its all about interarticular fractures of the distal humerus.

1. DISTAL HUMERUS FRACTURE
Presentor:Dr Balaji
VINAYAKA MISSION KIRUBANANDA
VARIYAR MEDICAL COLLEGE. SALEM

2. • The elbow joint is a hinge joint and consists of
three components.
– Humeroulnar articulation
– Humeroradial articulation and
– Radioulnar articulation.
• Humeroulnar articulation is responsible for
alignment, stability and strength.
• The other two joints help in forearm and hand
motion and position.

4. Distal humerus is a cylindrical diaphysis that
flattens above the elbow and diverges into
triangular medial and lateral columns.
Each column is bounded on its outer border
by supracondylar ridge and an outer non
articular surface and inner articular surface.

5. The articulating surface of the medial condyle
is called as trochlea
Similarly the articulation surface of the lateral
condyle is capitellum.
Anterior surface has two fossa the coronoid
and radial fossa
Posterior surface has olecranon fossa.

6. • The carrying angle: a line drawn from the long
axis of the arm and forearm forms an angle,
with elbow in extension and forearm in
supination.
• This is normal carrying in males is 7-9 degrees
and female it is 9-11 degree.

7. • Muscles common flexors (originate
from medial epicondyle)
– pronator teres
– flexor carpi radialis
– Palmaris longus
– Flexor Digitorum Superficialis
– Flexor Carpi Ulnaris

8. • common extensors (originate from lateral
epicondyle)
– anconeus
– Extensor carpi radialis longus
– Extensor carpi radialis brevis
– extensor digitorum comminus
– Extensor digiti minimi
– Extensor carpi ulnaris

9. • Ligaments medial collateral ligament
– anterior bundle originates from distal medial
epicondyle
– inserts on common extensor tendon
– primary restraint to valgus stress at the elbow
from 30 to 120 deg
– tight in pronation

10. • lateral collateral ligament
– originates from distal lateral epicondyle
– inserts on supinator crest on the ulna
– stabilizer against posterolateral rotational
instability
– taut in supination

11. • ROM:
• Flexion is about 0- 180*, it is restricted to
150* due the muscle bulk of the biceps.
• The majority of the daily living activites takes
place in the functional range of motion, from
40-120*.
• During assisted standing the joint force on the
elbow is maximum with forces reaching four
folds of that of body weight.

12. MECHANISM OF INJURY
• Most of the injuries are low energy with trivial
fall or domestic fall with elbow getting struck
directly or axially loaded in a fall with out
stretched hand.
• RTA

13. • Classifications:
• AO
• MILCH
• JUPITER

14. AO
• Type A: Extraarticular

15. • Type B: Intra-articular single column

16. • Type C: Intra-articular both column fracture

18. • MILCH CLASSIFICATION
• Milch type I:lateral trochlear ridge intact
• Milch type II: fracture through the lateral
trochlear ridge.

19. Milch classification

20. Milch classification

21. • Riseborough and Radin Classification.
• Type I: Nondisplaced.
• Type II: slight displacement with no rotation
between the condylar fragment in the frontal
plane
• Type III: Displacement with rotation.
• Type IV: Severe comminution of the articula
surface.

23. TREATMENT
X-ray
CT with 3D reconstruction.
Xray with AP and Lateral view(postivie fat pad
sign)

24. • Conservative management:
1. Cast or splint stabilization
2. Traction
3. Bag of bones technique.

25. • Cast or splint stabilization
• It can be used in minimal or non displaced
fractures.
• Disadvantage is that poor maintenance of
fractured fragments and lack of early
mobilization.

26. The bag of bone technique
• This technique involves placing the arm in a
collar and cuff with the elbow in marked
flexion.
• Elbow motion is initiated after the swelling
and pain subsides.
• Recommended for surgical unfit patients and
elderly whose functional goals are limited.

27. • Surgical intervention:
• Single column fracture(B1 and B2)
• Comprising 15% of all distal humerus fracture.
• Lateral column fractures addressed with
kocher approach
• Medial column fractures are apporached with
posterior triceps reflecting or transolecranon
approach.

28. • Bicolumn fractures
• Distal humerus are operated with olecranon
osteotomy, triceps-splitting or Triceps
Reflecting Anconeus Pedicle approach.
• Use of two orthogonal plates is the most
stable method of treating these fractures.
• 90-90* with medial and posterolateral
position.
• Medial and lateral position.

29. • Total elbow arthroplasty
• Semiconstrained hinge design is used to treat
unsalvageable nonunions.
• All the previous implants are removed and
arthroplasty is proceeded.
• External fixation with ring or hybrid ring
fixators.

30. SURGICAL APPROACH
POSTERIOR POSITION
• Lateral decubitus position also called as
swimmer’s position.
• Arm hanging over a post
• With tourniquet.

32. 1) Longitudinal midline skin incision
over the posterior aspect of the
elbow

33. • Beginning atleast
5cm proximal to
the tip of the
olecranon, curving
slightly laterally at
the tip, then
returning to the
midline and
extending 5 cm
distal to the tip of
the olecranon

34. • 2) Raising
subcutaneo
us flaps on
either side

35. • Isolation of the ulnar nerve.

36. Osteotomy Fixation
Single screw WITH TBW technique:
1) Expose the tip by sharp
dissection of soft tissues to see
the bone
2) Pre-drilling & tapping should
be done prior to osteotomy
3) cannulated cancellous screw
are used
4) A Tension band wiring done
before full tightening of the
screw

38. Osteotomy Fixation
Tension band technique
with K-wires:
• Easy to place
• May be less stable
than independent
lag screw or plate
• Implant irritation is
a problem

39. • Olecranon osteotomy.
• There are two types olecranon of two types
1. Transverse osteotomy
2. Chevron osteotomy.
• Soft tissue dissection is done to identify the
olecranon bone.

40. • A line of osteotomy is marked with the help of
a pen or cautery.

41. • Small, thin oscillating saw is used to cut about
95 % of the osteotomy along the previously
marked line.

42. • The osteotomy is completed using the
osteotome.

43. • The osteotomy fixation must be planned well
in advance.
• Osteotomy fixation can be done using
– Tension band wiring with k-wire fixation.
– Cancellous screw fixation

44. • Exposure of
the distal
humreus
especially the
intercondylar
area is
excellent after
an osteotomy.

45. • Osteotomy approach is best used to visualise
the distal humerus.
• Most suited for all type Communited fractures
• Disadvantages are
1. Nonunion at the osteotomy site
2. Hardware irritation

46. complications
• Early complications:
• Vascular injury
• Nerve injury
• Malunion
• Wound infection

47. • Delayed complications
• Heterotrophic ossification
• Elbow stiffness
• osteoarthritis