Anatomy of elbow and INTERCONDYLAR FRACTURE OF THE HUMERUS

1. ANATOMY OF ELBOW
- Vinaykumar .S. Appannavar

2. • Elbow joint is a hinge type of joint, formed by the
articulation between the lower end of the humerus with
ulna, and with the head of the radius
• Humeroulnar articulation
• Humeroradial articulation and
• Radioulnar articulation
• The lower end of the humerus is enlarged to form the
trochlea medially and capitulum laterally
• Medial to the trochlea is medial epicondyle and lateral to the
capitulum is the lateral epicondyle

3. • The two epicondyles are continuation of the medial and
lateral supracondylar ridges respectively
• Humeroulnar articulation is responsible for alignment,
stability and strength.
• The other two joints help in forearm and hand motion and
position.

5. • Three bony points relationship :

6. • Carrying angle :

7. • Stability of the elbow :

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

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

12. INTERCONDYLAR FRACTURE
OF THE HUMERUS

13. • It is a common fracture in adults
• It results from a fall on the point of the elbow so the
olecranon is driven into the distal humerus, splitting the two
humeral condyles apart

14. • Mechanism of injury:
•
Is by a force directed towards an
elbow which is flexed > 90° which
causes the ulna to drive against
the trochlea
• The fracture pattern may be
related to the position of elbow
flexion when the load is applied

15. • Riseborough and Radin Classification
• Type I: Nondisplaced
• Type II: Slight displacement with no rotation between the
condylar fragment.
• Type III: Displacement with rotation
• Type IV: Severe comminution of the articular surface

17. 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

18. • Radiographic exam
• Anterior-posterior and lateral radiographs
• Traction views may be helpful to evaluate intra-articular
extension and for pre-operative planning (creates a partial
reduction via ligamentotaxis)
•Traction removes overlap
• CT scan helpful in selected cases
• Comminuted capitellum or trochlea
• Orientation of CT cut planes can be confusing

19. Pathoanatomy
• The fracture line may take the shape of a T or Y. The fracture is
generally badly comminuted and displaced.
• Classification of Mehne and Matta:
1. High T.
2. Low T
3. Y-type
4. H-type.
5. Medial.
6. Lateral
• The Mehne and Matta classification describes the most often
encountered fracture patterns intraoperatively.

21. •Clinical Features:
1. The elbow maybe held in 90° flexion and forearm is kept
pronated
2. Crepitus may be elicited
3. Independent mobility of the medial and lateral condyle can
be elicited
4. The normal 3 point bony relationship between the
olecranon, medial epicondyle and lateral epicondyle is lost

22. Diagnosis :
• There is generally severe pain, swelling, ecchymosis and crepitus
around the elbow
• X-Rays:
Standard AP and lateral views are obtained
CT scan is helpful to further delineate the fracture pattern

23. Treatment :
• It depends upon the displacement. An undisplaced fracture needs
support in an above – elbow plaster slab for 3-4 weeks, followed by
exercises
• A displaced fracture is treated generally by open reduction and
internal fixation
• Operative Treatment
• Open reduction and internal fixation:
• Restores articular congruity
• Interfragmentary screws and dual-plate fixation: One plate is placed
medially and another plate posterolaterally. Reconstruction plate and
one-third plate are used commonly.
• Total elbow arthroplasty (semi constrained): May be considered in
markedly comminuted fractures and in fractures with osteoporotic
bone.

26. Outcomes
• Most daily activities can be accomplished with the following
final motion arcs:
• 30 –130 degrees extension-flexion
• 50 – 50 degrees pronation-supination
• Outcomes based on pain and function
• Patients not necessarily satisfied with above motion arcs

27. • Good elbow flexion is often the first to return
• Extension seems to progress more slowly
• Supination/pronation usually unaffected
• Pain- 25 % of patients describe exertional pain
• What patients may expect, for example:
• Lose 10-25 degs of flexion and extension
• Maintain full supination and pronation
• Decrease in muscle strength
• Overall:
• Good/excellent 75%
• Factors most likely to affect outcome
• Severity of injury
• Occurrence of a complication

28. Complications
• Failure of fixation
• Associated with stability of operative fixation
• K-wire fixation alone is inadequate
• Adult distal humerus is much different from pediatric distal humerus
• If diagnosed early, revision fixation indicated
• Late fixation failure must be tailored to radiographic healing and
patient symptoms
• Nonunion of distal humerus
• Uncommon
• Usually a failure of fixation
• Symptomatic treatment
• Bone graft with revision plating

29. •Non-union of olecranon osteotomy
• Rates as high as 5% or more
• Chevron osteotomy has a lower rate
• Treated with bone graft occasionally and
revision fixation
• Excision of proximal fragment is salvage
• 50% of olecranon must remain for joint stability
•Infection
• Range 0-6%
• Highest for open fractures
• No style of fixation has a higher rate than any
other

30. •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 (although routine transposition
is of unknown importance)

31. •Painful implants
• The most common complaint
• Common location
• Olecranon
• Medial implants (over medial epicondyle)
• Lateral implants (some plates prominent over posterior-lateral
aspect of lateral condyle)
• Implant removal
• After fracture union
• Patient may need to restrict activity for 6-12 weeks

32. THANK YOU