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Distal humeral fracture in Adults

นพ.อิสสรา ธรา, นพ. ศรัณย์ ตันติ์ทวิสุทธิ์

Classification

Presentation (Hx + PE) 

-    26% incomplete ulnar neuropathy [C3]
-    Soft tissue injuries around elbow , Close vs. Open , Vascular examination

Imaging and investigation : Rockwood and Green 7th edition

•     AP/Lateral film
•     Traction view (under GA + C-arm fluoroscopy) : Pre op. planninig
•     CT Scan :  Intra articular involvement / Shear type fracture [B3] / Elderly with highly comminution

    Treatment : Rockwood and Green 7th edition

•     Treatment principle
• •     Anatomic articular reduction
  •     Stable internal fixation of the articular surface
  •     Restoration of articular axial alignment
  •     Stable internal fixation of the articular segment to the metaphysis and diaphysis
  •     Early ROM of the elbow
•     AAOS : Instructional Course Lectures 2013 
  

xRs = radiographs, OR = operating room, 3DCT = 3 Dimensions CT, RA = Rheumatoid arthritis, ROM = range of motion and ExFix= external fixation

•   Nonoperative

• •     Indication : Completely  un-displaced fractures / Unable to tolerate anesthesia
  •     Immobilization of the elbow in 60 degree flexion 2-3 week
  •     Followed by gentle range-of-motion exercises

•   Operative

• • Indication : Displaced/Intra-articular fracture

Operative consideration :  
    Timing of Surgery : within 48-72 hours
    Surgical approach :  Postieror/Medial/Lateral/Anterior
    Posterior     

•     Olecranon osteotomy :
•     indication : Type B,C
•     Contraindication : Possible of TEA
•     Disadventage : Osteotomy complications
•     Paratricipital
•     Indication : Extra-articular , Simple articular [C1/C2]
•     Contraindication : Cominuted intra-articular fracture
•     Triceps splitting / Triceps reflecting / TRAP : To avoid Osteotomy complications
•     ORIF / TEA
•     Disadventage : Triceps insufficiency

Medial  : Medial column fracture, Trochlear fracture, MCL tears
    Lateral : B3 fracture
Anterior : Rarely used , use to repair brachial a. / median n.
    Fixation principle
    Anatomic articular surface
    Stable fixation

•     2 strong plates :  3.5 mm at a minimum
•     One-third tubular [option/additional plate]

    Early ROM
    Rehab : Early ROM

•     Complicaitons : Rockwood and Green 7th edition
•     Ulnar neuropathy : 26% in type C3 ,  if pre-op. ulnar n. symptom --> anterior transposition
•     Heterotopic ossification : prophylaxis with indomethacin or RT --> controversy
•     Nonunion : 6% : low fracture type , mark comminution , severe osteopenia

• •     Infection screening
  •     Treatment option : Revised fixation , TEA , Arthrodesis ,Resection arthroplasty
•     Elbow stiffness : PM&R , Static progressive splinting  surgical release
•    Wound complication : ATB +/- Surgical debridement
•    Olecranon osteotomy complication : Non-delay union 10%  R/O infection , Revision plate ORIF with BG , Excision with Triceps advancement  

References

•     Rockwood and Green 7th edition
•     Campbell 12th edition
•     AAOS : Instructional Course Lectures 2013
•     Aaron Nauth, MD McKee, MD J Bone Joint Surg Am. 2011;93:686-700

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