Open Reduction and Internal Fixation of Supracondylar and Intercondylar Fractures



Open Reduction and Internal Fixation of Supracondylar and Intercondylar Fractures


Joaquin Sanchez-Sotelo



PATIENT HISTORY AND PHYSICAL FINDINGS



  • Distal humerus fractures occur in two age groups:



    • Younger patients who sustain high-energy trauma


    • Older patients with underlying osteopenia


  • Comminution is the dominant feature of supracondylar and intercondylar fractures and complicates internal fixation. The complicated skeletal geometry of the distal humerus also contributes.


  • The goals of the initial evaluation are to



    • Understand the fracture pattern


    • Determine the existence of previous symptomatic elbow pathology


    • Determine the extent of associated soft tissue (open fractures)


    • Identify associated musculoskeletal or neurovascular injuries


IMAGING AND OTHER DIAGNOSTIC STUDIES



  • Elbow radiographs in the anteroposterior and lateral planes are the first imaging studies obtained and should be carefully scrutinized to identify the fracture lines and fragments as well as the extent of comminution. It is also important to look for associated injuries in the proximal radius and ulna.



    • A complete understanding of the fracture pattern is difficult to obtain based only on simple radiographs because of the complex geometry of the distal humerus and fragment overlapping (FIG 1A,B).


  • Computed tomography (CT) with three-dimensional reconstruction is extremely helpful, especially in the more complex cases. It allows the surgeon to look for specific fractured fragments at the time of fixation, facilitating accurate fracture reduction (FIG 1C,D).






    FIG 1A,B. Anteroposterior (AP) and lateral radiographs showing a comminuted intra-articular supraintercondylar fracture of the distal humerus. The complexity of the fracture is difficult to appreciate fully because of the geometry of the distal humerus, fracture comminution, and fragment overlapping. C,D. The use of CT with three-dimensional reconstruction and surface rendering helps understand the fracture configuration and anticipate the surgical findings.


  • Traction radiographs obtained in the operating room with the patient under anesthesia just before surgery also can be helpful, especially if a CT scan is not available.


SURGICAL MANAGEMENT



  • Internal fixation is the treatment of choice for most fractures of the distal humerus.


  • Modern fixation techniques seem to benefit from the following:



    • Fixation strategies designed to improve the mechanical stability of the construct


    • Use of precontoured periarticular plates


    • Use of screws locked to the plates


  • Elbow arthroplasty should be considered in elderly patients with previous elbow pathology or in very low comminuted fractures in patients with osteopenia.12, 14 However, internal fixation can be successful even in low transcondylar fractures.18


  • The goal of the internal fixation technique is to achieve a construct stable enough to allow immediate unprotected motion without fear of redisplacement.15, 16 This can be attained in most distal humerus fractures—even the most complex—provided the following principles are adhered to the following (FIG 2):



    • Plates used for internal fixation are applied so that fixation in the distal fragments is maximized.







      FIG 2A. Internal fixation using two parallel medial and lateral plates allows maximal fixation of the plates in the distal fragments and increased stability at the supracondylar level. B. This postoperative AP radiograph shows anatomic reduction of a complex distal humerus fracture and stable fixation using the principles and technique described in this chapter. The olecranon osteotomy was fixed with a plate. (A: Copyright Mayo Clinic.)


    • Distal screw fixation contributes to stability at the supracondylar level, where true interfragmentary compression is achieved.


Approaches



  • Adequate exposure is necessary to achieve satisfactory reduction and fixation.


  • The management of the ulnar nerve is controversial; some surgeons favor routine subcutaneous transposition, whereas others prefer to leave the nerve in its anatomic location at the end of the procedure. A number of patients will develop a transitory or permanent ulnar neuropathy, mostly sensitive, regardless of nerve management; preoperative counseling is important in this regard.


  • Most fractures require mobilization of the extensor mechanism of the elbow through an olecranon osteotomy, triceps reflection, or triceps split.


  • Simple fractures occasionally may be addressed working on both sides of the triceps without mobilization of the extensor mechanism.


  • Olecranon osteotomy is the preferred surgical approach for internal fixation for most distal humerus fractures.13



    • Advantages



      • Provides excellent exposure


      • Offers the potential of bone-to-bone healing, thereby limiting the risk of triceps dysfunction


    • Disadvantages



      • Complications: nonunion, intra-articular adhesions


      • Hardware removal may be needed.


      • Limits the ability for intraoperative conversion to elbow arthroplasty


      • May devitalize the anconeus muscle


      • The proximal ulna cannot be used as a template to judge reduction and motion.


  • Triceps reflection and triceps split9 allow preservation of the intact ulna.



    • Avoid complications related to olecranon osteotomy.


    • Facilitate intraoperative conversion to total elbow arthroplasty.


    • Allow use of the proximal ulna as a template for reduction of the distal humerus articular surface.


    • Allow assessment of extension deficit after fracture fixation, which is especially useful in fractures requiring metaphyseal shortening.


  • Bilaterotricipital approach1



    • Goals and indications



      • The goal is to provide adequate exposure for fracture fixation without violating the extensor mechanism.


      • This approach is used only for the more simple fracture patterns (eg, extra-articular or simple intra-articular distal humerus fractures [AO/OTA A, C1, C2]) or when elbow arthroplasty is being considered.


    • Advantages



      • This approach avoids complications related to the extensor mechanism.


      • No postoperative protection is needed.


      • Surgical time is decreased.


    • Disadvantage



      • The procedure provides limited exposure of the articular surface.


Jul 22, 2016 | Posted by in ORTHOPEDIC | Comments Off on Open Reduction and Internal Fixation of Supracondylar and Intercondylar Fractures

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