Distal humerus fractures in adults: a preview

Waseem Jerjes, Hiang Boon Tan, Peter Giannoudis

Introduction

A lot of the problems encountered in treating distal humerus fractures can be attributed to the complicated anatomy of the elbow joint. The extremely limited range of movement of the elbow joint causes it to absorb significant amount of energy following direct trauma. As a result, articular comminution may occur. The osteopenia observed in aged sufferers adds on to the complexity. These fractures can result in vital functional impairment (Figure 1).

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Figure 1: Diagrams showing distal humerus fractures (A) non-displaced T condylar fracture (B) displaced intercondylar fracture

The prevalence of fractures of the elbow joint is small compared to that of fractures of other bones. They comprise about 2% of all fractures and a third of all humeral fractures. The incidence in adults has been reported as being 5.7% per 100,000 per year. Bimodal age distribution have been describe in people sustaining such injuries; common in males between the age of 12 to 19 and in females older than 80 years of age.

Most distal humerus fracture injuries result from either excessive-energy mechanism (i.e. motor vehicle accident) or low-energy injury (i.e. fall while walking). The mechanism of injury also can assist to identify different related bony or ligamentous injuries. Furthermore, with high-energy injuries, associated accidents to the head and neck, chest, abdomen, spine, pelvis and/or other extremities must be suspected (Figure 2).

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Figure 2: Sketch of a patient with distal humeral fracture. Note the swelling in the area.

Distal humerus fractures mostly involve both the medial and lateral columns (condyles), known as intercondylar fractures. Single condylar fractures make up approximately 5%, while epicondylar and coronal shear fractures of the articular floor are much less commonly observed. As a rule of thumb, extension-type fracture account for most of the fractures in adults. Description of the fractures is highlighted in table 1.

Table 1Capitellum fractureCondylar fractureExtension-type supracondylar fractureFlexion-type supracondylar fractureIntercondylar fractureLateral epicondyle fractureMedial epicondyle fractureSupracondylar process fractureTranscondylar fractureTrochlea fracture

Basic bony anatomy

The distal humerus is divided into medial and lateral columns (or triangles). The cortical cylindrical form of the distal humerus slopes out into a slim isthmus to type the medial and lateral triangular columns. Those columns are separated by a really skinny layer of bone that posteriorly makes up the olecranon fossa and anteriorly composes the coronoid fossa. Each column has an articulating unit (condyle) of the distal humerus and non-articulating terminal (epicondyle) of the supracondylar ridge. The capitellum is the most distal part of the lateral column, while the medial epicondyle is the most distal part of the medial column. Lies intermediate between the capitellum and the medial epicondyle is the trochlea and is the medial most part of the articular segment. The articulating segment as a whole projects anterodistally by an angle 40-45 degrees. Furthermore the trochlear axis is 4-8 degrees in valgus when compared to the longitudinal axis, with 3-8 degrees external rotation (Figure 3).

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The three drawing above: Left-anterior view, Right-inferior view, and Middle-posterior view of the distal humerus. (A) Medial supracondylar ridge, (B) lateral supracondylar ridge, (C) medial epicondyle, (D) trochlear, (E) capitulum, (F) radial coronoid fossa, (G) radial fossa, and (H) olecranon fossa.

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The ulnohumeral articulation is slightly asymmetric. The trochlea is bigger in diameter medially than laterally and the trochlea ends more distally than the capitellum, resulting in a valgus during extension. The elbow joint consists of 3 different articulations: the radiocapitellar, olecranon-trochlear, and proximal radioulnar joints. The joint has the capability to flex and extend within the sagittal plane and in addition to rotate around an axis. The blood provide across the elbow is essentially fed via anastomotic vessels from the brachial artery.

Clinical evaluation

Clinically, the patient presents with a various signs and symptoms depending on the degree of swelling and displacement as well as the mechanism of injury. However, equilateral triangle between the olecranon, medial and lateral condyles is usually preserved and facilitate and accurate anatomical exam. Clinical examination should embrace examination of the injured extremity and a thorough primary and secondary survey. Full examination of the injured area and the associated joint should be undertaken with care with minimal movement as the later may lead to neurovascular

impairment. Examination starts with the skin overlying the fracture (i.e. breached in open fractures which are associated with high-power injuries), swelling, crepitation and reduced range of motion. The skin must be tested for bruising, ecchymosis, or lacerations, with these findings taken into consideration, particularly if operative intervention is to be initiated. Bruising, ecchymosis, or lacerations might represent important ligamentous damage and resultant instability. A sign of compartment syndrome (which can lead to Volkmann ischaemia) of the forearm or upper arm additionally needs to be clinically investigated with compartment pressure monitoring.

A whole examination of the neurovascular status of the extremity needs to be conducted. An accurate assessment ought to be made of the sensory and motor contributions of the median nerve (including the anterior interosseous), ulnar nerve, and radial nerve (including the posterior interosseous), in addition to the medial and lateral antebrachial cutaneous nerves. Vascular assessment includes the brachial artery and distal pulses, with comparisons made to the contralateral extremity. If concern about vascular compromise exists, duplex Doppler study or angiography must to be performed.

Radiological evaluation

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This AP projection of the elbow has the following structures labeled: A) humerus, B) olecranon fossa, C) lateral epicondyle, D) capitulum, E) capitulum-radial joint, F) radial head, G) neck of radius, H) radial tuberosity, I) coronoid, J) medial trochlea, K) medial epicondyle. On the right, a coronal CT slice demonstrates the olecranon process of the ulna within the olecranon fossa of the distal humerus (M) and the coronoid process articulating on the trochlear (L).

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Two radiographs of the elbow are shown, a true lateral projection on left, and an angled trauma lateral (a.k.a. radial head capitulum) projection on the right. The identified parts on these radiographs are: A) humerus, B) radius, C) ulna, D) supracondylar ridge, E) coronoid process of ulna seen through the radial head, F) olecranon process, G) olecranon, H) trochlear notch. The three joints of the elbow are seen on the trauma lateral view, the humeroulnar articulation (I); the humeroradial articulation (K), and the proximal radioulnar joint (J). The capitulum (L) and medial trochlea (M) are also demonstrated by this view.

Multiplane radiographs, together with anteroposterior (AP) and lateral views are appropriate. Full assessment of the fracture pattern, stage of comminution, displacement, articular involvement, bone quality and other related structures must be undertaken at this stage. AP views require the elbow to be flexed at 40 degrees with the X-rays beam directed perpendicular to the injured part. This permits disengagement of the olecranon from its fossa and lets in a greater view of the distal humerus. Also, if possible, traction views may lead to better identification of the fracture line. Oblique views can aid in assessing multiplane fracture lines and comminution. A medial epicondylar fracture ought to be suspected if a fraction is seen inside the joint and the epicondyle will no longer be visible. While, minimally displaced fractures may result in reduced condylar shaft angle which is identifiable on the lateral views.

Displacement of the adipose layer (anterior, posterior or supinator fat pad) overlying the joint capsule in the presence of effusion or haemarthrosis is known as “fat pad sign” and usually indicates non-displaced fractures. The posterior fat pad is essentially the most sensitive for pathology. Further elbow-associated injuries maybe identified using other views (i.e. radial head-capitellar view from better imaging of the radial head, coronoid view to better define the coronoid process).

Usually, CT scans monitor details that cannot be seen on easy radiographs. 3-dimensional reconstructions can be acquired but hardly ever contribute much to the overall assessment of the fracture. The integrity of the primary column, in addition to comminution and preexisting arthritic changes throughout the joint surfaces, ought to be observed. When querying vascular compromise, duplex Doppler ultrasonography or angiography can be performed.

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Preoperative xray shows very distal humerus fracture

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Preoperative lateral xray

Fracture classification

No perfect classification device has been developed for distal humerus fractures that allows correct path for treatment concerns and prognostic outcome. The numerous classifications which have been proposed often overlap.

Mehne and Jupiter separate fractures based on column involvement and whether the fractures are intra-articular, intracapsular, or extracapsular.[10, 11] Their type system contains features of many beforehand defined fracture types. For single column involvement, the Milch classification is usually used. It classifies fracture patterns as having medial or lateral condylar involvement and additional characterizes them as both low (sort I) or high (kind II), relying on how proximally the fracture began before traveling obliquely throughout the trochlea. These fractures usually happen from an abduction or adduction force. Kuhn and colleagues defined a divergent bicolumn fracture sample

that can occur with an axial force from the olecranon in patients with fenestrated olecranon/coronoid fossae.[12]

• Capitellar and trochlear fractures are seen sometimes, happen within the coronal airplane, and might be categorized into one of many following subtypes:

Type I - These are isolated capitellar fractures involving a large portion of cancellous bone; they are known as Hahn-Steinthal fractures.Type II - These are fractures involving the anterior cartilage, with a thin-sheared layer of subchondral bone; they are known as Kocher-Lorenz fractures.Type III fractures - These are comminuted osteochondral fractures.Type IV fractures - Classified by McKee and associates, these involve the capitellum and one half of the trochlea; they often result in the double-arc sign observed on lateral radiographs.

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Figure 17.5. (A) Type I (Hahn-Steinthal) capitellar fracture. A portion of the trochlea may be involved in this fracture. (B) Type II (Kocher-Lorenz) capitellar fracture. Very little subchondral bone is attached to the capitellar fragment. (From Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD, eds. Rockwood and Green’s Fractures in Adults, 4th ed, vol. 1. Philadelphia: Lippincott-Raven, 1996:960.)

• For bicolumn variations, the classification gadget introduced through Mehne and Matta takes into account the height of the fracture through each column.

Y and T fractures begin in the center of the trochlea, secondary to trochlear impaction into the olecranon-trochlear ridge, causing propagation of the fracture vertically and across each column. If a fracture involves both columns at a distal level, it may enter the olecranon and coronoid fossae and produce comminuted articular fragments too small to reconstruct.H-type fractures may produce a free-floating trochlear fragment, with the medial column fractured in 2 places. This can increase the risk of avascular necrosis of the articular fragment. The system does not identify comminution or fragment displacement.

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• Many proceed to make use of the straightforward category proposed by way of Riseborough and Radin.[5] It differentiates fractures on the basis of displacement and rotation. Using this type system is limited because it does not account for the massive number of fracture patterns. Riseborough and Radin's category is as follows:

Type I - Fractures involving minimally displaced articular fragmentsType II - Fractures involving displaced fragments that are not rotatedType III - Fractures involving displaced and rotated fragmentsType IV - Fractures involving comminuted fracture fragments

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Figure 17.3. Riesborough and Radin classification. (A) Type I undisplaced condylar fracture of the elbow. (B) Type II displaced but not rotated T-condylar fracture. (C) Type III displaced and rotated T-condylar fracture. (D) Type IV displaced, rotated, and comminuted condylar fracture. (From Bryan RS. Fractures about the elbow in adults. AAOS Instr Course Lect 1981;30:200–223.)

• The AO-ASIF classification is the most commonly used device for scientific research and treatment. The Orthopaedic Trauma Association and the International Society for Fracture Restore extended the AO-ASIF class to provide a more detailed machine for reproducibility. It incorporates 38 totally different fractures of the distal humerus and separates the styles into groups and subgroups based mostly on the specific fracture propagation and involvement. Subgroups are based mostly at the fracture comminution and orientation. For instance, a unicondylar fracture or tangential fracture of a single condyle would be a group B fracture, while a bicondylar fracture with extensive comminution of the condyles and columns could be a bunch C3 fracture. The crowd class is as follows:

Group A - Extra-articular fracturesGroup B - Partially articular fracturesGroup C - Entirely intra-articular fractures

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Figure 17.4. Classification of condylar fractures according to Milch and the location of the common fracture lines seen in Type I and II fractures of the lateral (B) and medial (C) condyles. (A) Anterior view of the anatomy of the distal articular surface of the humerus. The capitellotrochlear sulcus divides the capitellar and trochlear articular surfaces. The lateral trochlear ridge is the key to analyzing humeral condyle fractures. In Type I fractures, the lateral trochlear ridge remains with the intact condyle, providing medial to lateral elbow stability. In Type II fractures, the lateral trochlear ridge is a part of the fractured condyle, which may allow the radius and ulna to translocate in a medial to lateral direction with respect to the long axis of the humerus. (B) Fractures of the lateral condyle. In Type I fractures, the lateral trochlear ridge remains intact, therefore preventing dislocation of the radius and ulna. In Type II fractures, the lateral trochlear ridge is a part of the fractured lateral condyle. With capsuloligamentous disruption medially, the radius and ulna may dislocate. (C) Fractures of the medial condyle. In Type I fractures, the lateral trochlear ridge remains intact to provide medial-to-lateral stability of the radius and ulna. In Type II fractures, the lateral trochlear ridge is a part of the fractures medial condyle. With lateral capsuloligamentous disruption, the radius and ulna may dislocate medially on the humerus. (From Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD, eds. Rockwood and Green’s Fractures in Adults, 4th ed, vol. 1. Philadelphia: Lippincott-Raven, 1996:954.)

Orthopaedic trauma association classification of the distal humeral fractures…………..

Care in the Emergency Unit

Open fractures: Those wounds should to start with be handled with antibiotics and tetanus prophylaxis. A iodine-based dressing should be positioned over the wound to prevent additional wound colonization and exposure. A nicely-padded, effectively-molded splint with the elbow in moderate flexion and impartial rotation gives balance and ache reduction until definitive treatment is possible. The splint needs to be applied with a nonconstrictive dressing.

Care in the Orthopaedic Unit- non surgical approach

Non-surgical approach in not an uncommon with such injuries and is usually based on the fracture type. Usually, light closed reduction including axial traction in impartial rotation with correction of the deformity could be tried for maximal anatomic reduction. Casting and immobilisation can be usually employed in non-displaced or minimally displaced fractures. Furthermore it is the reasonably acceptable option when dealing with comminuted fractures and severe osteopenia in aged patients with limited functional ability. Also, this can be applied in patients with significant comorbid conditions preventing surgical intervention.

Extra-articular supracondylar and transcondylar fractures are usually posteriorly splinted after being placed in at least 90 degrees of elbow flexion and forearm in neutral position for 1-2 weeks. Following this, range of motion exercises are commenced in a hinge brace. The whole process may be stopped after 6 weeks. A serial radiographs are required to ensure satisfactory healing.

Intercondylar fractures are usually treated non-surgically with the idea to obtain a painless pseudoarthrosis which facilities motion. Bag of bones concept is usually applied; the arm is placed in collar and cuff after initial reduction in the most extreme flexion position. Here the gravity traction can help with the reduction and healing is monitored with serial radiographs. Cast immobilisation is rarely indicated as may lead to inadequate reduction and the patient suffers the complications of prolonged immobilisation.

Condylar and epicondylar fractures can be managed non-surgically by posterior splinting with the elbow flexed to 90 degrees and the forearm is position in supination for lateral condylar and epicondylar fractures and pronation for medial condylar and epicondylar fractures. While fractures of the capitellum and trochlea (Laugier’s), are immobilised in a posterior splint for 3 weeks prior to starting elbow motion exercises. In case of fractures involving the suprcondylar process, non-surgical approach is the desirable one in the majority of the case. Here symptomatic immobilisation in a posterior elbow splint in relative flexion until pain free is employed. This is followed by range of motion and strengthening exercises.

Although the result after non-surgical approach may lead to imperfections with distinguished callus formation and maybe even mild varus angulation, the range of motion at the elbow joint in not significantly affected and very few patients suffers a functional deformity. Articular involvement or fractures with comminution, displacement, or both are poorly tolerated and require surgical intervention, if not contra-indicated.

Care in the Orthopaedic Unit- surgical approach

Studies have supported the perception that distal humerus fractures in adults are optimally handled with open anatomic discount and steady fixation to permit for early anatomic recovery and upper extremity ROM. Whereas operative intervention is not without issues, unique consideration to anatomic reduction, delicate-tissue handling and protection, steady fixation, and early mobilization can cut back complications. For articular fractures and volatile nonarticular fractures, operative remedy with direct visualization of the joint surface and anatomic reduction and stabilization can stop sped up arthritis related to articular incongruity.

If the harm involves vital illness from external resources or bone devitalization, then osteosynthesis is not on time following serial irrigations and debridements. Non permanent fixation with a bridging external fixator, nevertheless, can be performed. Olecranon pores and skin traction is an option for individuals who have fractures with excessive delicate-tissue swelling and in patients with a quantity of demanding injuries who require fast, temporary skeletal stabilization. Other reconstruction choices embody autograft or allograft assist and fascial arthroplasty. In comparatively inactive aged sufferers with terrible bone high quality, total elbow arthroplasty (TEA) is indicated for comminuted distal humerus fractures whilst open discount and inner fixation aren't feasible.[16, 17] Elbow arthrodesis is a severely limiting different and may be very hardly ever performed.

Preoperative Particulars

Preoperative making plans is essential previous to operative therapy of a distal humerus fracture. Proper imaging research and bodily examination findings help to find out the suitable surgical method and techniques necessary for a functional outcome. Contralateral distal humerus radiographs may be required to create a template of the restored anatomy of the injured extremity. The delicate-tissue involvement could dictate the location of the incision. Tracing paper can be utilized to mark the fracture fragments and features as smartly as the anatomic reduction. The stairs of the procedure, including affected person place, surgical method, provisional fixation, and definitive remedy, needs to be mentioned and documented.

Discussion has begun regarding the timing of operative remedy for closed pediatric supracondylar humerus fractures. Usually, if the patient is neurovascularly stable, the arm is splinted and the affected person is taken to the working room as quickly as possible. Mehlman and co-workers supplied sturdy evidence that no distinction exists in perioperative difficulty rates for displaced supracondylar humerus fractures treated earlier than or after an 8-hour period.[18]

The objective of open reduction and internal fixation is recovery of regular anatomy. Distal humerus fractures always proceed to offer a reconstructive challenge to the surgeon. The choice to supply operative intervention for distal humerus fractures is based on many elements, together with fracture type, intra-articular involvement, fragment displacement, bone high quality, joint steadiness, and smooth-tissue high quality and coverage. As smartly as, particular person components, comparable to patient age, general health situation, useful extremity calls for, and patient compliance, are all considered. Preoperatively, patients must perceive outcome expectancies and the importance of rehabilitation.

Circumstances wherein operative intervention is supported include intra-articular fragment displacement, physeal displacement, supracondylar comminution and displacement, open fractures,

floating elbow patterns, neurovascular damage, compartment syndrome, and multiple worrying injuries.

Primary targets for operative intervention are to revive articular congruity and elbow stability. One other objective is to lower the opportunity of posttraumatic arthritis and elbow stiffness.

Related Anatomy

Hastings and Engles have defined a "spill over effect," during which inadequate recovery of a singularly injured joint can result in irregular wear and degenerative changes in an adjacent articulation. This impact can observe to the elbow.

The difficulty in treating complicated distal humerus fractures lies in the unique and particular anatomy of the distal humerus that permits it to articulate freely with the radius and ulna. The elbow is a trochoginglymoid joint; In precise fact,. Motion within the sagittal aircraft occurs at the ulnohumeral articulation within the semilunar notch.

Reconstruction of the premorbid anatomy of the trochlea is crucial to restoration of movement and stability. The lateral column lies in approximately 20° of valgus relative to the humeral shaft. The medial column is aligned at a forty° attitude to the shaft and ends within the trochlea. The capitellum is angulated 30-forty° anteriorly, while the trochlea is angulated 25° anteriorly.

Most distal humerus intra-articular fractures cut up via the trochlear waist, causing comminution and infrequently leading to narrowing of the trochlea after inner fixation. In addition, the condyles are turned around three-eight° internally and positioned in roughly 6° of valgus. Often, the olecranon blocks enough visualization of the trochlea and olecranon fossa, limiting analysis of fracture reduction.

Contraindications

Contraindications to operative intervention for distal humerus fractures are patient specific. Factors that needs to be considered embrace the patient's age, total well being condition, practical demands and expectancies, and the overlying soft-tissue high quality and bone quality. Lastly, the doctor should be in a position to make an honest evaluation of his or her potential to successfully carry out open reduction and inside fixation of the fracture pattern.

Historical past of the Procedure

Many physicians once believed that optimal restoration for advanced distal humerus fractures might be achieved by conservative treatment. In 1937, Eastwood described the "bag of bones" method, which involved compressive manipulation of the distal fragments with collar-and-cuff assist and the elbow in flexion.[3] After a 2-week period by which the elbow was once immobilized at one hundred twenty º of flexion, extension used to be gradually increased. Better results were noticed in aged

patients, with ulnohumeral motion averaging 116 º after 2.5 years of follow-up. However, Evans noticed that despite the purposeful vary of movement, the ultimate final result typically used to be a weak and volatile elbow.[4]

Regarding operative treatment, Watson-Jones commented that inspite of a perfect anatomic reduction, "the resulting joint movement is always less satisfactory than after less accurate reduction out there with external means." As late as 1969, Riseborough and Radin warned of the restrictions of operative intervention for distal humerus fractures.[5]

Numerous advocates of conservative therapy have described much less in depth operative methods for these fractures. In 1943, Watson-Jones really helpful closed remedy or a limited open reduction with Kirschner wires (Okay-wires) based mostly on bad results with intra-articular involvement. Percutaneous pinning of transcolumnar and supracondylar fractures in aged, relatively inactive patients remains to be a workable remedy option.

Lambotte, in the first decade of the twentieth century, was once one of many first to explain operative strategies for steady osteosynthesis of the distal humerus.[6] In the early Nineteen Sixties, with the formation of the Swiss Arbeitsgemeinschaft f ü r Osteosynthesefragen - Affiliation for the Examine of Internal Fixation (AO-ASIF) team, formal techniques to achieve anatomic discount with stable fixation started to evolve. Consequently, open discount and inner fixation of displaced distal humerus fractures has change into the standard of care for most patients. Even immediately, the operative technique keeps to evolve.

Surgical Remedy

Intraoperative Details

Radiograph of a supracondylar-intracondylar distal humerus fracture. Word the posteromedial and posterolateral column plate placement used for reconstruction with the chevron osteotomy. Lateral radiograph of a supracondylar-intracondylar distal humerus fracture. Be aware the distal quantity of the contoured plate positioned additional-articularly. Radiograph of a supracondylar-intracondylar humerus fracture. Observe the ipsilateral radial head fracture fastened through a posterior incision. Lateral radiograph of a supracondylar-intracondylar distal humerus fracture with an ipsilateral radial head fracture. Anteroposterior radiograph of a pediatric kind III supracondylar humerus fracture. Notice the lateral pinning. Lateral and medial pinning of a kind III extension-kind supracondylar humerus fracture. Lateral radiograph after open reduction and pinning of a type III supracondylar humerus fracture.

Affected person place

The patient ought to be located to allow adequate publicity and visualization of the complete involved area. Earlier authors have supported a variety of positions, from supine to susceptible to the lateral decubitus position.

For unmarried column or shear fractures, the supine position is useful in order to use the lateral approach to the elbow. An arm board or hand desk can be positioned together with the operating desk for assist of the medial element of the arm. The authors favor to make use of the lateral decubitus place with a beanbag for assist and a padded, sterile arm holder underneath the proximal

humerus. The hip-holder attachment to the Jackson desk additionally can be used as an arm holder. This allows adequate entry to the posterior element of the elbow joint and likewise allows the arm to be freely circled proximally for more accurate positioning. The hand and forearm are draped with a sterile stockinette. The shoulder is placed at ninety° of abduction, and the elbow is flexed over the arm holder at 90°. The lateral position additionally allows entry to either the anterior or posterior iliac crest in case a bone graft is needed. The inclined position is rarely used.

Different concerns for positioning ought to include associated injuries, simultaneous strategies that will be carried out throughout the identical anesthetic administration, and the patient's overall systemic demands (equivalent to those resulting from closed head injuries).

A tourniquet should be applied as some distance proximally at the brachium as possible. With supracondylar or high column fractures, a sterile tourniquet is needed. All the arm ought to be prepared and draped.

Surgical approaches

Several completely different surgical approaches, with permutations, have been described. For remoted unmarried column or epicondylar injuries, a lateral or immediately medial method is recommended.

The lateral (Kaplan) approach includes an incision proximal to the lateral epicondyle that is prolonged distally throughout the radiohumeral interval. Dissection is carried down among the extensor carpi radialis brevis and extensor digitorum communis (EDC) interval or among the EDC and extensor carpi radialis longus period till the supinator muscle is visualized. Detachment of the heads of the supinator finds the annular ligament and lateral column of the distal humerus. If the incision is to be prolonged distally, the posterior interosseous nerve must be protected.

The posterolateral (Kocher) strategy may be more secure for exposure of the lateral column as a outcome of it makes use of the anconeus and extensor carpi ulnaris (ECU) interval, better defending the posterior interosseous nerve. An incision is started just proximal to the lateral epicondyle and ends obliquely throughout the proximal ulna. The arm is kept pronated through the dissection to keep the posterior interosseous nerve away from the dissection field. Blunt dissection by the ECU fascia and thru the anconeus-ECU period results in the elbow joint capsule. Publicity distal to the annular ligament results in the posterior interosseous nerve. The lateral collateral ligament (LCL) is visualized by means of retracting the ECU and EDC anteriorly.

The capsular incision ought to be made anterior to the radiohumeral ligamentous advanced to avoid injury to the posterior fibers of the LCL complicated and to stop ensuing instability. If really mandatory for exposure, the LCL could also be detached from the lateral epicondyle and then reattached with nonabsorbable suture or suture anchors.

The medial method includes the period among the brachialis and medial collateral ligament. Proximal extension is made by method of the brachialis and triceps interval. A similar posteromedial method has been described as well for fracture fixation and medial placement of a single plate. This allows dissection of the radial nerve to be avoided but may no longer be applicable in settings with preoperative radial nerve injuries.[19]

The posterior (Campbell) incision is most often used for nonarticular supracondylar fractures or intra-articular fractures. The incision might be curved lightly, both medially or laterally, on the olecranon to keep away from impingement instantly over the apex. The ulnar nerve needs to be isolated rigorously and at the very least 6 cm mobilized each proximally and distally to the cubital tunnel to permit the nerve to lie within the subcutaneous tissues anteromedially to the cubital tunnel (transposition).[20, 21, 22] Cautious attention needs to be paid to the discharge of the medial intermuscular septum and distal dissection of the nerve inside the flexor carpi ulnaris (FCU).

A triceps-splitting method is mostly used for publicity of the distal humerus. This method includes deep dissection down the center of the arm over the olecranon, along with fascial and periosteal flap elevation along the sides of the bone. Medial triceps insertion avulsion has been pronounced and should be fastidiously avoided. The anconeus muscle fibers and the FCU muscle fibers are elevated off the bone laterally and medially for progressed distal exposure. Proximally, the radial nerve crosses throughout the deep muscle fiber origin of the medial triceps head thirteen-15 cm above the joint line. The triceps insertion needs to be preserved as a lot as doable and should be reattached via drill holes if released. This method has been stated to result in devascularization-triggered triceps rupture and should increase adhesion formation.

The triceps-sparing approach defined by Bryan and Morrey is especially recommended for use in intra-articular fractures of the distal finish of the humerus when conversion to an elbow arthroplasty or to a TEA is necessary as the primary treatment.[23] The ulnar nerve is remoted and is transposed anteriorly. The triceps is dissected subperiosteally and is increased from medial to lateral for exposure of the distal humerus. It is saved in continuity with the forearm fascia and periosteum, and the triceps insertion is immediately from the ulna. Versions of this system have described a lateral to medial reflection of the triceps mechanism. The ulnar collateral ligament could additionally be launched from the distal humerus to improve exposure. Reattachment is necessary after fracture restore, however reattachment is not obligatory following TEA.

A few authors prefer a nonarticular olecranon osteotomy, with proximal retraction of the triceps with its insertion for visualization of the distal humerus. This entails an osteotomy performed distal to the articular olecranon. The osteotomy will be directed transverse (changed MacAusland approach) or obliquely (Mueller approach). Because of the inherent risk of fracture nonunion, many authors prefer a triceps-sparing strategy or an intra-articular olecranon osteotomy. For improved publicity for intra-articular fractures, the posterior approach is usually mixed with an intra-articular osteotomy. Direct visualization allows accurate reduction of the joint surfaces. Both transverse and chevron osteotomies were described. The authors want a chevron osteotomy with direct fixation utilizing a rigidity band twine approach and Ok-wires.

The osteotomy can also be mounted with an intramedullary 6.5-mm cancellous screw, which might be predrilled and tapped before the osteotomy for simpler placement of the screw. The curvature of the proximal ulna might make accurate placement of the screw down the intramedullary canal difficult.

The olecranon is sharply dissected along the medial and lateral portions to raised view the semilunar notch. Sometimes, an oscillating thin-blade saw is used, with the osteotomy cuts converging obliquely and distally, simply distal to the midportion of the semilunar notch. The amount of articular cartilage is least here. The osteotomy is accomplished with an osteotome. Use of the

osteotome permits improved engagement of the fragments after reduction. The remaining capsular attachments and the comfortable tissue bordering the triceps are minimize to allow proximal retraction of the olecranon tip with the triceps insertion. The olecranon tip is elevated off the posterior aspect of the humerus. The ulnar nerve is remoted and transposed with this approach.

After distal humerus fracture fixation, the proximal ulna can be reattached utilizing standard AO-ASIF pressure band wire technique and both 2 parallel 0.0625-mm Ok-wires or a 6.five-mm in part threaded cancellous screw, as described previously. The tension band wire ought to be positioned beneath the triceps, towards the bone periosteal floor, and secured with both the Ok-wires or the cancellous screw. The transverse distal cord hole should be placed nicely distal to the osteotomy site.

Reduction and steady fixation

A methodical method must be taken to reduction and fixation of the fracture fragments. All the fracture fragments ought to be identified initially. Hematoma should be eliminated, and the fracture planes must be recognized and restored.

If one column stays intact, the discount could be simplified by means of assembling the fragments towards the intact column. For bicolumn involvement, a few physicians favor to first stabilize one column and then to reduce the second column to the first column. A more widespread method is to start with the articular floor and to anatomically scale back the joint surface. The metaphyseal fragments are then individually reduced and fixed. This successfully converts the fracture right into a 2-part fracture. Others favor a "best-match" method of anatomic restoration. By means of beginning with the portion that can be finest anatomically aligned and is least comminuted, errors in reduction may be minimized.

Provisional reduction could be completed with Ok-wires or bone-conserving forceps. Most surgeons start with reconstitution of the trochlea and work proximally. The trochlea will be stabilized back to the shaft and the least-fractured column. With articular comminution, you will want to restore the normal articular floor depth and width. Crucial comminution or lacking articular fragments should be replaced with bone graft bought from the iliac crest. Fixation should be received with interfragmentary 4.zero cancellous lag screws crossing each the medial and lateral column to take care of reduction. For more intensive comminution, a completely threaded, nonlagged 4.0 cancellous screw ought to be placed throughout the trochlea to forestall narrowing across the gap. Retrograde drilling via one of the fracture fragments is beneficial to maintain a primary position of the screw. The screw can then be placed from the capitellar fragment throughout the fracture website and into the trochlear fragment.

Low columnar fragments may additionally be fixed with small, cannulated differential pitch screws buried underneath the articular floor or small, threaded K-wires buried underneath the articular surface. Once the articular fragments were lowered, the stabilized distal fragment is reduced to the shaft. Precontoured plates can be placed onto the shaft over K-wires that stabilize the construct. A metaphyseally positioned screw can maintain the plate to begin with for stability.

Various implants are available at the moment for the diverse fracture styles observed within the distal humerus. A few plates are contoured particularly for the anatomy of the distal humerus.

Several companies have evolved anatomically primarily based precontoured condylar plate methods that may assist with fracture reduction. Screws starting from cannulated to noncannulated and varying in dimension from 2.7 mm (mini-fragment screws) to 3.5 mm and 4.5 mm (small- and large-fragment screws) may be needed. Such a lot small-fragment implant sets have 3.five-mm and partially threaded 4.zero-mm screws as a lot as 50 mm in length. If longer screws are wanted, 3.five-mm screws as so much as 110 mm in size are available. More moderen, minimally invasive, percutaneously inserted bridge plates even have been described and have been used to avoid in depth dissection and possible nerve injury. A few have proven excellent leads to their usage, regardless of prior radial nerve palsy expecting eventual nerve recovery.[24]

Plate placement is the keystone of fracture reduction. As soon as articular reconstruction is accomplished, the lateral column is mounted with a molded 3.five-mm dynamic compression plate, or a reconstruction plate is placed posterolaterally. The posterior side of the lateral condyle has a bare floor instantly proximal to the articular floor, making it safe for plate placement. Nonetheless, the posterior capitellar articular surface limits distal placement of the plate. Screws can be directed anterosuperiorly, above the capitellum, or directed anteriorly, gaining fixation distally only by means of the close to cortex (in order to avoid joint penetration) and gaining bicortical fixation proximally.

The medial column is stabilized with a one-third tubular plate or a 3.five-mm reconstruction plate positioned in an orthogonal trend with appreciate to the lateral plate. The medial column of the distal humerus is nonarticular, and a plate might be contoured into a semicircle alongside its distal finish to cradle the medial epicondyle. Probably the most distal screw could be oriented superiorly at a ninety° angle to the more proximal screws, improving balance, or obliquely, to have interaction the lateral column.[25]

Orthogonal plate placement has been proven to provide the best balance for fending off a wide selection of failure loads. However, Schemitsch and associates proven that with cortical touch, plates placed medially and laterally have been as inflexible as these placed orthogonally.[26] Care should be taken to stop olecranon hardware impingement in elbow extension. Jupiter has defined placing a 3rd plate laterally alongside the lateral column for extra fixation.[27, 20]

Primary ideas for internal fixation of those fractures include the next:

• All distal screws from one column ought to pass through a plate.

• All distal screws should move into a serious fragment on the alternative column.

• All screws ought to be so long as potential to interact the alternative cortex.

• All screws ought to engage as many fragments as possible.

• Screws drawing near the articular surfaces and fossae should be avoided.

O'Driscoll has described the usage of "touch with compression" in an effort to acquire elevated balance across the fracture site. Fixation of the articular fragments onto the proximal aiding columns creates the weakest link. Through acquiring compression throughout the fracture sight, the limb is shortened slightly. This leads to overlap of fragments, which improves total stability and the power to institute early vary of motion to forestall elbow stiffness.

Fixation of distal humerus fractures usually is determined by means of the fracture pattern. With divergent single column harm styles, 2-five lag screws positioned percutaneously from aspect to side could additionally be hired for sufficient fixation. For coronal shear fractures, small cannulated screws placed anterior to posterior through the articular surface anteriorly may be used. Partly threaded 4.zero-mm cancellous bone screws additionally may be positioned from posterior to anterior through the fracture line, gaining unicortical fixation.

After fixation is accomplished, it is vital to fastidiously assess the complete range of movement of the elbow to evaluate stability. If olecranon impingement limits extension, hardware might have to be modified or the end of the olecranon could also be excised. Different options to enhance stability embody bone autograft or allograft, bicortical interpositional grafting for bone loss (typically for malunions), and polymethylmethacrylate with screw augmentation. If this fails, then a hinged exterior fixator could also be thought of as a salvage procedure. TEA is an choice for comminuted distal humerus fractures in the elderly.

A drain is positioned, and the gentle tissue and pores and skin ought to be closed in layers. The elbow joint is immobilized in a well-padded, well-molded splint that is in full extension to limit swelling.

For pediatric supracondylar humerus fractures, extension-sort fractures are to begin with manipulated with the affected person fully comfortable with a view to obtain secure anatomic reduction. Traction is dependent, and then the limb is hyperextended with varus or valgus correction and hyperflexed to stabilize the fracture. Finally, forearm pronation is beneficial to stabilize the distal fragment in the coronal plane. Equally, with flexion-kind fractures, the elbow is decreased in extension and the beforehand talked about discount method is performed. Cautious attention should be paid to making use of pressure posteriorly onto the distal fragment by means of the forearm while flexing the elbow to take care of reduction of the distal fragment.

Kind III flexion-type injuries are infamous for requiring open reduction. Several authors have described varied closed methods of discount for this type of fracture. If open discount is required, an anteromedial method is commonly used as a outcome of anterolaterally displaced fragment. The proximal fragment is usually impaled throughout the triceps mechanism.

Controversy has persevered regarding the advantages of crossed percutaneous pinning as opposed to those of lateral pinning for steady fixation of supracondylar humerus fractures. Lee and colleagues, amongst others, have supplied biomechanical proof that move pinning supplies an improved construct.[28] Skaggs and associates have shown in retrospective research that the configuration of the pins doesn't have an effect on ultimate fracture discount of kind II or III supracondylar humerus fractures.[13]

The lateral pins are placed first with the elbow in hyperflexion and pronation. The pin or pins needs to be positioned within the heart of the lateral condyle and directed at 30° to the humeral axis. The medial pin or pins should be started at the medial epicondyle and directed anterolaterally. Before pin insertion, the ulnar nerve must be palpated or comfortable tissue should be dissected and the epicondyle visualized. Studies have shown a high incidence of ulnar nerve subluxation with flexion of the elbow through the discount maneuver. Attention should be paid to stopping pins from crossing at the fracture site. The pins are reduce outdoors of the pores and skin and bent back. The arm

needs to be positioned in an extended arm splint postoperatively, with transition to a protracted arm cast (worn for a minimum of 3 weeks).

Open reduction with pinning is the therapy of alternative for displaced pediatric lateral and medial condylar fractures. Rotational displacement could be very troublesome to judge with closed discount maneuvers. A direct lateral method to the elbow is really useful for lateral fragments via the brachioradialis-triceps interval. Posterolateral dissection ought to be avoided with a goal to protect the vascularity from the posteriorly located vessels. A posteromedial incision is used for medial fragments. The fracture site ought to be carefully debrided, and 2 smooth Ok-wires are inserted via the condyle or metaphyseal fragment and into the medial humeral metaphysis. The pins may be saved below or external to the pores and skin however require elimination after 3 weeks. The arm is safe in a long arm splint, with transition to an extended arm cast (worn for three weeks).

Fracture separation of the epiphysis may be treated with open reduction and pinning if recognized early. Separations are sometimes ignored, and if they're discovered after 5-7 days, they should be splinted and allowed to heal with remodeling.

Postoperative Details

The entire extremity should be increased above the extent of the center to minimize back swelling. The drain might be eliminated after 24-forty eight hours, when drainage diminishes. As soon as the swelling abates, the elbow might be positioned in a supportive brace or sling, and gentle, active ROM workouts could be initiated. Passive ROM workouts are not on time 6 weeks to allow for early fracture healing. In patients who've passed through a triceps-sparing method, energetic extension is prevented for the first 6 weeks. As an alternative, elbow extension is completed by gravity. Six weeks after surgical procedure, passive ROM, including dynamic flexion and extension splints as wanted, is instituted. Strengthening is started 10 weeks after surgery.

Most pediatric elbow fractures can first of all be treated in an extended arm posterior splint for consolation after surgery, with transition to an extended arm cast. The pins are removed after three weeks, and the cast is removed after three-4 weeks. Protected ROM might be initiated at this time.

Comply with-up

Inpatient care is really useful for 2-3 days, with the wound fastidiously tested 48-72 hours after surgery. As neatly as, excessive swelling and signs of compartment syndrome ought to be monitored. The wound ought to be examined again by way of 14 days after surgery, and the sutures needs to be removed. Fracture therapeutic ought to be assessed with serial radiographs to examine callus formation, alignment, and hardware integrity. Bony union is anticipated by means of three months after surgery. With pediatric fractures, bony union is anticipated quicker and ROM can be initiated earlier.

Issues

Probably the most generally noticed complication after operative therapy is loss of elbow motion. Bodily remedy, together with energetic and passive ROM, in addition to static progressive splinting, is helpful treatment. Nonoperative treatment is often profitable only for an extrinsic elbow contracture that has been present for less than 6 months.

If nonoperative remedy fails, operative launch is recommended. Most often, an open method is used. Mansat and Morrey have described a limited lateral approach to both the anterior and posterior tablet called the column procedure.[29] This includes elevating muscle groups from the lateral supracondylar osseous ridge. Mansat and Morrey had an 11% problem price; hematoma formation and ulnar nerve paresthesia have been the such a lot typical complications. Other authors have described arthroscopic strategies to capsular release.

Anatomic discount with secure fixation of fracture fragments, cautious dealing with of the ulnar nerve, and satisfactory fixation of an olecranon osteotomy can enhance results of surgical treatment. Failure of fixation is most frequently the results of poor preoperative planning and poor operative technique, although bone high quality may restrict secure fixation. Careful rehabilitation development can optimize the opposing forces of motion maintenance and fracture healing.

Nonunion rates for surgically handled distal humerus fractures range from 2-7%. Infection, bone osteoporosis, age, open fractures, multiple accidents, and inadequate fixation have been implicated as components resulting in nonunion. Signs embody persistent ache, weak point, and instability, although most patients keep up to an 80º arc of motion. If surgical therapy is selected, options embody revision open reduction and inside fixation, allograft reconstruction, and resection or distraction arthroplasty.[30] TEA could additionally be thought of in aged, much less active patients.[31] With pediatric elbow fractures, nonunions of the lateral condyle are probably the most common. Compression fixation and bone grafting are beneficial as treatment.

Heterotopic ossification can occur in up to 50% of circumstances after acute remedy of distal humerus fractures. It typically occurs within the posterolateral side of the elbow, from the lateral humeral condyle to the posterolateral olecranon. Hastings and Graham have defined a practical category gadget for elbow ectopic ossification that assists in medical analysis, therapy, and operative planning, as follows[32] :

• Elegance I - These fractures are related to no useful limitations.

• Magnificence II

o Class IIA - These fractures are related to useful hassle of flexion and extension; they lead to anterior or posterior ossification or ossification regarding each side of the elbow joint.

o Class IIB - These fractures contain useful challenge of supination and pronation and in addition may contain ossification of the interosseous membrane or distal radioulnar joint.

• Class III - Those fractures are associated with ankylosis that eliminates elbow ROM.

A few research have discovered a decrease occurrence of heterotopic ossification formation when open reduction and inner fixation are performed inside 24-48 hours of injury. Heterotopic ossification occurrence is increased with related injuries, similar to burns, head injuries, high-power injuries, and open injuries. In those patients, prophylactic remedy needs to be considered. Pressured passive manipulation also may increase the event of heterotopic bone formation.

Preventive measures embrace the use of nonsteroidal anti inflammatory medication (NSAIDs), low-dose radiation remedy, and continuous passive ROM exercises. So much research have checked out

heterotopic ossification treatment around the hip. Regardless, the therapy of heterotopic ossification remains to be controversial. Low-dose radiation with unmarried doses of six hundred-seven-hundred cGy to the elbow has been successful at preventing further progression. The timing of the irradiation (preoperative vs postoperative) does not appear to have an impact on operative outcomes. Some authors have recommended irradiation inside 72 hours of elbow trauma. The issues of neoplasm development after radiation therapy are evident. NSAIDs have been used with success against heterotopic ossification. Indomethacin is essentially the most generally used drug for heterotopic ossification prevention and has been proven to decrease heterotopic ossification prevalence and severity. The beneficial dose is seventy five mg orally 2 instances according to day for 3 weeks.

Sucralfate, at a dose of one g orally four times in line with day, has been really helpful to prevent gastrointestinal disturbances in patients taking indomethacin.

Operative excision of heterotopic ossification is really useful three hundred and sixty five days after the injury, though studies have shown excellent outcomes with remedy 3-6 months following injury. Declining levels of serum alkaline phosphatase and the radiographic confirmation of mature heterotopic bone can be used to help expect timing for heterotopic bone excision. Nevertheless, research have proven no difference in serum alkaline phosphatase levels in matched populations with or without ectopic ossification. In consequence, they don't appear to be routinely indicated. Mixed medial and lateral approaches are advisable for elimination of heterotopic bone. Lower bone surfaces should be cauterized and covered with bone wax, and intensive capsular launch needs to be performed.

Patient complaints related to ulnar nerve dysfunction are among the most widespread findings after surgical treatment of distal humerus fractures, affecting up to 15% of patients. Revision operative approaches have revealed extensive fibrosis and fracture healing that reasons the ulnar nerve to adhere to the medial epicondylar area. Mobilization and anterior transposition at the time of index surgical procedure decreases the occurrence of this complication. Additional, a 2011 study means that appearing intramedullary antegrade nailing, fairly than crossed Okay-cord fixation, because the index surgery for supracondylar humeral fractures reduces the danger of ulnar nerve injury.[33]

Instability after distal humerus fracture fixation is rare. It's most often observed with untreated type II unmarried column injuries or radial head or coronoid fractures. With comminuted intra-articular fractures, it may not be attainable to reconstruct related ligamentous injuries. Corridor and co-workers described using a hinged exterior fixator to deal with associated posterolateral instability of a critically comminuted distal humerus fracture after having been unable to stabilize the joint following open discount and inner fixation.[34] Though the distal humeral condyles may be fractured, the medial and lateral ligamentous attachments usually remain preserved, lending stability to the elbow after operative stabilization.

Avascular necrosis is extremely uncommon after distal humerus fractures. Isolated research have reported an elevated danger after H-kind intra-articular distal humerus fractures of avascular necrosis of the unfastened-floating fragment.

The such a lot common nerve injuries which can be related to open discount and inner fixation of distal humerus fractures are ulnar nerve injuries. Ulnar neuropathy has been mentioned to occur in

7-15% of cases. The ulnar nerve, due to its proximity to the dissection, must be uncovered and identified with eventual anterior transposition. Postoperative ulnar nerve dysesthesia signs with intact motor exam findings are common and will be closely monitored. With extra proximally concerned fractures, the radial nerve ought to be identified upon exposure. It would possibly be broken by retraction, plate impingement, or tissue dissection in the process the operation. If a change in baseline motor nerve operate on postoperative examination happens, reexploration is recommended. Brachial artery accidents have been defined and are extra widespread with extension-kind elbow injuries. The brachial artery could be damaged by the sharp ends of the proximal fragment penetrating its wall.

Dormans and co-workers, along with Cramer and colleagues, have studied the high prevalence of anterior interosseous nerve injuries which have been associated with closed pediatric supracondylar fractures.[35, 36] Go back of operate passed off inside 10 months with out surgical intervention. Total, the authors found a 9.five% incidence of nerve injury. Radial nerve injuries had been found to be more widespread with posteromedial displaced fractures, whereas median nerve injuries had been associated with posterolateral angulated fractures.

Avascular necrosis of the trochlea is related to extra distally based pediatric humerus fractures. Damage to the physeal vasculature of the medial trochlea can lead to avascular necrosis, resulting in a fishtail deformity. Malreduction of a lateral condylar fracture can lead to growth of a bony bar throughout the physis and to growth of a fishtail deformity.

Angular deformities, corresponding to cubitus varus and cubitus valgus, are rare complications after pediatric supracondylar humerus fractures. Usually, anatomic discount prevents development of those deformities. Cubitus valgus is very rare and infrequently happens with posterolateral fracture patterns. It often results in more functional loss (typically of extension) than does cubitus varus. Lateral condylar fractures can result in cubitus varus angulation. A mixture of nonanatomic discount and physeal progress stimulation results in this deformity. More ceaselessly than not, the degree of deformity is of little consequence. Oh and associates defined 7 of 12 young children in whom fracture separation of the distal humeral epiphysis resulted in cubitus varus deformity, with growth of avascular necrosis of the medial humeral condyle happening in 6 of the 7 patients.[37]

Consequence and Prognosis

Lack of terminal extension is frequently noticed after distal humerus fracture. Persistent exertional ache will be noticed in up to 25% of sufferers who've suffered such injury.

Henley and other authors have said good to wonderful ends in 92% of treated sufferers at 1.5-yr follow-up.[38] Other studies have reported related numbers, with a variety of 60-90% and good to excellent results. Wang and co-workers mentioned that the majority bad outcomes are most probably to occur with complicated team C3 fractures and are associated to related injuries and complications.[21] Of their study of 20 patients, 4 complications took place: 1 nonunion, 1 malunion, 1 deep infection, and 1 brachial artery laceration.

McKee and co-workers studied useful consequence following surgical remedy for displaced intra-articular distal humerus fractures.[39] After 37 months of follow-up, they discovered a imply flexion

contracture of 25° and an arc of movement of 108°. Significant decreases in imply muscle strength have been found in both elbow flexion and extension (seventy five% of normal).

Consequence research have reported healing rates of eighty-one hundred% postoperatively. Jupiter suggested postoperative arc of motion improved to a hundred°, with 83% just right or wonderful useful results.[27, 20]

Relating to surgical exposure for distal humerus fractures, a nonunion fee of as a lot as forty% has been reported from chevron osteotomy results, although some authors contend that poor approach is often the supply of the complications. Contributory components include lack of interdigitation of the osteotomy site, malposition of the intramedullary fixation screw, infection, and damaged implants.

Future and Controversies

Distal humerus fractures stay a difficult reconstructive problem for orthopedic surgeons. Nonetheless, long term expertise could hold many solutions. With the advent of more modern, more potent biocompatible supplies, various hardware choices allow advanced reduction and fixation of distal humerus fractures. Decrease profile plates and smaller screws permit the health practitioner to take care of the unique articular congruity needed to stop posttraumatic arthrosis, which allows for sooner and innovative postoperative rehabilitation.

In addition, for the unreconstructable elbow, primary TEA is slowly gaining acceptance. Important improvements in its layout and surgical method have produced dependable ache relief and purposeful restoration. Whereas inflexible affected person selection standards should be adhered to with this surgical choice, TEA might help elderly sufferers with extreme bone loss and comminution.

Anterolateral Approach

Adequate for: proximal 1/3, midshaft fx,distal 1/3 fx, Postion: supine or modified beach chair Incision: longitudinal just lateral to biceps. Proximal exposure between deltoid and pec major insertions. Distal exposure splits brachialis origin off humerus with medial retraction of biceps

muscle.

Extension: can be extended into deltopectoral approach to the proximal humerus. Risks: Radial nerve, lateral antebrachial cutaneous nerve, cephalic vein.

1. Cephalic vein 2. Lateral antebrachial cutaneous nerve 3. Radial nerve 4. Brachialis origin

Simple sketch in black and white – the only colouring I need is (yellow for nerve, blue for vein)

Posterior Approach

Adequate for: midshaft fx,distal 1/3 fx, radial nerve palsy

1. Lateral Brachial cutaneous nerve 2. Radial nerve 3. Profunda brachii artery 4. Triceps - medial (deep) head 5. Ulnar nerve

Simple sketch in black and white – the only colouring I need is (yellow for nerve, blue red for artery)

Anteromedial Approach

Rarely used Anteromedial incision proximal to medial epicondyle Dissection posterior to intermuscular septum Ulnar nerve freed from triceps and reflected medially. Median nerve and brachial artery reflected laterally. Risks: Ulnar nerve, median nerve, brachial artery.

1. Ulnar nerve 2. Brachial artery and veins 3. Median nerve 4. Cephalic vein

Simple sketch in black and white – the only colouring I need is (yellow for nerve, blue for vein and red for artery)

1. ECRL 2. Brachioradialis 3. Radial nerve 4. Biceps 5. Cephalic vein

6. Brachialis 7. Brachial artery and veins 8. Median nerve 9. Pronator teres 10. Basilic vein 11. Common flexor tendon 12. Ulnar nerve 13. Superficial ulnar collateral artery 14. Trochlea 15. Capitellum 16. Olcranon 17. Anconeus

Simple sketch in black and white – the only colouring I need is (yellow for nerve, blue for vein and red for artery)

Simple sketch in black and white

Simple sketch in black and white

Simple sketch in black and white

Simple sketch in black and white

Postoperative AP xray after primary elbow replacement

Simple sketch in black and white

Postoperative lateral xray