Surgical treatment: oPen reduction

Intra-articular distal humerus fractures can be among the most challenging injuries treated by orthopedic surgeons. The goals of surgical treatment are anatomical restoration of the articular surface and stable fixation 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. Intra-articular distal humerus fractures can be among the most challenging injuries treated by orthopedic surgeons. The goals of surgical treatment are anatomical restoration of the articular surface and stable fixation of the fracture fragments to allow for early motion.1-4 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. PreoPerative evaluation A focused history should assess prior trauma and function of the extremity, functional demands of the patient, and medical comorbidities. Physical examination should start with a thorough evaluation of the neurovascular status of the extremity. Vascular examination may reveal a diminished or absent pulse, which may be restored with fracture reduction. If, after reduction, the perfusion of the extremity is compromised, then angiography or exploration is warranted. Neurologic examination may reveal an associated nerve injury. Inspection of the extremity should focus on assessment of the soft-tissue envelope to detect any open fracture wounds. Radiographic assessment includes standard anteroposterior and lateral plain films. We have found traction anteroposterior views to be helpful for assessing fracture morphology. Computed tomography provides more details about the fracture pattern, especially with 3-D reconstructions with subtraction of the proximal ulna. However, direct, intraoperative visualization of the fracture site may reveal a fracture line not well visualized during preoperative evaluation, especially in gunshot injuries. Intra-articular fractures of the distal humerus are classified with the Mehne and Matta system as 1-column fractures (medial or lateral column), 2-column fractures (T, Y, H, or lambda), or fractures involving the capitellum 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 (ORIF); 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 fractures not amenable to stable osteosynthesis.5 Kamineni and Morrey5 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 follow-up, mean flexion arc was 24° to 131°, and mean Mayo Elbow Performance Score was 93 (maximum, 100 points). Fractures in high-risk surgical candidates may be treated nonoperatively. 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 supine position 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 approach, and an assistant is needed to hold the extremity because gravity tends to malalign the fracture. On the other hand, the lateral position does not require an assistant, and gravity helps maintain the reduction. The entire upper extremity is prepared and draped, and a sterile tourniquet may be applied according to surgeon preference. Use of a nonsterile tourniquet limits the proximal extension of the surgical approach and is not recommended. The contralateral iliac crest should be preOperative Treatment of Intra-Articular Distal Humerus Fractures Charalampos G. Zalavras, MD, PhD, Elizabeth T. McAllister, MD, Anshuman Singh, MD, and John M. Itamura, MD A Review Paper 8 A Supplement to The American Journal of Orthopedics® Dr. Zalavras is Associate Professor, Dr. McAllister is Resident, Dr. Singh is Resident, and Dr. Itamura is Associate Professor, Los Angeles County + USC Medical Center, Keck School of Medicine, University of Southern California, Los Angeles, California. Am J Orthop. 2007;36(12 suppl):8-12. Copyright Quadrant HealthCom Inc. 2007. All rights reserved. pared and draped so that, if bone graft is needed, a second surgeon can harvest the graft simultaneously. Surgical Approach The surgical approach may be performed through an olecranon osteotomy or reflection of the triceps (Bryan-Morrey or triceps-reflecting anconeus pedicle approach).3,6 The December 2007 9 C. G. Zalavras et al A B Figure 1. Exposure of fracture site after olecranon osteotomy. Figure 2. Fixation of olecranon osteotomy with a 6.5-mm cannulated screw and a washer. As noted in both the anteroposterior (A) and lateral views (B), the treaded part of the screw engages the isthmus of the ulna, resulting in compression of the osteotomy site and stable fixation. Figure 3. A very low intra-articular fracture of the distal humerus as seen in the preoperative anteroposterior (A) and lateral radiographs (B) is an especially challenging injury because of the limited distal bone stock available for fixation. The bone fragments are reduced and provisionally stabilized using reduction clamps and Kirschner wires (K-wires). Note that positioning of the K-wires does not interfere with plate application. (C) The implants should be applied so as to maximize fixation of the distal fragments to the metaphysis/diaphysis of the humerus. As many screws as possible should be placed through the plates into the distal fragments (6 such screws in this case), and each distal screw should be long and engage as many articular fragments as possible (D). Both plates should be applied with compression at the supracondylar level. Note the isthmic fit of the screw used for fixation of the osteotomy as noted in the lateral view (E). Following these principles will ensure that the fracture site is stabilized enough to allow early motion of the elbow, and uncompromised fracture healing (F) with a satisfactory outcome. A B