Treatment of Distal Humerus Fractures - achot.cz

1 6/CURRENT CONCEPTS REVIEWSOUBORN REFER TACTACHIRURGIAE ORTHOPAEDICAEET TRAUMATOLOGIAE ECHOSL., 75, 2008, p. 6 15 Treatment of Distal Humerus FracturesL ba zlomenin dist ln ho humeruA. M. ILYAS1, Surgery Temple University Hospital, Philadelphia, USA2 Orthopaedic Surgery Harvard Medical School, Boston, USASUMMARYThe elbow is a complex joint and is vital in positioning the hand in space. We believe that open reduction internal fixationoffers the best chance for return to function following intra-articular Fractures of the Distal Humerus . We advocate the followingprinciples for the effective Treatment of these injuries: identification and protection of the ulnar nerve followed by transposition,broad exposure of the fracture utilizing an olecranon osteotomy, anatomic restoration of the articular surface with preservationof all osteochondral fragments, rigid fixation of both columns using pre-contoured plates and screws, and the institution of ear-ly range of motion the anatomy of the Distal Humerus iscritical to effective Treatment of Distal Humerus medial and lateral columns of bone supportthe Distal humeral articular surface in an inverted-Yconfiguration.

2 The medial column diverges from the cent-ral humeral axis at an angle of 45 degrees, and the late-ral column at an angle of 20 degrees (22, 32).The trochlea lies in the center and links the twocolumns and articulates with the olecranon. Stability ofthe elbow is a product of bony articulations, soft tissuetension, and the musculotendinous forces acting acrossit. The central sulcus of the trochlea inter-digitates withthe corresponding articular ridge on the olecranon pro-viding significant bony stability to the elbow throughthis highly congruent articulation. The trochlea is cove-red by articular cartilage over an arc of almost 300degrees and subsequently permits a broad range of moti-on at the ulno-humeral joint.

3 Compromise of the tro-chlea in the form of shortening, bone loss, or residualincongruity can translate into significant loss of elbowmotion and capitellum resides on the lateral column and pro-vides 180 degrees of articulating area. In contrast to thetrochlea, the posterior aspect of the lateral column isnon-articular and allows for posterior placement ofimplants without risk of injury to cartilage or risk ofimpingement with flexion and Distal articular surface lies in 4 to 8 degrees ofvalgus and is externally rotated 3 to 4 degrees relativeto the central axis of the Humerus . The capitellum andtrochlea are translated anteriorly relative to the hume-ral diaphysis, creating an angle between the centralhumeral axis and the Distal articular segment of 30 toINTRODUCTIOND istal Humerus Fractures remain a challenging inju-ry to manage, particularly as the population ages andthe prevalence of osteopenic Fractures grow (9).

4 Seve-ral variables are important in successful managementof these Fractures : restoration of articular congruity,secure bony fixation, achievement of bony healing,maintenance of a functional range of motion, and avo-idance of complications such as heterotopic ossificati-on and ulnar neuropathy. Our understanding of fractu-re morphology, operative approaches, and implantdesigns have substantially added to our ability to treatthese Fractures more Humerus Fractures make up to 2% of allfractures, but up to 30% of Fractures involving the elbow(58). In addition, the incidence of Distal Humerus frac-tures among the elderly seems to be increasing. Palva-nen et al identified more than a 2-fold increase in theage-adjusted incidence of Distal Humerus Fractures inFinnish women older than 60 between 1970 and 1995,and predicted a 3-fold increase by the year 2030 (44).

5 This is reinforced by Court-Brown & Caesar who alsoidentified an increasing trend in osteoporotic distalhumerus Fractures as people are living longer and theprevalence of osteoporosis grows (9).In adults, most Distal Humerus Fractures are intra-arti-cular and involve both the medial and lateral columns(58, 22). The distribution of Distal Humerus fracturesfollows a bimodal age distribution. High-energy injuri-es tend to occur among younger patients, while low-energy injures are more common in older 15:10 Str nka 67/ACTACHIRURGIAE ORTHOPAEDICAEET TRAUMATOLOGIAE ECHOSL., 75, 2008 CURRENT CONCEPTS REVIEWSOUBORN REFER T40 degrees. The lateral column and epicondyle followthis anterior translation, whereas the medial column andepicondyle are in line with the humeral shaft.

6 Compro-mise of these dimensions during Treatment can risk lossof elbow to the articular surface are depressions inthe metaphyseal level of the Distal Humerus , the radialand coronoid fossae, that accommodate the radial headand coronoid process, respectively. Posteriorly, the olec-ranon fossa accepts the olecranon process within it andmust remain free of hardware during repair to allow addition to the stability provided by the highly con-gruent ulno-humeral articulation, the medial and lateralcollateral ligament complexes of the elbow significant-ly add to elbow stability. Typically with Distal humerusfractures not associated with a concomitant dislocationinjury to the collateral ligament would be , knowledge of their anatomy must be consideredduring the Treatment of Distal Humerus Fractures .

7 Themedial collateral ligament has its proximal attachmentalong the anteroinferior aspect of the medial epicondy-le and has its Distal attachment along the medial aspectof the ulna immediately Distal to the coronoid process(8). The lateral collateral ligament complex has its pro-ximal attachment at a point along the lateral epicondy-le that marks the axis of the ulno-humeral joint and atta-ches to the lateral ulna along a broad base whilecoalescing with fibers of the annular ligament complex(8).CLASSIFICATIONThe traditional classification of Distal Humerus frac-tures has centered around the terminal ends, or the con-dyles, of the Humerus . When discussing intra-articularfractures of the Distal Humerus , the term condyle isconverted to columns for the sake of column Fractures in adults are uncommon andgenerally involve the lateral column.

8 Both column frac-tures on the other hand are the most classification systems for intra-articular bothcolumn Fractures of the Distal Humerus have been pro-posed. In 1936, Reich first described T and Y inter-condylar Fractures (46). In 1969, Riseborough andRadin described 4 types of intercondylar T-type distalhumerus Fractures : Type 1 was a non-displaced fractu-re, Type 2 was displaced but without rotation of the frag-ments, Type 3 includes fragment rotation, and Type 4involved severe comminution (48). Although initiallyrelevant for its descriptive value, these classificationsproved inadequate in reliably describing the fracture anddirecting Treatment as these injuries were more frequ-ently being treated Orthopaedic Trauma Association s alpha-nume-ric system, based on The Comprehensive Classificationof Fractures of Long Bones, assigned three main types:Type A (extra-articular), Type B (partial articular), andType C (complete articular) (38).

9 Sub-types are giventhereafter for further fracture details. Although usefulfor cataloging Fractures for research purposes, the OTAsystem s clinical application is limited and is hinderedby poor inter-observer reliability beyond identificationof the basic three types (57).The classification system proposed by Jupiter andMehne describes Distal humeral fracture patterns ana-tomically based upon intra-operative findings yieldingsix categories: High or Low T, Y, H, and Medialor Lateral Lambda Fractures (22). Recently, isolated she-aring injuries of the Distal humeral articular surface havealso been described (47). This spectrum of injury pat-terns identified through operative and radiographic fin-dings yielded five fracture patterns: 1.

10 The capitellumand the lateral aspect of the trochlea, 2. the lateral epi-condyle, 3. the posterior aspect of the lateral epicondy-le, 4. the posterior aspect of the trochlea, and 5. the me-dial TREATMENTThe indication for non-operative Treatment of distalhumerus Fractures is limited and primarily involves pati-ents with very low demand or in poor health. The bagof bones technique can be successfully employed withabrief course of immobilization followed by gradualreturn to supervised motion. Functional results areacceptable as long as patient expectations are risk of fracture displacement, malunion, and non-union is high with non-operative TREATMENTDue to the characteristic intra-articular involvement,displacement, and poor control of fracture fragmentswith closed Treatment , we typically treat these fracturesoperatively.