T-Intercondylar Distal Humerus Fracture



T-Intercondylar Distal Humerus Fracture


Carley Vuillermin, MBBS, MPH, FRACS







Patient Positioning: Supine, Lateral Decubitus, or Prone



  • Lateral decubitus position (most common) (Figure 8-3)


  • Arm holder


  • Axillary role


  • Mayo stand padded


  • C-arm from the head






Figure 8-3 ▪ Patient positioned in lateral decubitus for ORIF.



Surgical Approaches



  • Posterior approaches



    • Paratricipital


    • Olecranon osteotomy


    • Triceps reflecting (Bryan-Morrey)


    • Triceps V-Y/split


  • Curve the incision around the tip of the olecranon


  • Full thickness fasciocutaneous flaps elevated with coagulation of penetrating vessels,



    • usually with a knife or careful bovie particularly near the medial and lateral edges due to proximity to ulnar and radial nerves, respectively


  • Scissor dissection down to the level of the intermuscular septum on both sides, taking care on the medial side to identify the ulnar nerve with vessel loop placement for



    • identification, decompression, and protection of ulnar nerve throughout the case,


    • lateral triceps edge flap carries radial nerve with it if dissection has to go more proximal.


  • Triceps V-Y/split exposure: Only for AO C1 and C2 fractures



    • Long, oblique incisions from medial (protecting ulna nerve distally) and lateral (being aware of radial nerve more proximally) to the central point on triceps proximally to create a tongue of triceps fascia (a direct posterior split is also possible; however, less exposure is achieved)


    • Elevate central triceps tendon from proximal to distal to olecranon, exposing fossa and fractures


    • Elbow flexion allows visualization of the posterior portion of the articular surface and reduction of fracture fragments


  • Triceps elevating (Bryan-Morrey) exposure: AO C1, C2, and C3 fractures



    • Partial elevation of triceps off the olecranon to roll the triceps either medial or lateral for complete exposure of fracture fragments. Careful elevation is required; the very distal insertion of the triceps is left attached to the ulna.


    • In children with a nonossified or open apophysis, additional care in elevation of the triceps insertion and periosteum off the apophysis is necessary so as to not button-hole the triceps fascia and create risk of triceps rupture or deviate into the cartilaginous anlage. This should be done precisely with a sharp blade.


  • Olecranon osteotomy exposure: AO C1, C2, and C3 fractures. Best for fractures with anterior comminution, most extensile



    • Confirm desired apex distal chevron osteotomy site on fluoroscopy, this should be at the location of the bare area, midpoint of the olecranon (Figure 8-4).






      Figure 8-4 ▪ Anatomic location of planned olecranon osteotomy.



    • Predrilling the intramedullary compression screw before osteotomy (for later osteotomy fixation)



      • Place a 2.8 mm guide wire parallel to the subcuticular border of the ulna to run intramedullary, perpendicular to the planned osteotomy site


      • Predrill the proximal ulna with a 5.0 mm cannulated drill


      • Place and remove partially threaded cancellous screw that is wide enough to get distal cortical purchase within the ulna canal


    • Position two retractors over the central part of the olecranon groove.


    • Reconfirm the site of osteotomy with fluoroscopy (Figure 8-4) and then use an oscillating saw to score the cut approximately 75% and complete with an osteotome (this creates an ‘uneven’ edge for anatomic interdigitation during final fixation)


    • Retract the olecranon tip and triceps proximally to reveal the distal articular humeral surface


Reduction and Fixation Techniques (Figure 8-5)



  • Carefully identify fracture lines and fragments.



    • Preoperative CT and/or traction fluoroscopy taken once asleep can be very helpful.


    • Anatomic realignment is very important; if needed, use fluoroscopy for proper orientation of complex fractures (Figure 8-6).


  • Copious irrigation and removal of any small-comminuted pieces of the distal intra-articular segment.



    • If fragments are too small for screw fixation, then suture or bioabsorbable pins may be used to not leave a large articular gap.


  • First priority is anatomic stable reduction of the articular fragments (Figure 8-7)


  • Then reduce the stable joint fracture fragments to the metaphysis and diaphysis fragments for both columns


  • Articular Fracture Fragment Reduction

Feb 5, 2020 | Posted by in ORTHOPEDIC | Comments Off on T-Intercondylar Distal Humerus Fracture

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