Distal Humeral fractures
Fractures of the distal humerus
account for 2% of all fractures and one-third of those at the elbow.
For diaphyseal fractures of the
distal third of the humerus
(see humeral shaft fractures)
Fractures of the distal humerus may
be divided descriptively into:
Distal third of humerus (see humeral
Supracondylar (High and low supracondylar;
flexion and extension)
Intercodylar (Intra articular)
Riseborough and Radin
Described a series of intercondylar
T-fractures and divided them into four types reflecting severity as follows:
Type I. No displacement
Type II. The trochlear and
capitellar fragments are separated but not appreciably rotated.
Type III. As for type II but the
fragments are also significantly rotated.
Type IV. Severe comminution of the articular surface and wide separation of the humeral
Humerus = 1
Distal segment = 3
Type A. Extra-articular fractures.
Type B. Partial articular fractures;
these maintain some continuity between the shaft and the articular surface.
Type C. Complete articular fractures.
These are then further subdivided
subdivided into groups 1, 2 and 3 on the basis of the location of the line of
the fracture and the amount of fragmentation.
They in turn are further subdivided
into subgroups •1, •2 and •3 by specific further qualifications.
( click on image for larger version)
Jupiter and Mehne
Three basic categories:
Grade I. Intra-articular fractures
Grade II. Extra-articular,
Grade III. Extracapsular fractures.
Intra articular fractures are subdivided into: single column; bicolumnar; capitellar; trochlear.
Grade I Intra-articular (Bi-column
and single column)
Bi - column
1. High T intercondylar
2. Low T intercondylar
3. Y intercondylar
4. H intercondylar
5. Lambda pattern (lateral)
6. Lambda pattern (medial)
||1. Low medial
2. High medial
3. Low lateral
4. High lateral
Grade II Extra-articular - intracapsular
||1. High transcolumn 1a. extension, 1b. flexion
transcolumn 2a extension, 2b flexion
Grade III Extra-capsular
||1. Medial epicondyle
2. Lateral epicondyle
It can sometimes be difficult to classify on initial radiographs, radiographs in traction
MUA and K-WIRE
for undisplaced fractures.
In elderly patients with osteopoenia
and displaced fractures, careful decision making is required on non operative
and operative intervention ORIF or Arthroplasty.
MUA and K wiring is
not a good
solution for fractures around the elbow in adults.
Percutaneous screw fixation is
possible for relatively stable single column fractures, Absorbable PDS pins and
headless screws can be used for capitellar fractures.
ORIF requires considerable expertise
and appropriate implants
Arthroplasty is indicated in
multifragmentary fractures not reconstructible or in osteopoenic bone where the
implant is not likely to hold till the fracture has healed.
External fixation may be used
temporarily for severely contaminated open wounds.
surgical approaches to the elbow
Extraarticular fractures a triceps
splitting approach is best, a paratricipital approach is possible.
Intra articular fractures require an
anatomical reduction and rigid fixation.
Approaches include Olecranon
osteotomy OR a triceps reflecting procedure, each have their own pro's and cons.
For Olecranon osteotomies an
intraarticular chevron osteotomy is best to achieve stable fixation,
intraarticular transverse osteotomies and extraarticular oblique osteotomies
have a higher risk of non-union. (See
Several methods of triceps reflection
have been described
Campbell's Posterior Approach - Triceps aponeurosis and deep medial
head, midline split. Gschwend modified
this by elevating osteoperiosteal flaps.
Campbell triceps tongue - A tongue of
triceps aponeurosis, left attached to the olecranon, is elevated with division
of the deep head in the midline. Only indicated if patient has significant FFD
requiring V-Y lengthening of triceps.
Alonso-Llames Approach - "bilaterotricipital
approach", triceps is approached from medial and lateral aspects and elevated from each intermuscular septum.
It allows for easy conversion to olecranon osteotomy if further exposure is
Bryan and Morrey Approach - Incision along medial aspect of the triceps,
distally through the posterior bundle of the medial collateral ligament and
joint capsule and then obliquely across the fascia over flexor carpi ulnaris,
crossing the subcutaneous border of the ulna to the extensor carpi ulnaris,
where it ends. This mandates anterior ulna nerve transposition. The triceps and
fascia are elevated as one flap from medial to lateral. Variations include
elevation of osteoperiosteal flap to avoid button holing thin fascia.
Excise the tip of the olecranon to improve joint surface visualisation. Reflect
the anterior medial collateral ligament by sharp
dissection from the humerus, dislocate the elbow, providing
exposure for a linked total elbow arthroplasty if needed.
Boyd Approach - Elevate the muscles on the lateral side of the ulna sub
periosteally off the ulna. Retract anconeus and
supinator to expose the joint capsule overlying the radial head and neck. This
lateral capsule contains the lateral ligamentous complex and its division can
lead to posterolateral rotatory instability.
Stanley posterior approach
triceps tendon, with 75% of muscle lateral and 25% medial, continued distally to split the
superficial fascia of the forearm for 6 or 7 cm. The
medial triceps, with the superficial fascia of the forearm
and the periosteum over the medial aspect of the olecranon, is then reflected
medially as a single unit. Reflect subperiosteally, deep to the ulnar nerve and over
the tip of the medial epicondyle, then reflect the lateral 75% of the
triceps from the tip of the olecranon.
Principles of internal fixation
Two philosophies exist:
J. R. Williams, A. M. Wainwright, and
A. J. Carr; Interobserver and intraobserver variation in classification systems
for fractures of the distal humerus; JBJS - Br, Jul 2000; 82-B: 636.
Patterson, Stuart D. MBChB +; Bain,
Gregory I. MBBS **; Mehta, Janak A. MS; Surgical Approaches to the Elbow.
Clinical Orthopaedics & Related Research. (370):19-33, January 2000.
G.I. Bain, N. Ashwood, R. Baird, and R. Unni
Management of Mason Type-III Radial Head Fractures with a Titanium Prosthesis,
Ligament Repair, and Early Mobilization
J Bone Joint Surg Am. 2005;87(Supp 1):136-147
S. A. Shahane and D. Stanley;
A posterior approach to the elbow joint;
J Bone Joint Surg Br, Nov 1999; 81-B: 1020
Anglen J.; Distal humerus fractures.;
J Am Acad Orthop Surg. 2005 Sep;13(5):291-7. Review.
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