dr. Ranveer Patel
Orthopaedic Surgeon,
Shreeji Orthopaedic Care

Functional Anatomy
 Hinged joint with single
axis of rotation
(trochlear axis)
 Trochlea is center point
with a lateral and
medial column
 ..
distal
humeral
triangle

Functional Anatomy
 The distal humerus
angles forward
 Lateral positioning
during ORIF facilitates
reconstruction of this
angle

Surgical Anatomy
 The trochlear axis
compared to
longitudinal axis is 4-8
degrees in valgus
 The trochlear axis is 3-
8 degrees externally
rotated
 The intramedullary
canal ends 2-3 cm
above the olecranon
fossa

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
applied

Evaluation
 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

Evaluation
 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
(13-A)
 Partial articular fracture
(13-B)
 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
fragments
 Type II - Fractures involving
displaced fragments that are
not rotated
 Type III - Fractures involving
displaced and rotated
fragments
 Type IV - Fractures involving
comminuted fracture fragments

Capitellar and trochlear fractures
 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
fractures.
 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
radiographs.

Anatomical Classifications
(1) supracondylar fractures
(2) transcondylar fractures
(3) intercondylar fractures
(4) fractures of the condyles (lateral and
medial)
(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
surface
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 fractures*
 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
columns
 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
recon plate
3.5mm
LCPCP,DCP
3.5mm LCP
3.5mm LCP distal
humerus

AO Implants
3.5mm LCP extra
articular distal humerus
3mm headless
compression screw
4.5mm can.screw
LCP 1/3rd tubular
plate

AO Implants
Elbow hinge fixator
Ex fix. Modular
frame
Ring fixator

SUPRACONDYLAR FRACTURES
 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
affected.

Treatment
 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 fixation
 Crossed screws or
crossed threaded
pins.
 The screws or pins
should be placed in the
medial and lateral pillars
and should engage the
posterior cortex of the
bone.
 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
skin,
 or the patient’s overall
condition, displaced
supracondylar fractures -
-- side arm or overhead
olecranon pin traction
until operative treatment
can be performed.

TRANSCONDYLAR FRACTURES
 Often grouped with supracondylar fractures
 Rare injury requires special consideration.
 The fracture line usually extends transversely
across the condyles and often is
intraarticular.
 Quite unstable and unite slowly when treated
conservatively.

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

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

Classification
 Mehne and Mehta
classification system

Riseborough and Radin Classification of intercondylar fractures of distal
humerus.
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

Treatment
 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.

Exposures
 Exposure affects ability to achieve reduction
 Reduction influences outcome in articular
fractures
 Exposure influences outcome!
 Choose the exposure that fits the fracture
pattern

Approaches
 Campbell posterior
approach
 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.

 McConnell cosmetic
extensile approach to
posterior elbow.

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
laterally
 Resection of extra-articular tip of olecranon

 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
available.

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
fractures
 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.

Literature:
 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

Literature:
 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.

Literature:
 Cobb & Morrey, 1997
 20 patients
 (avg age 72 yrs)
 TEA for distal humeral
fracture
 Conclusion
 TEA is viable treatment
option in elderly patient
with distal humeral
Fracture
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Result
Excellent Good Fair/poor

Literature:
 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 fixation
 TECHNIQUE
 Prone position with elbow
flexed over arm board
facilitates open reduction
of fractures involving
elbow joint and lower
metaphyseal region of
humerus.

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
tape.

..
 Open reduction and internal
fixation of Y fracture of
condyles through posterior
approach.

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 segments
 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
metaphysis.

Reduction and fixation of condyles
 Reduce the condyles
and hold them firmly
with a bone-holding
clamp.
 Fix small fragments
temporarily one at a
time with small
Kirschner wires
inserted with power
equipment.

 Insert malleolar or cancellous AO
screws across the major
fragments.
 Then remove as many of the
previously inserted Kirschner
wires as possible and still maintain
fixation.
 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
fossae.
 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 metaphysis
 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
technique

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
pillar

Lateral comminution
 If the medial pillar is not
severely comminuted, a
rigid, prebent DuPont
plate can be applied
alone to the lateral pillar

..
 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
sutures.

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 canal.
 Use no.20G wire for tension
band in a figure of eight
manner.

Tension band screw
Tension band Wire

Osteotomy Fixation
 Dorsal plating
 Low profile periarticular
implants now available
allowing antishear screw
placement through the
plate
 No clinical or
biomechanical studies
yet published using these
plates

Aftertreatment.
 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
permits.
 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.

FRACTURES OF CONDYLES OF HUMERUS
(MEDIAL OR LATERAL)
 Isolated fractures of the
medial or lateral
condyle of the humerus
in adults are
uncommon.
 When the condyle is
displaced, open
reduction and internal
fixation are the best
treatment.

Treatment
 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

Aftertreatment
 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.

FRACTURES OF ARTICULAR SURFACE
OF DISTAL HUMERUS
 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
comminution.
 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
fixation
 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

TECHNIQUE
 Lateral approach
 Detach the extensor muscles from
the lateral epicondyle by sharp
dissection
 Carefully replace the large
articular fragment in its normal
position.
 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
screws.

Outcomes
 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

Co-morbidity
 Dementia/mental
impairment
 Diabetes mellitus
 Immunocompromise
 Parkinson's disease
 Rheumatoid arthritis
 Disseminated malignancy
 Steroid medication
 Heavy tobacco usage
 Alcohol abuse
Operative Risk
 Poor compliance with
rehabilitation
 Deep infection
 Nonunion/infection
 Fixation failure
 Nonunion
 Nonunion, poor
compliance with
rehabilitation
Summary of the Medical Co-Morbidities Commonly Associated
with Increased Risk of Surgical Complications

Complications
 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

Complications
 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

Complications
 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.

Complications
 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

Complications
 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

Complications
 Nonunion of distal
humerus
 Uncommon
 Usually a failure of
fixation
 Symptomatic treatment
 Bone graft with revision
plating

Complications
 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
technique
 Excision of proximal fragment is salvage
 50% of olecranon must remain for joint stability

Complications
 Infection
 Range 0-6%
 Highest for open fractures
 No style of fixation has a higher rate than any
other

Case Examples
Case 1: 18 y/o H/o fall
Lateral epicondyle and capitellum
Fx’s

Lateral approach
Capitellum: Post to Ant lag screws
Epicondyle: Screw + buttress plate
Healed
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
Healed
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

Healed
Lacks 20 degs flex & ext.
Osteotomy healed without complications

anatomy of elbow & fractures around elbow & surgical options in adults

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anatomy of elbow & fractures around elbow & surgical options in adults