Case

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  Type 13-C1 fracture, stabilized with lag screws and reconstruction plate

Introduction

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  The Müller AO/OTA Classification divides distal humeral fractures into three groups:

  
  
  
  
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    type 13-A: extraarticular fractures of the distal humeral metaphysis

    
    
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    type 13-B: partial articular fractures of the distal humerus

    
    
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    type 13-C: complete articular fractures of the distal humerus

  
  
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  Fractures of the distal humerus occur in all age groups, but tend to have a bimodal incidence occurring in high-velocity injuries in young adults, usually males; and in relatively osteoporotic bone with low-velocity injuries, usually in elderly women.

  
  
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  Isolated, undisplaced fractures of the distal humerus can be treated nonoperatively with splintage and carefully supervised mobilization.

  
  
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  Extraarticular fractures of the distal humerus are common in pediatric patients, but are not covered in this chapter.

  
  
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  Complete articular fractures of the distal humerus are relatively uncommon and are surgically challenging fractures.

  
  
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  Surgery is always indicated unless the patient is not fit enough for anesthesia.

  
  
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  The surface anatomy of the distal humerus is complex, can be difficult to reconstruct, and always requires a good view of the joint surface.

  
  
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  The fractures have a short distal or “joint block” segment which requires anatomical reconstruction. This block has to be accurately and firmly fixed to the humeral shaft with plates to allow early mobilization of the elbow.

  
  
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  Detailed planning of distal humeral fracture reconstruction is mandatory.

  
  
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  The most common exposure is through a posterior approach mobilizing the distal triceps. This may be combined with an olecranon osteotomy (usually chevron shaped) of the proximal part of the olecranon and its triceps attachment. The olecranon requires fixation back in place at the end of the procedure.

  
  
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  The key to accurate surgical reconstruction is using K-wires to provide provisional reduction and stabilization of the joint segment, then alignment of this segment with the rest of the humerus. Details of the K-wire placement forms part of the surgical tactic.

Müller AO/OTA Classification—distal humerus

3.5.1 Intraarticular distal humeral fracture (13–C2): stabilization with 4.0 mm cancellous bone screws and two reconstruction plates 3.5

Surgical management

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  Stabilization with:

  
  
  
  
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    4.0 mm cancellous bone screws as lag screws

    
    
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    Two reconstruction plates 3.5

Alternative implants

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  LCP reconstruction plates 3.5

  
  
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  Distal humeral contoured locking plates 3.5/2.7

1 Introduction

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  There is debate about the exact placement of plates when fixing these fractures. A posterior plate on the lateral side combined with a medial plate at 90° is described. A combined posteromedial and posterolateral plate configuration is used by some surgeons.

  
  
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  The use of a locked screw fixation and precontoured implants are both techniques that improve mechanical support. These options are described.

  
  
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  Occasionally bone grafting is necessary and should be considered before preparation of the patient to allow draping of the donor site, if required.

  
  
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  Nonunion of these fractures is rare and usually occurs early because of inadequate mechanical support from the implants selected.

  
  
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  Caution the patient that even with excellent anatomical reduction, some loss of motion can be expected.

2 Preoperative preparation

Operating room personnel (ORP) need to know and confirm:

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  Site and side of fracture

  
  
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  Type of operation planned

  
  
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  Ensure that operative site has been marked by the surgeon

  
  
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  Condition of the soft tissues (fracture open or closed)

  
  
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  Implants to be used (care: different plates may be used)

  
  
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  Patient positioning

  
  
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  Details of the patient (including a signed consent form and appropriate antibiotic and thromboprophylaxis)

  
  
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  Comorbidities, including allergies

Instrumentation required:

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  Small fragment instrument and screw set 3.5 mm

  
  
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  Reconstruction plate 3.5 set

  
  
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  Bending tools

  
  
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  Tension band wiring set

  
  
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  K-wire selection 1.4–2.0 mm

  
  
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  Bone graft set

  
  
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  Vessel loops

  
  
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  General orthopaedic instruments

  
  
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  Compatible air or battery drill with attachments

  
  
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  Oscillating saw for olecranon osteotomy

Equipment required:

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  Radiolucent operating table

  
  
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  Positioning accessories to assist with prone or lateral position of the patient

  
  
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  Image intensifier

  
  
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  X-ray protection devices for personnel and patient

  
  
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  Tourniquet (optional)

3 Anesthesia

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  This procedure is performed with the patient under general anesthesia.

  
  
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  While technically possible, regional anesthesia is not advised as the procedure can be prolonged.

4 Patient and x-ray positioning

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  With the patient anesthetized, positioning should allow the arm and the elbow free to be straightened and bent to at least a right angle.

  
  
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  This can be achieved either with the patient prone or in the lateral position.

Prone position

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  Place the patient prone as far toward the same side of the table as possible.

  
  
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  Position the arm over a bolster or custom-made support with appropriate padding so that the elbow movement is free (Fig 3.5-2a).

  
  
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  Secure the patient’s body with padded side supports.

  
  
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  Ensure that the shoulder is not too extended so there is no tension on the brachial plexus.

Lateral position

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  Secure the patient’s body with padded side supports (Fig 3.5-2b).

  
  
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  Abduct the operated arm across the body with the shoulder at 90°, and over a custom-made support or bolster with appropriate padding (Fig 3.5-2c).

  
  
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  To allow adequate access for imaging, position the patient as far as possible toward the side of the table from which the arm will be accessed.

  
  
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  Always ensure the anesthetist is satisfied with the position and support of the patient’s face and has adequate access to the airway at all times.

  
  
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  Take great care with the soft tissue and skin pressure points, particularly in the elderly.

  
  
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  Autogenous bone grafting is a possibility and access to an iliac crest or to another bone graft harvest site will be required.

  
  
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  Imaging can be performed with plain films or with the use of the image intensifier. Plain films are more appropriate if it is difficult to obtain adequate access with the image intensifier.

  
  
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  Ensure there is adequate access for imaging before disinfecting and draping.

  
  
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  If a tourniquet (sterile or nonsterile) is to be used, make sure the cuff is narrow enough that it will not encroach on the surgical field required for exposure.