Distal Humeral Fractures

CHAPTER 10
Distal Humeral Fractures

Brian J. Hartigan

Indications

1. Intra-articular fracture

2. Unstable nonarticular fracture

3. Associated vascular injury requiring repair

Contraindications

1. Open fracture with contaminated wound

2. Inadequate soft tissue coverage

3. High-operative risk (relative)

4. Severe osteoporosis or comminution (relative)

Preoperative Preparation

1. Evaluate patient for other injuries.

2. Assess for open wounds.

3. Document complete neurologic and vascular examination.

a. If vascular compromise, perform closed reduction and reassess. If continued vascular compromise, plan for operative exploration and vascular repair/bypass in addition to skeletal stabilization.

4. Obtain adequate radiographs.

a. AP and lateral of elbow

b. Consider AP and lateral with longitudinal traction.

c. Consider radiographs of contralateral extremity for preoperative planning purposes.

d. Consider CT scan, especially for intra-articular comminuted fractures.

5. Splint elbow at 90 degrees flexion and ice/elevate until definitive operative fixation.

6. Understand normal elbow anatomy (Fig. 10–1)

a. Lateral column diverges approximately 20 degrees from sagittal axis and projects 30 to 40 degrees anteriorly, ending at the capitellar articular surface (Fig. 10–1D).

b. Medial column diverges approximately 45 degrees from sagittal axis and projects 10 to 20 degrees anteriorly, ending proximal to the trochlea (Fig. 10–1C).

c. Olecranon fossa and coronoid fossa lie between lateral and medial columns and proximal to the trochlea.

d. Trochlea internally rotated 3 to 8 degrees and has valgus inclination of 94 to 98 degrees (Figs. 10–1A and 1B).

e. Diameter of trochlear sulcus is much smaller than that of the medial trochlear ridge and the lateral condyle.

7. Create operative plan for exposure, reduction and fixation.

8. Consider the need for bone graft.

Figure 10–1 (A) Normal elbow anatomy. Trochlea has valgus inclination of 94 to 98 degrees. (B) Normal elbow anatomy.Trochlea internally rotated 3 to 8 degrees. (C) Normal elbow anatomy. Medial column projects 10 to 20 degrees anteriorly, ending proximal to the trochlea. (D) Normal elbow anatomy. Lateral column projects 30 to 40 degrees anteriorly, ending at the capitellar articular surface

Figure 10–2 Patient position. The patient is placed in a prone position with the arm on a short armboard and the elbow flexed.

Figure 10–3 Skin incision. A longitudinal incision is made on the posterior aspect of the elbow. It begins 10 to 12 cm proximal to the tip of the olecranon, in the midline of the posterior aspect of the arm. The incision curves around the lateral side of the olecranon, and extends into the forearm just lateral to the subcutaneous border of the ulna.

Figure 10–4 Olecranon osteotomy. The tip of the olecranon and the attached triceps tendon are reflected proximally to visualize the distal humerus.

Figure 10–5 Reconstruction plates.The medial and lateral columns are fixed to the humeral shaft using medial and posterolateral reconstruction plates.