6: Open Reduction and Internal Fixation of Intra-Articular Fractures of the Distal Humerus

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PROCEDURE 6 Open Reduction and Internal Fixation of Intra-Articular Fractures of the Distal Humerus

Paul R.T. Kuzyk, Emil H. Schemitsch

Indications

Controversies

• Elderly patients with comminuted fractures may benefit from primary total elbow arthroplasty.

Displaced intra-articular distal humerus fractures

Examination/Imaging

Treatment Options

• Open reduction and internal fixation is the “gold standard” treatment for these intra-articular fractures.

• Total elbow arthroplasty may be considered for elderly, low-demand patients with comminuted fractures.

• Closed management consisting of 2 weeks of rigid splinting follwed by unrestricted range of motion in a hinge brace (i.e., “bag of bones” technique) may be effective for very elderly low-demand patients who have medical contraindications to surgery.

Clinical examination should include: inspection of the skin for any lacerations indicating an open fracture; evaluation of median, ulnar, and radial nerve function; and examination of the wrist and shoulder for any associated injuries.

Anteroposterior and lateral radiographs are required for preoperative planning. A traction radiograph of the elbow provides an excellent view of comminuted fractures; however, this is difficult to obtain as it is painful for the patient.

High-quality computed tomography scans with coronal and sagittal reformats may also be useful for planning reduction and internal fixation in comminuted fractures.

Surgical Anatomy

Muscular anatomy (Fig. 1A): medial head, lateral head, and long head of the triceps; triceps tendon, intermuscular septum, flexor carpi ulnaris, anconeus, and extensor carpi ulnaris

Neurologic anatomy (see Fig. 1A): radial nerve, ulnar nerve, and posterior antebrachial cutaneous nerve

Bony anatomy (Fig. 1B): medial and lateral epicondyles, trochlea, capitellum, olecranon fossa, and olecranon

FIGURE 1

Positioning

Equipment

• Axillary roll

• Sterile stockinette for the hand

• Sterile tourniquet

The patient may be placed in the lateral decubitus position with the operative side facing upward (Fig. 2A) or, alternatively, the patient may be placed in the prone position (Fig. 2B).

The operative arm is placed over a padded bolster so that the elbow may hang freely at an approximate angle of 90°.

FIGURE 2

Portals/Exposures

Triceps-splitting approach

• A midline skin incision is made extending along the subcutaneous border of the ulna, over the olecranon and proximally in the midline of the humerus (Fig. 3A). Generous subcutaneous dissection is performed both medially and laterally to expose both epicondyles.

• The ulnar nerve is identified over the posterior aspect of the medial epicondyle (see Fig. 3A). The nerve is released both proximally and distally and retracted with a vessel loop.

• The triceps tendon and muscle are split in the midline (dotted line in Fig. 3A). The radial nerve must be identified and protected if the triceps muscle split is extended proximal to the distal third of the humerus.

• Any traumatic defects in the triceps tendon should be incorporated into the triceps split. These traumatic defects are often encountered with open fractures as the bone tears through the triceps tendon before piercing the skin.

• The triceps tendon should be sharply dissected off the olecranon, preserving a continuous layer medially and laterally that can be easily repaired at the end of the procedure (Fig. 3B).

♦ The medial and lateral edges are retracted to expose the distal end of the humerus.

♦ A towel clip can be used to retract the olecranon posteriorly, allowing for better visualization of the fracture.

Triceps-sparing approach

• A midline skin incision is made similar to that used for the triceps-splitting approach and the ulnar nerve is released and retracted (see Fig. 3A).

• The ulnar nerve is followed proximally along its course over the intermuscular septum.

♦ The medial (ulnar) window is created by dissecting out the ulnar nerve and mobilizing the medial head of the triceps laterally to expose the humerus (Fig. 4A).

♦ The ulnar window provides some exposure of the medial humerus that may be adequate for simple fracture patterns.

• Greater exposure of the lateral side of the humerus is obtained by creating a lateral window.

♦ The lateral window is created by mobilizing the lateral head of the triceps off the lateral intermuscular septum toward the ulnar side (Fig. 4B).

♦ Distally, the anconeus muscle is detached from the radius to allow for greater exposure.

Olecranon osteotomy approach

• A midline skin incision is made similar to that used for the triceps-splitting approach and the ulnar nerve is released and retracted (Fig. 5).

• A hole maybe predrilled through the olecranon to allow for anatomic reattachment of the olecranon at the end of the operation. This hole is made with a 3.2-mm drill bit for fixation with a 6.5-mm cancellous screw (Fig. 6A).

♦ Alternatively, two 1.5-mm Kirschner wires (K-wires) may be used to predrill holes through the olecranon and anterior cortex of the ulna, then removed prior to performing the osteotomy (Fig. 6B). This is useful if if the osteotomy is to be fixed using a tension band technique.

• The osteotomy should be made through the nonarticular portion of the olecranon, which is located between the olecranon articular facet and the coronoid articular facet (the bare area).

♦ Subperiosteal dissection along the medial and lateral sides of the olecranon allows the surgeon to view the ulnohumeral joint and locate the bare area. An apex distal chevron osteotomy is then marked on the olecranon (see Fig. 6A).

♦ An oscillating saw is used to cut two thirds of the way through the olecranon. An osteotome should be used to complete the osteotomy through to the articular surface.

♦ The triceps is released off the posterior aspect of the humerus and retracted with the distal portion of the olecranon to expose the distal humerus (Fig. 7).

FIGURE 3

FIGURE 4

FIGURE 5

FIGURE 6

FIGURE 7

PEARLS

• The olecranon osteotomy approach provides the best exposure of the articular surface of the distal humerus. Approximately 52% of the articular surface may be seen through the olecranon osteotomy approach. The triceps-splitting approach provides exposure of 37% of the articular surface, and the triceps-sparing approach provides exposure of 26% of the articular surface.

• Choice of approach to the distal humerus is determined by the type of distal humerus fracture. Simple articular fractures (AO type C1 and C2) may be addressed through the triceps-sparing approach. More complex articular fractures (AO type C3) require a triceps-splitting or olecranon osteotomy approach.

Controversies

• The most common complication associated with olecranon osteotomy is prominent hardware that requires a second procedure for removal. Nonunion of the osteotomy has also been reported; however, this is an uncommon complication. Some surgeons suggest plate fixation of the osteotomy as this reduces the chance of nonunion.

Procedure

PEARLS

• Obtain anatomic reduction of the trochlear groove.

PITFALLS

• Do not use lag screws if there is significant comminution of the articular surface. Over-reduction of the trochlear groove will lead to incongruity of the ulnohumeral articulation.

Instrumentation/Implantation

• Small fragment set with reduction forceps and K-wires.

STEP 1

Once the distal humerus has been appropriately exposed, the elbow should be flexed greater than 140° to provide greater access to the distal humerus.

The fracture fragments should be identified and cleaned of hematoma or intervening soft tissues.

Reduction should begin with restoration of the articular surface (Fig. 8A).

• Restoration of the normal anatomic alignment of the trochlea is most important.

• Congruency of the ulnohumeral articulation is required for normal range of motion and stability of the elbow. Care should be taken not to over compress the trochlear notch and thereby cause incongruency of the ulnohumeral joint.

The reduction of the articular surface should be held provisionally with pointed reduction forceps and K-wires (Fig. 8B). Several 4.0-mm cancellous screws may then be used to rigidly stabilize the articular surface. The surgeon must take care to ensure that these screws do not enter the olecranon fossa or protrude through the articular surface and into the joint.

FIGURE 8

STEP 2

PEARLS

• Two rigid plates are required for any bicondylar distal humerus fracture to provide adequate stability for early postoperative range of motion.

Instrumentation/Implantation

• Small fragment set

• 3.5-mm periarticular distal humerus plates or 3.5-mm reconstruction plates

• K-wires

After reduction of the articular surface, the nonarticular supracondylar component of the fracture is reduced and the articular surface is provisionally fixed to the humeral shaft using K-wires (Fig. 9A).

Rigid fixation of the fracture using two plates (one on each column) is mandatory (Fig. 9B). Either precontoured 3.5-mm periarticular distal humerus plates or 3.5-mm reconstruction plates may be used to provide rigid fixation.

Biomechanical studies suggest that plates may be placed either parallel (i.e., one plate medial and one plate lateral) or perpendicular (i.e., one plate medial and one plate posterolateral) to provide rigid constructs.

FIGURE 9

STEP 3

Controversies

• Arrangement of the plates to provide greatest biomechanical stability is a matter of ongoing debate. Parallel plate (medial and lateral side of the humerus) and perpendicular plate (medial and posterolateral humerus) configurations seem to provide greatest stability.

PITFALLS

• Good visualization of the olecranon fossa is required prior to closure to ensure there are no screws within the fossa which may block extension.

Prior to closure, the elbow should be taken through a range of motion (flexion, extension, pronation, and supination) to ensure the elbow is stable and that there are no blocks to motion. The reduction and the position of the hardware should be checked using fluoroscopy.

If a triceps-splitting approach was used, care must be taken to ensure the triceps tendon is appropriately repaired.

• After repair of the distal humerus fracture, drill holes are placed in the olecranon to allow for repair of the triceps tendon (Fig. 10A).

• Heavy nonabsorbable suture is used to repair the triceps tendon (Fig. 10B). Interrupted sutures are placed through the drill holes in the olecranon.

If an olecranon osteotomy was used, this must be rigidly fixed. There are three reported methods for fixation of an olecranon osteotomy:

• One 6.5-mm cancellous screw and a tension band wire (Fig. 11A)

• Two 1.5-mm K-wires with a tension band wire (Fig. 11B)

• A 3.5-mm reconstruction plate contoured to fit the olecranon (Fig. 11C)

Subcutaneous transposition of the ulnar nerve may be considered if the nerve is under tension or directly overlying the plate.

FIGURE 10

FIGURE 11

Evidence

Coles CP, Barei DP, Nork SE, Taitsman LA, Hanel DP, Bradford Henley M. The olecranon osteotomy: a six-year experience in the treatment of intraarticular fractures of the distal humerus. J Orthop Trauma. 2006;20:164-171.

In this case series of 67 patients with intra-articular distal humerus fractures treated with olecranon osteotomies, no nonunions were encountered, 3% required revision of osteotomy fixation due to malreduction, and 8% required removal of osteotomy fixation due to prominent hardware. The authors concluded that olecranon osteotomy can be useful in the visualization of complex articular injuries, allowing accurate articular reduction. (Grade C recommendation; Level IV evidence).

Dakouré PW, Ndiaye A, Ndoye JM, Sané AD, Niane MM, Séye SI, Dia A. Posterior surgical approaches to the elbow: a simple method of comparison of the articular exposure. Surg Radiol Anat. 2007;29:671-674.

This cadaveric study examined the amount of articular surfaced exposed by three different posterior approaches to the elbow. The median exposed articular surface for the triceps-sparing approach, the triceps-splitting approach, and the olecranon osteotomy was 26%, 37%, and 52%, respectively..

Doornberg JN, van Duijn PJ, Linzel D, Ring DC, Zurakowski D, Marti RK, Kloen P. Surgical treatment of intra-articular fractures of the distal part of the humerus: functional outcome after twelve to thirty years. J Bone Joint Surg [Am]. 2007;89:1524-1532.

In this case series, 39 patients were evaluated at a mean follow-up of 19 years (range, 12–30 years). The authors found that long-term results of open reduction and internal fixation of intra-articular distal humerus fractures were similar to those reported in the short term (70% good to excellent results), suggesting that the results are durable. They found that functional ratings and perceived disability were predicated more on pain than on functional impairment and did not correlate with radiographic signs of arthrosis. Approximately 40% of patients required a repeat operative intervention. (Level IV evidence).

Hewins EA, Gofton WT, Dubberly J, MacDermid JC, Faber KJ, King GJ. Plate fixation of olecranon osteotomies. J Orthop Trauma. 2007;21:58-62.

In this case series of 17 patients with intra-articular distal humerus fractures that were treated with an olecranon osteotomy fixed with a 3.5-mm reconstruction plate, there were two reoperations related to the osteotomy. The authors concluded that plate fixation of an olecranon osteotomy provides a construct with predictable healing and few complications. (Grade C recommendation; Level IV evidence).

McKee MD, Kim J, Kebaish K, Stephen DJ, Kreder HJ, Schemitsch EH. Functional outcome after open supracondylar fractures of the humerus: the effect of the surgical approach. J Bone Joint Surg [Br]. 2000;82:646-651.

This retrospective comparative study evaluated functional outcome of 26 open distal humerus fractures (13 treated using a triceps-splitting approach and 13 treated using an olecranon osteotomy). The authors concluded that immediate open reduction and internal fixation of open intra-articular fractures of the distal humerus is a safe and effective technique with a low rate of complications and good limb-specific outcome. Patients whose fractures were fixed by a triceps-splitting approach, incorporating any traumatic defects in the triceps into the approach, had improved limb-specific and pain scores compared with those who had an olecranon osteotomy. (Grade B recommendation; Level III evidence).

McKee MD, Veillette CJ, Hall JA, Schemitsch EH, Wild LM, McCormack R, Perey B, Goetz T, Zomar M, Moon K, Mandel S, Petit S, Guy P, Leung I. A multicenter, prospective, randomized, controlled trial of open reduction—internal fixation versus total elbow arthroplasty for displaced intra-articular distal humeral fractures in elderly patients. J Shoulder Elbow Surg. 2009;18:3-12.

This study found that total elbow arthroplasty for the treatment of comminuted intra-articular distal humerus fractures in elderly patients (age > 65 years) resulted in more predictable and improved 2-year functional outcomes compared with open reduction and internal fixation. (Grade A recommendation; Level I evidence).

McKee MD, Wilson TL, Winston L, Schemitsch EH, Richards RR. Functional outcome following surgical treatment of intra-articular distal humeral fractures through a posterior approach. J Bone Joint Surg [Am]. 2000;82:1701-1707.

This study provided evidence that open reduction with internal fixation of intra-articular distal humerus fractures is an effective procedure that reliably maintains general health status as measured by patient-based questionnaires. There was a significant decrease in the elbow range of motion and muscle strength of these patients as compared to the contralateral elbow at the time of final follow-up (mean 37-month follow-up), indicating that intra-articular distal humerus fractures are severe injuries with long-term sequelae. (Grade C recommendation; Level IV evidence).

Figures 1, 5, 6, and 7 modified from Hoppenfeld S, deBoer P. Surgical Exposures in Orthopaedics: The Anatomic Approach. 3rd ed. Philadelphia: Lippincott Williams and Wilkins, 2003. Figures 2, 4, and 11B modified from AO Surgery Reference Online (www.aofoundation.org). Figures 3 and 10 modified from McKee MD, Kim J, Kebaish K, Stephen DJ, Kreder HJ, Schemitsch EH. Functional outcome after open supracondylar fractures of the humerus: the effect of the surgical approach. J Bone Joint Surg [Br]. 2000;82:646–51. Figures 8 and 9 modified from Jupiter JB, Neff U, Holzach P, Allgöwer M. Intercondylar fractures of the humerus. An operative approach. J Bone Joint Surg [Am]. 1985;67:226–39.