Orthopedics in Motion Tristan Hartzell, MD January 27, 2016

Transcription

1 Orthopedics in Motion 2016 Tristan Hartzell, MD January 27, 2016

2 Humerus fractures Proximal Shaft Distal

3 Objectives 1) Understand the anatomy 2) Epidemiology and mechanisms of injury 3) Types of fractures 3) Treatment

4 History Sir John Charnley: It is perhaps the easiest of major long bones to treat by conservative methods??

5 Well-enveloped in muscle and soft tissue good prognosis for healing Anatomy

6 The septums Used as key landmarks Anatomical approaches

7 The Radial Nerve The most important piece of anatomy to know relative to the humerus Document radial nerve function from the start!

8 Epidemiology 3-5% of all fractures The energy spectrum of injury Young males high energy (direct trauma) Elderly females low energy (indirect trauma)

9 Our Numbers Pediatric humerus fractures 37 Adult humerus fractures

10 Imaging X-ray (above/below joint) CT scan (rotation) (proximal and distal) MRI scan (pathologic) Nerve conduction studies (radial nerve) Evaluation Physical exam Closed vs open Threatened skin Nerve and vascular function

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12 Associated injuries Radial nerve injury Neuropraxia at time of injury generally resolves Decreased nerve function after manipulation or surgery nerve entrapped or injured and needs exploration

13 Classification Closed versus open Location proximal, middle, distal Fracture pattern transverse, spiral, oblique, comminuted segmental, unicondylar, bicondylar Soft tissue status Gustilo classification AO system research purposes mostly

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15 Treatment Humeral shaft: Goal establish union with acceptable alignment in an acceptable timeframe Distal humerus: Goal establish union with congruent articular surface in a manner that can begin early motion

16 Humeral Shaft Non-operative Non-displaced closed simple fractures Displaced closed fractures with less than 20 degrees anterior angulation, 30 varus/valgus angulation, less than 3 cm of shortening

17 Non-operative treatment Coaptation splint Initial care

18 Non-operative treatment Hanging arm cast

19 Non-operative treatment Sarmiento brace or humeral fracture brace Transtion to these Treating fractures while allowing function

20 Non-operative outcomes >90% heal 2 months Or until clinical/radiographic evidence of healing Those that don t Interposed tissue Medical co-morbidities

21 Humeral shaft - Operative Unable to maintain reduction Nerve injuries after reduction Open Segmental Multiple extremities Intra-articular extension

22 Operation types External fixation IM rodding Plate fixation

23 Nailing Intramedullary Rod

24 The standard of care Plate fixation

25 Surgical approaches Lateral and variants Lateral Anterolateral More proximal Posterior More distal

26 Anterolateral Universal approach to the entire humerus Coracoid to lateral supracondylar ridge Postioning Supine

27 Posterior Better for more distal fractures Tip of olecranon distally to posterolateral corner of acromion proximally Positioning Supine Decubitus Prone

28 Fixation Four holes on each side of fracture Large plates 4.5 mm LCP

29 Plate fixation High union rate, low complication rate, rapid return to function Immediate return to motion Minimally invasive plating

30 Complications Non-union Plate failure Iatrogenic injury Dictate nerve status and location

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32 Distal Humerus Treatment Very different Much more difficult

33 Surgical Anatomy Medial and lateral columns diverge from humeral shaft at 45 degree angle The columns are the important structures for support of the distal humeral triangle

34 Treatment Principles 1. Anatomic articular reduction 2. Stable internal fixation of the articular surface 3. Restoration of articular axial alignment 4. Stable internal fixation of the articular segment to the metaphysis and diaphysis 5. Early range of motion of the elbow

35 Distal humerus Non-operative Non-displaced Closed Rare

36 Non-operative treatment Posterior long arm splint

37 Non-operative treatment Hinged elbow brace

38 Essentially anything that is displaced Operative

39 Surgical Treatment Lateral decubitus position Prone positioning possible Supine position difficult Arm hanging over a post Sterile tourniquet if desired Midline posterior incision

40 Exposures Reduction influences outcome in articular fractures Exposure affects ability to achieve reduction Exposure influences outcome! Choose the exposure that fits the fracture pattern

41 Surgical exposures Intra-articular olecranon osteotomy Difficult joint reduction Triceps splitting, paratricipital, etc Easy joint reduction Or extra-articular Extra-articular olecranon osteotomy Little role

42 Osteotomy Fixation Single screw technique Long screw may be beneficial for adequate fixation Short screw may loosen or toggle with contraction of triceps against olecranon segment 30% non-union rate Hak and Golladay, JAAOS, 8:266-75, 2000

43 Engage anterior ulnar cortex here with wires to improve fixation stability/strength Tension band wire Length of screw may be important to resist toggling and loss of reduction Tension band screw

44 Osteotomy Fixation Dorsal plating Low profile periarticular implants now available Axial screw through plate Good results after plate fixation Hewin et al (2007) J Orthop Trauma 21:58 Tejwani et al (2002) Bull Hosp Jt Dis 61:27

45 To transpose or not to transpose? Identification and mobilization of the ulnar nerve is often required Ulnar nerve palsy may be related to injury, surgical exposure/mobilization/stripping, compression by implant, or scar formation

46 Fixation Implants determined by fracture pattern Extra-articular fractures may be stabilized by one or two contoured plates Locked vs. nonlocked based upon bone quality, working length for fixation, surgeon preference Intra-articular fractures Dual plates most often used in 1 of 2 configurations 90-90: medial and posterolateral Medial and lateral plating

47 The standard of care most of the time Dual plating

48 90/90 plating

49 All purpose

50 Other Potential Surgical Options Total elbow arthroplasty Comminuted intra-articular fracture in the elderly Promotes immediate ROM Usually limited by poor remaining bone stock Bag of bones technique Rarely indicated if at all

51 Complications Non-union Infection Stiffness?

52 Rehab The elbow gets stiff! Ideal early active motion if solid fixation If not healed normal anatomy and do later second operation for stiffness We have excellent therapists

53 Thank you!