Distal humeral fracture in Adults

นพ.อิสสรา ธรา, นพ. ศรัณย์ ตันติ์ทวิสุทธิ์

Classification

ota-ao

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 

ota-ao2

                                   

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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