DISTAL HUMERUS
FRACTURES WHEN TO DO
OLECRANON OSTEOTOMY
Steven A Chandler DO FAOAO Associate Clinical Professor Midwestern University
South Chicago Orthopedic Specialists SC
2315 E 93rd St Suite 200
Chicago Illinois 60617
(872) 228-0235
Distal Humerus Fractures
Incidence and Distribution Overall incidence in adults is small
lt057
Majority involve the articular segment 85
Partially articular comprising 5 and nonarticular fractures comprise 10
Bimodal distribution young males 12-19 yo result of high energy trauma or elderly females with osteoporotic bone secondary to falls
Distal Humerus Fractures
Anatomy
The distal humerus is widest distally in the coronal dimension to a maximum between the medial and lateral epicondyle
The joint surface to shaft axis is 4 to 8 degrees of valgus giving rise to the carrying angle
The articular segment projects anterior to the axis of the shaft at an angle of 400
(the capitellum slightly more forward then the trochlea)
Distal Humerus Fractures
Anatomy
Medial and lateral columns roughly triangular composed of an epicondyle (non articulating) and condyle (articulating)
Displacement of condylar fragment is common due to absence of muscle attachment to oppose those attached to the epicondyles
The medial epicondyle is closely related to the ulnar nerve and is the site of attachment of the ulnar collateral ligaments This being the strongest ligament of the elbow
Distal Humerus Fractures
AO Classification
AO Classification
Type A Extraarticular Fx
A1 apophyseal avulsion
A2 metaphyseal simple
A3 metaphyseal multifragmentary
Type B Partially articular part
of the articular segment remains
in congruity with the shaft
B1 lateral sagittal
B2 medial sagittal
B3 frontal
Distal Humerus Fractures
AO Classification AO Classification
Type C Complete articular no articular fracture fragment
remains in congruity with the shaft
C1 articular simple metaphyseal simple
C2 articular simple metaphyseal multifragmented
C3 articular and metaphyseal multifragmented
Distal Humerus Fractures
Mechanism and Assessment Mechanism of Injury
axial load through the elbow with the joint flexed beyond 90 degrees or direct trauma
Clinical Assessment Careful physical and neurovascular exam is
imperative checking for open wounds neurological and arterial injuries
Plain x-ray AP and Lateral while maintaining gentle longitudinal traction
Stress x-rays can help assess ligamentus stability
CT Scan to evaluate articular comminution
Distal Humerus Fractures
Treatment based on AO Classification
Nonoperative Treatment Nondisplaced distal humeral fractures
Patients who canrsquot tolerate anesthesia advanced dementia
Traction with conversion to cast functional brace or hinged brace when fracture is ldquostickyrdquo controlled motion is started
Outcomes of modern operative fixation is indicated in most cases
Other Methods ldquoBag of bonesrdquo arm is placed in a collar and cuff with as much flexion as possible elbow is left hanging free allowing gravity to exert a ligamentotaxis effect
Distal Humerus Fractures Operative
Treatment based on AO Classification
Evidence supports Operative Treatment in patients who can tolerate anesthesia with early ROM if appropriate
Displaced distal humerus fractures Exceptions
Frail or debilitated individuals Open woundsdegloving injury Blast or open crush injury Extreme osteoporosis
Intra-articular fractures
Distal Humerus Fractures Operative
Treatment based on AO Classification
Controversy in approach Triceps splitting
Triceps reflecting Triceps reflecting with anconeus pedicle Triceps sparing with and without olecranon osteotomy
Insufficient evidence to recommend or against ulnar nerve transposition
Speaker preference Triceps sparing or
reflecting for extra-articular or simple intra-articular fractures
Olecranon osteotomy for comminutedcomplex intra-articular fractures
No ulnar nerve transposition
Distal Humerus Fractures Operative
Treatment based on AO Classification
A Triceps splitting
B Triceps reflecting with anconeus pedicle
C Triceps reflecting
D Triceps sparing with amp wo olecranon osteotomy
Distal Humerus Fractures Operative
Treatment based on AO Classification
Triceps sparing Avoids extensor
violation
Utilizes medial and lateral windows on triceps
Good for extra-articular fractures and C-1 2 types
Disadvantage poor visualization of articular surface Can be converted to
olecranon osteotomy or TEA
Distal Humerus Fractures Operative
Treatment based on AO Classification
Triceps splitting Midline incision
leaves triceps tendon intact with extensorflexor fascia
Triceps repaired transosseous to olecranon functional studies equivalent to osteotomy
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon osteotomy Chervon osteotomy
25-3 cm from olecranon tip
Oscillating saw finished with osteotomy
Osteotomy fixated with either tension band intermedullary screw plate or IM nail
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon
osteotomy
Superior
visualization of
articular surface
Retrospective
Studies show no
functional difference
with triceps splitting
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon
osteotomy
6-30 hardware
removal
0-9 nonunion
rates
Distal Humerus Fractures Operative
Treatment based on AO Classification
Plate fixation Since 1970 AO introduction of dual column fixation substantial improvement in surgical outcomes Anatomic articular
reduction Rigid fixation with 2 plates 35 mm minimum
In cases of severe comminution of metaphysis or substantial bone loss Treat with
shortening but maintain alignment
Distal Humerus Fractures Operative
Treatment based on AO Classification
Debate on location of plate placement Perpendicular or
parallel to each other
Most studies show no significant difference in functional outcomes
Parallel plates had slight higher nonunion rate but stronger with metaphyseal comminution
Distal Humerus Fractures Operative
Treatment based on AO Classification
Use of locked
plating has been
controversial
proven superior in
osteoporotic bone
and comminuted
fractures
No data to go
against locked
plating
Distal Humerus Fractures Operative
Treatment based on AO Classification
Coronal Shear fracture OTAAO type B3
Uncommon involves capitellum trochlea or both
Usually associated with elbow dislocation
Often missed on plain x-rays 66 sensitivity CT recommended
Distal Humerus Fractures
Capitellum Fractures
Classification Type I Hahn-Steinthal
Fragment Large osseous component of capitellum sometimes with trochlear involvement
Type II Kocher-Lorenz Fragment Articular cartilage with minimal subcondylar bone attachment ldquo uncapping of the condylerdquo
Type III markedly comminuted
Distal Humerus Fractures
Capitellum Fractures Treatment Nonoperative Treatment
Primarily for nondisplaced fx Posterior splint immobilization for 3 weeks
Operative Treatment Goal is anatomic reduction ORIF
Indicated for displaced type I fractures Screws placed via lateral approach or posterior with olecranon
osteotomy for trochlea component or medial comminution headless screws may be placed anterior to posterior direction plate added to lateral column for comminution
Fixation should be stable enough to allow early ROM Excision
Contraindicated in the presence of associated elbow fractures Allows for early mobilization and less morbidity but associated
with instability Recommended treatment in old missed fractures with limited
ROM
Distal Humerus Fractures
Capitellum Fractures Complications
Complications Osteonecrosis uncommon
Posttraumatic arthritis increased with failure to restore articular congruity
Cubitus valgus may result with excision of the articular fragment or with associated lateral condylar or radial head fx It is associated with tardy ulnar palsy
Loss of motion (flexion) associated with retained chondral or osseous fragment that may become entrapped in the coronoid or radial fossae
Distal Humerus Fractures Operative
Treatment
Total Elbow Arthroplasty (TEA) Reserved for elderly
patients with poor bone quality low physical demands not amenable to ORIF
Goodexcellent results compared to ORIF in elderly as primary treatment
Distal Humerus Fractures Operative
Treatment
Total Elbow
Arthroplasty (TEA)
Higher rate of
infection nerve
injury implant
failure
Olecranon
Osteotomy
contraindicated
Distal Humerus Fractures
Complications
Ulnar nerve injury Due to initial
trauma or operative treatment
Transposition not proven to beneficial even when nerve is out preoperatively
Decompression recommended when nerve is out preop
Heterotopic Ossification (HO)
After operative fixation
Limits ROM
Prophylactic treatment indications are controversial
Use of indomethacin didnrsquot significantly reduce HO
When prophylaxis used 0-21 clinically significant HO
Distal Humerus Fractures Complications
Heterotopic
Ossification (HO)
1 dose post op
radiation and 2 weeks
indomethacin
treatment 3 rate
clinically significant
HO
Benefits weighted
against risks of union
with prophylactic
treatment
Heterotopic
Ossification (HO)
Risk factors CNS
injury delay in
operative treatment
sx prior to definitive
treatment
Distal Humerus Fractures Complications
Modern dual plate
fixation 89-100
union rates
Failing to adhere to
these principles
increase nonunion
rates
Nonunion treated with
revision ORIF bone
grafting selective
releases
Mean flex-ext arc
ROM 99deg-112deg
Recommended start
ROM at 2 weeks
Functional outcomes
after ORIF 84-100
goodexcellent
Regain 70-75
strength compared
to contra lateral side
DJ 2018 - OleON PPT
Tension Band w K-Wires
65 Cancellous Screw w Tension Band
Lag Screw w Tension Band
Plate Fixation
Current AO product options
Distal Humerus Fractures Fixation
Options of Olecranon Osteotomies
DJ 2018 - OleON PPT
Clinical needs
ndash Improved method to maintain reduction of olecranon osteotomy
ndash Intermedullary solution for fixation of an olecranon osteotomy
Indications The Olecranon Osteotomy Nail is indicated to treat osteotomies of the
olecranon
and simple olecranon fractures
The Olecranon Osteotomy Nail
Overview
DJ 2018 - OleON PPT
Main features and Benefits
Pre-osteotomy fixation ensuring anatomic alignment
Simpler fixation of olecranon osteotomy than current
commonly used techniques after distal humerus
surgery
Simple instrumentation for easy insertion and locking
of nail
Low profile minimizing soft tissue irritation and re-
operation
More stable fixation than current methods
Targeted locking to minimize size of incision
Mechanical testing on file at Synthes
The Olecranon Osteotomy Nail
Overview
Overall
Decision making made on most recent literature
Best available treatment option
Surgeon preference and comfort
Informed decision with patient
Need for prospective multicenter large scale study
Use sound surgical
techinque and use
AO fixation
prinicles
Distal Humerus Fractures
References
Fractures in Adults Rockwood and Wilkins Lippincott William amp Wilkins 2005 6th Edition
Handbook of Fractures Koval and Zuckerman Lippincott William amp Wilkins 2002 2nd Edition
Campbellrsquos Operative Orthopaedics Mosby tenth edition
Chapmans Orthopaedic Surgery 3rd Edition Lippincott Williams amp Wilkins
Distal Humerus Fractures
References Current Concepts Review Distal humerus Fractures in
Adults A Nauth MD M Mckee MD B Ristevski MD JBJS 2011 vol 93-A no 7 4-6-2011
The olecranon osteotomy a six-year experience in the treatment of intraarticular fractures of the distal humerus Coles CP Barei DP Nork SE Taitsman LA Hanel DP Bradford Henley M J Orthop Trauma 2006 Mar20(3)164-71
A true triceps-splitting approach for treatment of distal humerus fractures a preliminary report Ziran BH Smith WR Balk ML Manning CM Agudelo JF J Trauma 2005 Jan58(1)70-5
Distal Humeral Hemiarthroplasty vs Total Elbow Arthroplasty for Acute Distal Humeral Fractures R Rangarajan MD R Papandrea MD A Cil MD Orthopedics JanFeb vol40 no 113-23
Extra Articular fracture Distal Humerus fx
in 67 yo F after someone tried to steal her
purse
SP ORIF Extra Articular fracture with
triceps reflecting
24 yo male GSW
Under went ORIF triceps reflecting
approach
23 yo running from police for no
reasonhellip
SP ORIF with 90-90 plating with
olecranon osteotomy
21 yo SP GSW
SP ORIF with Triceps sparing
approach
2 weeks post op
89 YO SP Mechanical fail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
Distal Humerus Fractures
Incidence and Distribution Overall incidence in adults is small
lt057
Majority involve the articular segment 85
Partially articular comprising 5 and nonarticular fractures comprise 10
Bimodal distribution young males 12-19 yo result of high energy trauma or elderly females with osteoporotic bone secondary to falls
Distal Humerus Fractures
Anatomy
The distal humerus is widest distally in the coronal dimension to a maximum between the medial and lateral epicondyle
The joint surface to shaft axis is 4 to 8 degrees of valgus giving rise to the carrying angle
The articular segment projects anterior to the axis of the shaft at an angle of 400
(the capitellum slightly more forward then the trochlea)
Distal Humerus Fractures
Anatomy
Medial and lateral columns roughly triangular composed of an epicondyle (non articulating) and condyle (articulating)
Displacement of condylar fragment is common due to absence of muscle attachment to oppose those attached to the epicondyles
The medial epicondyle is closely related to the ulnar nerve and is the site of attachment of the ulnar collateral ligaments This being the strongest ligament of the elbow
Distal Humerus Fractures
AO Classification
AO Classification
Type A Extraarticular Fx
A1 apophyseal avulsion
A2 metaphyseal simple
A3 metaphyseal multifragmentary
Type B Partially articular part
of the articular segment remains
in congruity with the shaft
B1 lateral sagittal
B2 medial sagittal
B3 frontal
Distal Humerus Fractures
AO Classification AO Classification
Type C Complete articular no articular fracture fragment
remains in congruity with the shaft
C1 articular simple metaphyseal simple
C2 articular simple metaphyseal multifragmented
C3 articular and metaphyseal multifragmented
Distal Humerus Fractures
Mechanism and Assessment Mechanism of Injury
axial load through the elbow with the joint flexed beyond 90 degrees or direct trauma
Clinical Assessment Careful physical and neurovascular exam is
imperative checking for open wounds neurological and arterial injuries
Plain x-ray AP and Lateral while maintaining gentle longitudinal traction
Stress x-rays can help assess ligamentus stability
CT Scan to evaluate articular comminution
Distal Humerus Fractures
Treatment based on AO Classification
Nonoperative Treatment Nondisplaced distal humeral fractures
Patients who canrsquot tolerate anesthesia advanced dementia
Traction with conversion to cast functional brace or hinged brace when fracture is ldquostickyrdquo controlled motion is started
Outcomes of modern operative fixation is indicated in most cases
Other Methods ldquoBag of bonesrdquo arm is placed in a collar and cuff with as much flexion as possible elbow is left hanging free allowing gravity to exert a ligamentotaxis effect
Distal Humerus Fractures Operative
Treatment based on AO Classification
Evidence supports Operative Treatment in patients who can tolerate anesthesia with early ROM if appropriate
Displaced distal humerus fractures Exceptions
Frail or debilitated individuals Open woundsdegloving injury Blast or open crush injury Extreme osteoporosis
Intra-articular fractures
Distal Humerus Fractures Operative
Treatment based on AO Classification
Controversy in approach Triceps splitting
Triceps reflecting Triceps reflecting with anconeus pedicle Triceps sparing with and without olecranon osteotomy
Insufficient evidence to recommend or against ulnar nerve transposition
Speaker preference Triceps sparing or
reflecting for extra-articular or simple intra-articular fractures
Olecranon osteotomy for comminutedcomplex intra-articular fractures
No ulnar nerve transposition
Distal Humerus Fractures Operative
Treatment based on AO Classification
A Triceps splitting
B Triceps reflecting with anconeus pedicle
C Triceps reflecting
D Triceps sparing with amp wo olecranon osteotomy
Distal Humerus Fractures Operative
Treatment based on AO Classification
Triceps sparing Avoids extensor
violation
Utilizes medial and lateral windows on triceps
Good for extra-articular fractures and C-1 2 types
Disadvantage poor visualization of articular surface Can be converted to
olecranon osteotomy or TEA
Distal Humerus Fractures Operative
Treatment based on AO Classification
Triceps splitting Midline incision
leaves triceps tendon intact with extensorflexor fascia
Triceps repaired transosseous to olecranon functional studies equivalent to osteotomy
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon osteotomy Chervon osteotomy
25-3 cm from olecranon tip
Oscillating saw finished with osteotomy
Osteotomy fixated with either tension band intermedullary screw plate or IM nail
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon
osteotomy
Superior
visualization of
articular surface
Retrospective
Studies show no
functional difference
with triceps splitting
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon
osteotomy
6-30 hardware
removal
0-9 nonunion
rates
Distal Humerus Fractures Operative
Treatment based on AO Classification
Plate fixation Since 1970 AO introduction of dual column fixation substantial improvement in surgical outcomes Anatomic articular
reduction Rigid fixation with 2 plates 35 mm minimum
In cases of severe comminution of metaphysis or substantial bone loss Treat with
shortening but maintain alignment
Distal Humerus Fractures Operative
Treatment based on AO Classification
Debate on location of plate placement Perpendicular or
parallel to each other
Most studies show no significant difference in functional outcomes
Parallel plates had slight higher nonunion rate but stronger with metaphyseal comminution
Distal Humerus Fractures Operative
Treatment based on AO Classification
Use of locked
plating has been
controversial
proven superior in
osteoporotic bone
and comminuted
fractures
No data to go
against locked
plating
Distal Humerus Fractures Operative
Treatment based on AO Classification
Coronal Shear fracture OTAAO type B3
Uncommon involves capitellum trochlea or both
Usually associated with elbow dislocation
Often missed on plain x-rays 66 sensitivity CT recommended
Distal Humerus Fractures
Capitellum Fractures
Classification Type I Hahn-Steinthal
Fragment Large osseous component of capitellum sometimes with trochlear involvement
Type II Kocher-Lorenz Fragment Articular cartilage with minimal subcondylar bone attachment ldquo uncapping of the condylerdquo
Type III markedly comminuted
Distal Humerus Fractures
Capitellum Fractures Treatment Nonoperative Treatment
Primarily for nondisplaced fx Posterior splint immobilization for 3 weeks
Operative Treatment Goal is anatomic reduction ORIF
Indicated for displaced type I fractures Screws placed via lateral approach or posterior with olecranon
osteotomy for trochlea component or medial comminution headless screws may be placed anterior to posterior direction plate added to lateral column for comminution
Fixation should be stable enough to allow early ROM Excision
Contraindicated in the presence of associated elbow fractures Allows for early mobilization and less morbidity but associated
with instability Recommended treatment in old missed fractures with limited
ROM
Distal Humerus Fractures
Capitellum Fractures Complications
Complications Osteonecrosis uncommon
Posttraumatic arthritis increased with failure to restore articular congruity
Cubitus valgus may result with excision of the articular fragment or with associated lateral condylar or radial head fx It is associated with tardy ulnar palsy
Loss of motion (flexion) associated with retained chondral or osseous fragment that may become entrapped in the coronoid or radial fossae
Distal Humerus Fractures Operative
Treatment
Total Elbow Arthroplasty (TEA) Reserved for elderly
patients with poor bone quality low physical demands not amenable to ORIF
Goodexcellent results compared to ORIF in elderly as primary treatment
Distal Humerus Fractures Operative
Treatment
Total Elbow
Arthroplasty (TEA)
Higher rate of
infection nerve
injury implant
failure
Olecranon
Osteotomy
contraindicated
Distal Humerus Fractures
Complications
Ulnar nerve injury Due to initial
trauma or operative treatment
Transposition not proven to beneficial even when nerve is out preoperatively
Decompression recommended when nerve is out preop
Heterotopic Ossification (HO)
After operative fixation
Limits ROM
Prophylactic treatment indications are controversial
Use of indomethacin didnrsquot significantly reduce HO
When prophylaxis used 0-21 clinically significant HO
Distal Humerus Fractures Complications
Heterotopic
Ossification (HO)
1 dose post op
radiation and 2 weeks
indomethacin
treatment 3 rate
clinically significant
HO
Benefits weighted
against risks of union
with prophylactic
treatment
Heterotopic
Ossification (HO)
Risk factors CNS
injury delay in
operative treatment
sx prior to definitive
treatment
Distal Humerus Fractures Complications
Modern dual plate
fixation 89-100
union rates
Failing to adhere to
these principles
increase nonunion
rates
Nonunion treated with
revision ORIF bone
grafting selective
releases
Mean flex-ext arc
ROM 99deg-112deg
Recommended start
ROM at 2 weeks
Functional outcomes
after ORIF 84-100
goodexcellent
Regain 70-75
strength compared
to contra lateral side
DJ 2018 - OleON PPT
Tension Band w K-Wires
65 Cancellous Screw w Tension Band
Lag Screw w Tension Band
Plate Fixation
Current AO product options
Distal Humerus Fractures Fixation
Options of Olecranon Osteotomies
DJ 2018 - OleON PPT
Clinical needs
ndash Improved method to maintain reduction of olecranon osteotomy
ndash Intermedullary solution for fixation of an olecranon osteotomy
Indications The Olecranon Osteotomy Nail is indicated to treat osteotomies of the
olecranon
and simple olecranon fractures
The Olecranon Osteotomy Nail
Overview
DJ 2018 - OleON PPT
Main features and Benefits
Pre-osteotomy fixation ensuring anatomic alignment
Simpler fixation of olecranon osteotomy than current
commonly used techniques after distal humerus
surgery
Simple instrumentation for easy insertion and locking
of nail
Low profile minimizing soft tissue irritation and re-
operation
More stable fixation than current methods
Targeted locking to minimize size of incision
Mechanical testing on file at Synthes
The Olecranon Osteotomy Nail
Overview
Overall
Decision making made on most recent literature
Best available treatment option
Surgeon preference and comfort
Informed decision with patient
Need for prospective multicenter large scale study
Use sound surgical
techinque and use
AO fixation
prinicles
Distal Humerus Fractures
References
Fractures in Adults Rockwood and Wilkins Lippincott William amp Wilkins 2005 6th Edition
Handbook of Fractures Koval and Zuckerman Lippincott William amp Wilkins 2002 2nd Edition
Campbellrsquos Operative Orthopaedics Mosby tenth edition
Chapmans Orthopaedic Surgery 3rd Edition Lippincott Williams amp Wilkins
Distal Humerus Fractures
References Current Concepts Review Distal humerus Fractures in
Adults A Nauth MD M Mckee MD B Ristevski MD JBJS 2011 vol 93-A no 7 4-6-2011
The olecranon osteotomy a six-year experience in the treatment of intraarticular fractures of the distal humerus Coles CP Barei DP Nork SE Taitsman LA Hanel DP Bradford Henley M J Orthop Trauma 2006 Mar20(3)164-71
A true triceps-splitting approach for treatment of distal humerus fractures a preliminary report Ziran BH Smith WR Balk ML Manning CM Agudelo JF J Trauma 2005 Jan58(1)70-5
Distal Humeral Hemiarthroplasty vs Total Elbow Arthroplasty for Acute Distal Humeral Fractures R Rangarajan MD R Papandrea MD A Cil MD Orthopedics JanFeb vol40 no 113-23
Extra Articular fracture Distal Humerus fx
in 67 yo F after someone tried to steal her
purse
SP ORIF Extra Articular fracture with
triceps reflecting
24 yo male GSW
Under went ORIF triceps reflecting
approach
23 yo running from police for no
reasonhellip
SP ORIF with 90-90 plating with
olecranon osteotomy
21 yo SP GSW
SP ORIF with Triceps sparing
approach
2 weeks post op
89 YO SP Mechanical fail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
Distal Humerus Fractures
Anatomy
The distal humerus is widest distally in the coronal dimension to a maximum between the medial and lateral epicondyle
The joint surface to shaft axis is 4 to 8 degrees of valgus giving rise to the carrying angle
The articular segment projects anterior to the axis of the shaft at an angle of 400
(the capitellum slightly more forward then the trochlea)
Distal Humerus Fractures
Anatomy
Medial and lateral columns roughly triangular composed of an epicondyle (non articulating) and condyle (articulating)
Displacement of condylar fragment is common due to absence of muscle attachment to oppose those attached to the epicondyles
The medial epicondyle is closely related to the ulnar nerve and is the site of attachment of the ulnar collateral ligaments This being the strongest ligament of the elbow
Distal Humerus Fractures
AO Classification
AO Classification
Type A Extraarticular Fx
A1 apophyseal avulsion
A2 metaphyseal simple
A3 metaphyseal multifragmentary
Type B Partially articular part
of the articular segment remains
in congruity with the shaft
B1 lateral sagittal
B2 medial sagittal
B3 frontal
Distal Humerus Fractures
AO Classification AO Classification
Type C Complete articular no articular fracture fragment
remains in congruity with the shaft
C1 articular simple metaphyseal simple
C2 articular simple metaphyseal multifragmented
C3 articular and metaphyseal multifragmented
Distal Humerus Fractures
Mechanism and Assessment Mechanism of Injury
axial load through the elbow with the joint flexed beyond 90 degrees or direct trauma
Clinical Assessment Careful physical and neurovascular exam is
imperative checking for open wounds neurological and arterial injuries
Plain x-ray AP and Lateral while maintaining gentle longitudinal traction
Stress x-rays can help assess ligamentus stability
CT Scan to evaluate articular comminution
Distal Humerus Fractures
Treatment based on AO Classification
Nonoperative Treatment Nondisplaced distal humeral fractures
Patients who canrsquot tolerate anesthesia advanced dementia
Traction with conversion to cast functional brace or hinged brace when fracture is ldquostickyrdquo controlled motion is started
Outcomes of modern operative fixation is indicated in most cases
Other Methods ldquoBag of bonesrdquo arm is placed in a collar and cuff with as much flexion as possible elbow is left hanging free allowing gravity to exert a ligamentotaxis effect
Distal Humerus Fractures Operative
Treatment based on AO Classification
Evidence supports Operative Treatment in patients who can tolerate anesthesia with early ROM if appropriate
Displaced distal humerus fractures Exceptions
Frail or debilitated individuals Open woundsdegloving injury Blast or open crush injury Extreme osteoporosis
Intra-articular fractures
Distal Humerus Fractures Operative
Treatment based on AO Classification
Controversy in approach Triceps splitting
Triceps reflecting Triceps reflecting with anconeus pedicle Triceps sparing with and without olecranon osteotomy
Insufficient evidence to recommend or against ulnar nerve transposition
Speaker preference Triceps sparing or
reflecting for extra-articular or simple intra-articular fractures
Olecranon osteotomy for comminutedcomplex intra-articular fractures
No ulnar nerve transposition
Distal Humerus Fractures Operative
Treatment based on AO Classification
A Triceps splitting
B Triceps reflecting with anconeus pedicle
C Triceps reflecting
D Triceps sparing with amp wo olecranon osteotomy
Distal Humerus Fractures Operative
Treatment based on AO Classification
Triceps sparing Avoids extensor
violation
Utilizes medial and lateral windows on triceps
Good for extra-articular fractures and C-1 2 types
Disadvantage poor visualization of articular surface Can be converted to
olecranon osteotomy or TEA
Distal Humerus Fractures Operative
Treatment based on AO Classification
Triceps splitting Midline incision
leaves triceps tendon intact with extensorflexor fascia
Triceps repaired transosseous to olecranon functional studies equivalent to osteotomy
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon osteotomy Chervon osteotomy
25-3 cm from olecranon tip
Oscillating saw finished with osteotomy
Osteotomy fixated with either tension band intermedullary screw plate or IM nail
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon
osteotomy
Superior
visualization of
articular surface
Retrospective
Studies show no
functional difference
with triceps splitting
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon
osteotomy
6-30 hardware
removal
0-9 nonunion
rates
Distal Humerus Fractures Operative
Treatment based on AO Classification
Plate fixation Since 1970 AO introduction of dual column fixation substantial improvement in surgical outcomes Anatomic articular
reduction Rigid fixation with 2 plates 35 mm minimum
In cases of severe comminution of metaphysis or substantial bone loss Treat with
shortening but maintain alignment
Distal Humerus Fractures Operative
Treatment based on AO Classification
Debate on location of plate placement Perpendicular or
parallel to each other
Most studies show no significant difference in functional outcomes
Parallel plates had slight higher nonunion rate but stronger with metaphyseal comminution
Distal Humerus Fractures Operative
Treatment based on AO Classification
Use of locked
plating has been
controversial
proven superior in
osteoporotic bone
and comminuted
fractures
No data to go
against locked
plating
Distal Humerus Fractures Operative
Treatment based on AO Classification
Coronal Shear fracture OTAAO type B3
Uncommon involves capitellum trochlea or both
Usually associated with elbow dislocation
Often missed on plain x-rays 66 sensitivity CT recommended
Distal Humerus Fractures
Capitellum Fractures
Classification Type I Hahn-Steinthal
Fragment Large osseous component of capitellum sometimes with trochlear involvement
Type II Kocher-Lorenz Fragment Articular cartilage with minimal subcondylar bone attachment ldquo uncapping of the condylerdquo
Type III markedly comminuted
Distal Humerus Fractures
Capitellum Fractures Treatment Nonoperative Treatment
Primarily for nondisplaced fx Posterior splint immobilization for 3 weeks
Operative Treatment Goal is anatomic reduction ORIF
Indicated for displaced type I fractures Screws placed via lateral approach or posterior with olecranon
osteotomy for trochlea component or medial comminution headless screws may be placed anterior to posterior direction plate added to lateral column for comminution
Fixation should be stable enough to allow early ROM Excision
Contraindicated in the presence of associated elbow fractures Allows for early mobilization and less morbidity but associated
with instability Recommended treatment in old missed fractures with limited
ROM
Distal Humerus Fractures
Capitellum Fractures Complications
Complications Osteonecrosis uncommon
Posttraumatic arthritis increased with failure to restore articular congruity
Cubitus valgus may result with excision of the articular fragment or with associated lateral condylar or radial head fx It is associated with tardy ulnar palsy
Loss of motion (flexion) associated with retained chondral or osseous fragment that may become entrapped in the coronoid or radial fossae
Distal Humerus Fractures Operative
Treatment
Total Elbow Arthroplasty (TEA) Reserved for elderly
patients with poor bone quality low physical demands not amenable to ORIF
Goodexcellent results compared to ORIF in elderly as primary treatment
Distal Humerus Fractures Operative
Treatment
Total Elbow
Arthroplasty (TEA)
Higher rate of
infection nerve
injury implant
failure
Olecranon
Osteotomy
contraindicated
Distal Humerus Fractures
Complications
Ulnar nerve injury Due to initial
trauma or operative treatment
Transposition not proven to beneficial even when nerve is out preoperatively
Decompression recommended when nerve is out preop
Heterotopic Ossification (HO)
After operative fixation
Limits ROM
Prophylactic treatment indications are controversial
Use of indomethacin didnrsquot significantly reduce HO
When prophylaxis used 0-21 clinically significant HO
Distal Humerus Fractures Complications
Heterotopic
Ossification (HO)
1 dose post op
radiation and 2 weeks
indomethacin
treatment 3 rate
clinically significant
HO
Benefits weighted
against risks of union
with prophylactic
treatment
Heterotopic
Ossification (HO)
Risk factors CNS
injury delay in
operative treatment
sx prior to definitive
treatment
Distal Humerus Fractures Complications
Modern dual plate
fixation 89-100
union rates
Failing to adhere to
these principles
increase nonunion
rates
Nonunion treated with
revision ORIF bone
grafting selective
releases
Mean flex-ext arc
ROM 99deg-112deg
Recommended start
ROM at 2 weeks
Functional outcomes
after ORIF 84-100
goodexcellent
Regain 70-75
strength compared
to contra lateral side
DJ 2018 - OleON PPT
Tension Band w K-Wires
65 Cancellous Screw w Tension Band
Lag Screw w Tension Band
Plate Fixation
Current AO product options
Distal Humerus Fractures Fixation
Options of Olecranon Osteotomies
DJ 2018 - OleON PPT
Clinical needs
ndash Improved method to maintain reduction of olecranon osteotomy
ndash Intermedullary solution for fixation of an olecranon osteotomy
Indications The Olecranon Osteotomy Nail is indicated to treat osteotomies of the
olecranon
and simple olecranon fractures
The Olecranon Osteotomy Nail
Overview
DJ 2018 - OleON PPT
Main features and Benefits
Pre-osteotomy fixation ensuring anatomic alignment
Simpler fixation of olecranon osteotomy than current
commonly used techniques after distal humerus
surgery
Simple instrumentation for easy insertion and locking
of nail
Low profile minimizing soft tissue irritation and re-
operation
More stable fixation than current methods
Targeted locking to minimize size of incision
Mechanical testing on file at Synthes
The Olecranon Osteotomy Nail
Overview
Overall
Decision making made on most recent literature
Best available treatment option
Surgeon preference and comfort
Informed decision with patient
Need for prospective multicenter large scale study
Use sound surgical
techinque and use
AO fixation
prinicles
Distal Humerus Fractures
References
Fractures in Adults Rockwood and Wilkins Lippincott William amp Wilkins 2005 6th Edition
Handbook of Fractures Koval and Zuckerman Lippincott William amp Wilkins 2002 2nd Edition
Campbellrsquos Operative Orthopaedics Mosby tenth edition
Chapmans Orthopaedic Surgery 3rd Edition Lippincott Williams amp Wilkins
Distal Humerus Fractures
References Current Concepts Review Distal humerus Fractures in
Adults A Nauth MD M Mckee MD B Ristevski MD JBJS 2011 vol 93-A no 7 4-6-2011
The olecranon osteotomy a six-year experience in the treatment of intraarticular fractures of the distal humerus Coles CP Barei DP Nork SE Taitsman LA Hanel DP Bradford Henley M J Orthop Trauma 2006 Mar20(3)164-71
A true triceps-splitting approach for treatment of distal humerus fractures a preliminary report Ziran BH Smith WR Balk ML Manning CM Agudelo JF J Trauma 2005 Jan58(1)70-5
Distal Humeral Hemiarthroplasty vs Total Elbow Arthroplasty for Acute Distal Humeral Fractures R Rangarajan MD R Papandrea MD A Cil MD Orthopedics JanFeb vol40 no 113-23
Extra Articular fracture Distal Humerus fx
in 67 yo F after someone tried to steal her
purse
SP ORIF Extra Articular fracture with
triceps reflecting
24 yo male GSW
Under went ORIF triceps reflecting
approach
23 yo running from police for no
reasonhellip
SP ORIF with 90-90 plating with
olecranon osteotomy
21 yo SP GSW
SP ORIF with Triceps sparing
approach
2 weeks post op
89 YO SP Mechanical fail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
Distal Humerus Fractures
Anatomy
Medial and lateral columns roughly triangular composed of an epicondyle (non articulating) and condyle (articulating)
Displacement of condylar fragment is common due to absence of muscle attachment to oppose those attached to the epicondyles
The medial epicondyle is closely related to the ulnar nerve and is the site of attachment of the ulnar collateral ligaments This being the strongest ligament of the elbow
Distal Humerus Fractures
AO Classification
AO Classification
Type A Extraarticular Fx
A1 apophyseal avulsion
A2 metaphyseal simple
A3 metaphyseal multifragmentary
Type B Partially articular part
of the articular segment remains
in congruity with the shaft
B1 lateral sagittal
B2 medial sagittal
B3 frontal
Distal Humerus Fractures
AO Classification AO Classification
Type C Complete articular no articular fracture fragment
remains in congruity with the shaft
C1 articular simple metaphyseal simple
C2 articular simple metaphyseal multifragmented
C3 articular and metaphyseal multifragmented
Distal Humerus Fractures
Mechanism and Assessment Mechanism of Injury
axial load through the elbow with the joint flexed beyond 90 degrees or direct trauma
Clinical Assessment Careful physical and neurovascular exam is
imperative checking for open wounds neurological and arterial injuries
Plain x-ray AP and Lateral while maintaining gentle longitudinal traction
Stress x-rays can help assess ligamentus stability
CT Scan to evaluate articular comminution
Distal Humerus Fractures
Treatment based on AO Classification
Nonoperative Treatment Nondisplaced distal humeral fractures
Patients who canrsquot tolerate anesthesia advanced dementia
Traction with conversion to cast functional brace or hinged brace when fracture is ldquostickyrdquo controlled motion is started
Outcomes of modern operative fixation is indicated in most cases
Other Methods ldquoBag of bonesrdquo arm is placed in a collar and cuff with as much flexion as possible elbow is left hanging free allowing gravity to exert a ligamentotaxis effect
Distal Humerus Fractures Operative
Treatment based on AO Classification
Evidence supports Operative Treatment in patients who can tolerate anesthesia with early ROM if appropriate
Displaced distal humerus fractures Exceptions
Frail or debilitated individuals Open woundsdegloving injury Blast or open crush injury Extreme osteoporosis
Intra-articular fractures
Distal Humerus Fractures Operative
Treatment based on AO Classification
Controversy in approach Triceps splitting
Triceps reflecting Triceps reflecting with anconeus pedicle Triceps sparing with and without olecranon osteotomy
Insufficient evidence to recommend or against ulnar nerve transposition
Speaker preference Triceps sparing or
reflecting for extra-articular or simple intra-articular fractures
Olecranon osteotomy for comminutedcomplex intra-articular fractures
No ulnar nerve transposition
Distal Humerus Fractures Operative
Treatment based on AO Classification
A Triceps splitting
B Triceps reflecting with anconeus pedicle
C Triceps reflecting
D Triceps sparing with amp wo olecranon osteotomy
Distal Humerus Fractures Operative
Treatment based on AO Classification
Triceps sparing Avoids extensor
violation
Utilizes medial and lateral windows on triceps
Good for extra-articular fractures and C-1 2 types
Disadvantage poor visualization of articular surface Can be converted to
olecranon osteotomy or TEA
Distal Humerus Fractures Operative
Treatment based on AO Classification
Triceps splitting Midline incision
leaves triceps tendon intact with extensorflexor fascia
Triceps repaired transosseous to olecranon functional studies equivalent to osteotomy
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon osteotomy Chervon osteotomy
25-3 cm from olecranon tip
Oscillating saw finished with osteotomy
Osteotomy fixated with either tension band intermedullary screw plate or IM nail
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon
osteotomy
Superior
visualization of
articular surface
Retrospective
Studies show no
functional difference
with triceps splitting
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon
osteotomy
6-30 hardware
removal
0-9 nonunion
rates
Distal Humerus Fractures Operative
Treatment based on AO Classification
Plate fixation Since 1970 AO introduction of dual column fixation substantial improvement in surgical outcomes Anatomic articular
reduction Rigid fixation with 2 plates 35 mm minimum
In cases of severe comminution of metaphysis or substantial bone loss Treat with
shortening but maintain alignment
Distal Humerus Fractures Operative
Treatment based on AO Classification
Debate on location of plate placement Perpendicular or
parallel to each other
Most studies show no significant difference in functional outcomes
Parallel plates had slight higher nonunion rate but stronger with metaphyseal comminution
Distal Humerus Fractures Operative
Treatment based on AO Classification
Use of locked
plating has been
controversial
proven superior in
osteoporotic bone
and comminuted
fractures
No data to go
against locked
plating
Distal Humerus Fractures Operative
Treatment based on AO Classification
Coronal Shear fracture OTAAO type B3
Uncommon involves capitellum trochlea or both
Usually associated with elbow dislocation
Often missed on plain x-rays 66 sensitivity CT recommended
Distal Humerus Fractures
Capitellum Fractures
Classification Type I Hahn-Steinthal
Fragment Large osseous component of capitellum sometimes with trochlear involvement
Type II Kocher-Lorenz Fragment Articular cartilage with minimal subcondylar bone attachment ldquo uncapping of the condylerdquo
Type III markedly comminuted
Distal Humerus Fractures
Capitellum Fractures Treatment Nonoperative Treatment
Primarily for nondisplaced fx Posterior splint immobilization for 3 weeks
Operative Treatment Goal is anatomic reduction ORIF
Indicated for displaced type I fractures Screws placed via lateral approach or posterior with olecranon
osteotomy for trochlea component or medial comminution headless screws may be placed anterior to posterior direction plate added to lateral column for comminution
Fixation should be stable enough to allow early ROM Excision
Contraindicated in the presence of associated elbow fractures Allows for early mobilization and less morbidity but associated
with instability Recommended treatment in old missed fractures with limited
ROM
Distal Humerus Fractures
Capitellum Fractures Complications
Complications Osteonecrosis uncommon
Posttraumatic arthritis increased with failure to restore articular congruity
Cubitus valgus may result with excision of the articular fragment or with associated lateral condylar or radial head fx It is associated with tardy ulnar palsy
Loss of motion (flexion) associated with retained chondral or osseous fragment that may become entrapped in the coronoid or radial fossae
Distal Humerus Fractures Operative
Treatment
Total Elbow Arthroplasty (TEA) Reserved for elderly
patients with poor bone quality low physical demands not amenable to ORIF
Goodexcellent results compared to ORIF in elderly as primary treatment
Distal Humerus Fractures Operative
Treatment
Total Elbow
Arthroplasty (TEA)
Higher rate of
infection nerve
injury implant
failure
Olecranon
Osteotomy
contraindicated
Distal Humerus Fractures
Complications
Ulnar nerve injury Due to initial
trauma or operative treatment
Transposition not proven to beneficial even when nerve is out preoperatively
Decompression recommended when nerve is out preop
Heterotopic Ossification (HO)
After operative fixation
Limits ROM
Prophylactic treatment indications are controversial
Use of indomethacin didnrsquot significantly reduce HO
When prophylaxis used 0-21 clinically significant HO
Distal Humerus Fractures Complications
Heterotopic
Ossification (HO)
1 dose post op
radiation and 2 weeks
indomethacin
treatment 3 rate
clinically significant
HO
Benefits weighted
against risks of union
with prophylactic
treatment
Heterotopic
Ossification (HO)
Risk factors CNS
injury delay in
operative treatment
sx prior to definitive
treatment
Distal Humerus Fractures Complications
Modern dual plate
fixation 89-100
union rates
Failing to adhere to
these principles
increase nonunion
rates
Nonunion treated with
revision ORIF bone
grafting selective
releases
Mean flex-ext arc
ROM 99deg-112deg
Recommended start
ROM at 2 weeks
Functional outcomes
after ORIF 84-100
goodexcellent
Regain 70-75
strength compared
to contra lateral side
DJ 2018 - OleON PPT
Tension Band w K-Wires
65 Cancellous Screw w Tension Band
Lag Screw w Tension Band
Plate Fixation
Current AO product options
Distal Humerus Fractures Fixation
Options of Olecranon Osteotomies
DJ 2018 - OleON PPT
Clinical needs
ndash Improved method to maintain reduction of olecranon osteotomy
ndash Intermedullary solution for fixation of an olecranon osteotomy
Indications The Olecranon Osteotomy Nail is indicated to treat osteotomies of the
olecranon
and simple olecranon fractures
The Olecranon Osteotomy Nail
Overview
DJ 2018 - OleON PPT
Main features and Benefits
Pre-osteotomy fixation ensuring anatomic alignment
Simpler fixation of olecranon osteotomy than current
commonly used techniques after distal humerus
surgery
Simple instrumentation for easy insertion and locking
of nail
Low profile minimizing soft tissue irritation and re-
operation
More stable fixation than current methods
Targeted locking to minimize size of incision
Mechanical testing on file at Synthes
The Olecranon Osteotomy Nail
Overview
Overall
Decision making made on most recent literature
Best available treatment option
Surgeon preference and comfort
Informed decision with patient
Need for prospective multicenter large scale study
Use sound surgical
techinque and use
AO fixation
prinicles
Distal Humerus Fractures
References
Fractures in Adults Rockwood and Wilkins Lippincott William amp Wilkins 2005 6th Edition
Handbook of Fractures Koval and Zuckerman Lippincott William amp Wilkins 2002 2nd Edition
Campbellrsquos Operative Orthopaedics Mosby tenth edition
Chapmans Orthopaedic Surgery 3rd Edition Lippincott Williams amp Wilkins
Distal Humerus Fractures
References Current Concepts Review Distal humerus Fractures in
Adults A Nauth MD M Mckee MD B Ristevski MD JBJS 2011 vol 93-A no 7 4-6-2011
The olecranon osteotomy a six-year experience in the treatment of intraarticular fractures of the distal humerus Coles CP Barei DP Nork SE Taitsman LA Hanel DP Bradford Henley M J Orthop Trauma 2006 Mar20(3)164-71
A true triceps-splitting approach for treatment of distal humerus fractures a preliminary report Ziran BH Smith WR Balk ML Manning CM Agudelo JF J Trauma 2005 Jan58(1)70-5
Distal Humeral Hemiarthroplasty vs Total Elbow Arthroplasty for Acute Distal Humeral Fractures R Rangarajan MD R Papandrea MD A Cil MD Orthopedics JanFeb vol40 no 113-23
Extra Articular fracture Distal Humerus fx
in 67 yo F after someone tried to steal her
purse
SP ORIF Extra Articular fracture with
triceps reflecting
24 yo male GSW
Under went ORIF triceps reflecting
approach
23 yo running from police for no
reasonhellip
SP ORIF with 90-90 plating with
olecranon osteotomy
21 yo SP GSW
SP ORIF with Triceps sparing
approach
2 weeks post op
89 YO SP Mechanical fail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
Distal Humerus Fractures
AO Classification
AO Classification
Type A Extraarticular Fx
A1 apophyseal avulsion
A2 metaphyseal simple
A3 metaphyseal multifragmentary
Type B Partially articular part
of the articular segment remains
in congruity with the shaft
B1 lateral sagittal
B2 medial sagittal
B3 frontal
Distal Humerus Fractures
AO Classification AO Classification
Type C Complete articular no articular fracture fragment
remains in congruity with the shaft
C1 articular simple metaphyseal simple
C2 articular simple metaphyseal multifragmented
C3 articular and metaphyseal multifragmented
Distal Humerus Fractures
Mechanism and Assessment Mechanism of Injury
axial load through the elbow with the joint flexed beyond 90 degrees or direct trauma
Clinical Assessment Careful physical and neurovascular exam is
imperative checking for open wounds neurological and arterial injuries
Plain x-ray AP and Lateral while maintaining gentle longitudinal traction
Stress x-rays can help assess ligamentus stability
CT Scan to evaluate articular comminution
Distal Humerus Fractures
Treatment based on AO Classification
Nonoperative Treatment Nondisplaced distal humeral fractures
Patients who canrsquot tolerate anesthesia advanced dementia
Traction with conversion to cast functional brace or hinged brace when fracture is ldquostickyrdquo controlled motion is started
Outcomes of modern operative fixation is indicated in most cases
Other Methods ldquoBag of bonesrdquo arm is placed in a collar and cuff with as much flexion as possible elbow is left hanging free allowing gravity to exert a ligamentotaxis effect
Distal Humerus Fractures Operative
Treatment based on AO Classification
Evidence supports Operative Treatment in patients who can tolerate anesthesia with early ROM if appropriate
Displaced distal humerus fractures Exceptions
Frail or debilitated individuals Open woundsdegloving injury Blast or open crush injury Extreme osteoporosis
Intra-articular fractures
Distal Humerus Fractures Operative
Treatment based on AO Classification
Controversy in approach Triceps splitting
Triceps reflecting Triceps reflecting with anconeus pedicle Triceps sparing with and without olecranon osteotomy
Insufficient evidence to recommend or against ulnar nerve transposition
Speaker preference Triceps sparing or
reflecting for extra-articular or simple intra-articular fractures
Olecranon osteotomy for comminutedcomplex intra-articular fractures
No ulnar nerve transposition
Distal Humerus Fractures Operative
Treatment based on AO Classification
A Triceps splitting
B Triceps reflecting with anconeus pedicle
C Triceps reflecting
D Triceps sparing with amp wo olecranon osteotomy
Distal Humerus Fractures Operative
Treatment based on AO Classification
Triceps sparing Avoids extensor
violation
Utilizes medial and lateral windows on triceps
Good for extra-articular fractures and C-1 2 types
Disadvantage poor visualization of articular surface Can be converted to
olecranon osteotomy or TEA
Distal Humerus Fractures Operative
Treatment based on AO Classification
Triceps splitting Midline incision
leaves triceps tendon intact with extensorflexor fascia
Triceps repaired transosseous to olecranon functional studies equivalent to osteotomy
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon osteotomy Chervon osteotomy
25-3 cm from olecranon tip
Oscillating saw finished with osteotomy
Osteotomy fixated with either tension band intermedullary screw plate or IM nail
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon
osteotomy
Superior
visualization of
articular surface
Retrospective
Studies show no
functional difference
with triceps splitting
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon
osteotomy
6-30 hardware
removal
0-9 nonunion
rates
Distal Humerus Fractures Operative
Treatment based on AO Classification
Plate fixation Since 1970 AO introduction of dual column fixation substantial improvement in surgical outcomes Anatomic articular
reduction Rigid fixation with 2 plates 35 mm minimum
In cases of severe comminution of metaphysis or substantial bone loss Treat with
shortening but maintain alignment
Distal Humerus Fractures Operative
Treatment based on AO Classification
Debate on location of plate placement Perpendicular or
parallel to each other
Most studies show no significant difference in functional outcomes
Parallel plates had slight higher nonunion rate but stronger with metaphyseal comminution
Distal Humerus Fractures Operative
Treatment based on AO Classification
Use of locked
plating has been
controversial
proven superior in
osteoporotic bone
and comminuted
fractures
No data to go
against locked
plating
Distal Humerus Fractures Operative
Treatment based on AO Classification
Coronal Shear fracture OTAAO type B3
Uncommon involves capitellum trochlea or both
Usually associated with elbow dislocation
Often missed on plain x-rays 66 sensitivity CT recommended
Distal Humerus Fractures
Capitellum Fractures
Classification Type I Hahn-Steinthal
Fragment Large osseous component of capitellum sometimes with trochlear involvement
Type II Kocher-Lorenz Fragment Articular cartilage with minimal subcondylar bone attachment ldquo uncapping of the condylerdquo
Type III markedly comminuted
Distal Humerus Fractures
Capitellum Fractures Treatment Nonoperative Treatment
Primarily for nondisplaced fx Posterior splint immobilization for 3 weeks
Operative Treatment Goal is anatomic reduction ORIF
Indicated for displaced type I fractures Screws placed via lateral approach or posterior with olecranon
osteotomy for trochlea component or medial comminution headless screws may be placed anterior to posterior direction plate added to lateral column for comminution
Fixation should be stable enough to allow early ROM Excision
Contraindicated in the presence of associated elbow fractures Allows for early mobilization and less morbidity but associated
with instability Recommended treatment in old missed fractures with limited
ROM
Distal Humerus Fractures
Capitellum Fractures Complications
Complications Osteonecrosis uncommon
Posttraumatic arthritis increased with failure to restore articular congruity
Cubitus valgus may result with excision of the articular fragment or with associated lateral condylar or radial head fx It is associated with tardy ulnar palsy
Loss of motion (flexion) associated with retained chondral or osseous fragment that may become entrapped in the coronoid or radial fossae
Distal Humerus Fractures Operative
Treatment
Total Elbow Arthroplasty (TEA) Reserved for elderly
patients with poor bone quality low physical demands not amenable to ORIF
Goodexcellent results compared to ORIF in elderly as primary treatment
Distal Humerus Fractures Operative
Treatment
Total Elbow
Arthroplasty (TEA)
Higher rate of
infection nerve
injury implant
failure
Olecranon
Osteotomy
contraindicated
Distal Humerus Fractures
Complications
Ulnar nerve injury Due to initial
trauma or operative treatment
Transposition not proven to beneficial even when nerve is out preoperatively
Decompression recommended when nerve is out preop
Heterotopic Ossification (HO)
After operative fixation
Limits ROM
Prophylactic treatment indications are controversial
Use of indomethacin didnrsquot significantly reduce HO
When prophylaxis used 0-21 clinically significant HO
Distal Humerus Fractures Complications
Heterotopic
Ossification (HO)
1 dose post op
radiation and 2 weeks
indomethacin
treatment 3 rate
clinically significant
HO
Benefits weighted
against risks of union
with prophylactic
treatment
Heterotopic
Ossification (HO)
Risk factors CNS
injury delay in
operative treatment
sx prior to definitive
treatment
Distal Humerus Fractures Complications
Modern dual plate
fixation 89-100
union rates
Failing to adhere to
these principles
increase nonunion
rates
Nonunion treated with
revision ORIF bone
grafting selective
releases
Mean flex-ext arc
ROM 99deg-112deg
Recommended start
ROM at 2 weeks
Functional outcomes
after ORIF 84-100
goodexcellent
Regain 70-75
strength compared
to contra lateral side
DJ 2018 - OleON PPT
Tension Band w K-Wires
65 Cancellous Screw w Tension Band
Lag Screw w Tension Band
Plate Fixation
Current AO product options
Distal Humerus Fractures Fixation
Options of Olecranon Osteotomies
DJ 2018 - OleON PPT
Clinical needs
ndash Improved method to maintain reduction of olecranon osteotomy
ndash Intermedullary solution for fixation of an olecranon osteotomy
Indications The Olecranon Osteotomy Nail is indicated to treat osteotomies of the
olecranon
and simple olecranon fractures
The Olecranon Osteotomy Nail
Overview
DJ 2018 - OleON PPT
Main features and Benefits
Pre-osteotomy fixation ensuring anatomic alignment
Simpler fixation of olecranon osteotomy than current
commonly used techniques after distal humerus
surgery
Simple instrumentation for easy insertion and locking
of nail
Low profile minimizing soft tissue irritation and re-
operation
More stable fixation than current methods
Targeted locking to minimize size of incision
Mechanical testing on file at Synthes
The Olecranon Osteotomy Nail
Overview
Overall
Decision making made on most recent literature
Best available treatment option
Surgeon preference and comfort
Informed decision with patient
Need for prospective multicenter large scale study
Use sound surgical
techinque and use
AO fixation
prinicles
Distal Humerus Fractures
References
Fractures in Adults Rockwood and Wilkins Lippincott William amp Wilkins 2005 6th Edition
Handbook of Fractures Koval and Zuckerman Lippincott William amp Wilkins 2002 2nd Edition
Campbellrsquos Operative Orthopaedics Mosby tenth edition
Chapmans Orthopaedic Surgery 3rd Edition Lippincott Williams amp Wilkins
Distal Humerus Fractures
References Current Concepts Review Distal humerus Fractures in
Adults A Nauth MD M Mckee MD B Ristevski MD JBJS 2011 vol 93-A no 7 4-6-2011
The olecranon osteotomy a six-year experience in the treatment of intraarticular fractures of the distal humerus Coles CP Barei DP Nork SE Taitsman LA Hanel DP Bradford Henley M J Orthop Trauma 2006 Mar20(3)164-71
A true triceps-splitting approach for treatment of distal humerus fractures a preliminary report Ziran BH Smith WR Balk ML Manning CM Agudelo JF J Trauma 2005 Jan58(1)70-5
Distal Humeral Hemiarthroplasty vs Total Elbow Arthroplasty for Acute Distal Humeral Fractures R Rangarajan MD R Papandrea MD A Cil MD Orthopedics JanFeb vol40 no 113-23
Extra Articular fracture Distal Humerus fx
in 67 yo F after someone tried to steal her
purse
SP ORIF Extra Articular fracture with
triceps reflecting
24 yo male GSW
Under went ORIF triceps reflecting
approach
23 yo running from police for no
reasonhellip
SP ORIF with 90-90 plating with
olecranon osteotomy
21 yo SP GSW
SP ORIF with Triceps sparing
approach
2 weeks post op
89 YO SP Mechanical fail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
Distal Humerus Fractures
AO Classification AO Classification
Type C Complete articular no articular fracture fragment
remains in congruity with the shaft
C1 articular simple metaphyseal simple
C2 articular simple metaphyseal multifragmented
C3 articular and metaphyseal multifragmented
Distal Humerus Fractures
Mechanism and Assessment Mechanism of Injury
axial load through the elbow with the joint flexed beyond 90 degrees or direct trauma
Clinical Assessment Careful physical and neurovascular exam is
imperative checking for open wounds neurological and arterial injuries
Plain x-ray AP and Lateral while maintaining gentle longitudinal traction
Stress x-rays can help assess ligamentus stability
CT Scan to evaluate articular comminution
Distal Humerus Fractures
Treatment based on AO Classification
Nonoperative Treatment Nondisplaced distal humeral fractures
Patients who canrsquot tolerate anesthesia advanced dementia
Traction with conversion to cast functional brace or hinged brace when fracture is ldquostickyrdquo controlled motion is started
Outcomes of modern operative fixation is indicated in most cases
Other Methods ldquoBag of bonesrdquo arm is placed in a collar and cuff with as much flexion as possible elbow is left hanging free allowing gravity to exert a ligamentotaxis effect
Distal Humerus Fractures Operative
Treatment based on AO Classification
Evidence supports Operative Treatment in patients who can tolerate anesthesia with early ROM if appropriate
Displaced distal humerus fractures Exceptions
Frail or debilitated individuals Open woundsdegloving injury Blast or open crush injury Extreme osteoporosis
Intra-articular fractures
Distal Humerus Fractures Operative
Treatment based on AO Classification
Controversy in approach Triceps splitting
Triceps reflecting Triceps reflecting with anconeus pedicle Triceps sparing with and without olecranon osteotomy
Insufficient evidence to recommend or against ulnar nerve transposition
Speaker preference Triceps sparing or
reflecting for extra-articular or simple intra-articular fractures
Olecranon osteotomy for comminutedcomplex intra-articular fractures
No ulnar nerve transposition
Distal Humerus Fractures Operative
Treatment based on AO Classification
A Triceps splitting
B Triceps reflecting with anconeus pedicle
C Triceps reflecting
D Triceps sparing with amp wo olecranon osteotomy
Distal Humerus Fractures Operative
Treatment based on AO Classification
Triceps sparing Avoids extensor
violation
Utilizes medial and lateral windows on triceps
Good for extra-articular fractures and C-1 2 types
Disadvantage poor visualization of articular surface Can be converted to
olecranon osteotomy or TEA
Distal Humerus Fractures Operative
Treatment based on AO Classification
Triceps splitting Midline incision
leaves triceps tendon intact with extensorflexor fascia
Triceps repaired transosseous to olecranon functional studies equivalent to osteotomy
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon osteotomy Chervon osteotomy
25-3 cm from olecranon tip
Oscillating saw finished with osteotomy
Osteotomy fixated with either tension band intermedullary screw plate or IM nail
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon
osteotomy
Superior
visualization of
articular surface
Retrospective
Studies show no
functional difference
with triceps splitting
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon
osteotomy
6-30 hardware
removal
0-9 nonunion
rates
Distal Humerus Fractures Operative
Treatment based on AO Classification
Plate fixation Since 1970 AO introduction of dual column fixation substantial improvement in surgical outcomes Anatomic articular
reduction Rigid fixation with 2 plates 35 mm minimum
In cases of severe comminution of metaphysis or substantial bone loss Treat with
shortening but maintain alignment
Distal Humerus Fractures Operative
Treatment based on AO Classification
Debate on location of plate placement Perpendicular or
parallel to each other
Most studies show no significant difference in functional outcomes
Parallel plates had slight higher nonunion rate but stronger with metaphyseal comminution
Distal Humerus Fractures Operative
Treatment based on AO Classification
Use of locked
plating has been
controversial
proven superior in
osteoporotic bone
and comminuted
fractures
No data to go
against locked
plating
Distal Humerus Fractures Operative
Treatment based on AO Classification
Coronal Shear fracture OTAAO type B3
Uncommon involves capitellum trochlea or both
Usually associated with elbow dislocation
Often missed on plain x-rays 66 sensitivity CT recommended
Distal Humerus Fractures
Capitellum Fractures
Classification Type I Hahn-Steinthal
Fragment Large osseous component of capitellum sometimes with trochlear involvement
Type II Kocher-Lorenz Fragment Articular cartilage with minimal subcondylar bone attachment ldquo uncapping of the condylerdquo
Type III markedly comminuted
Distal Humerus Fractures
Capitellum Fractures Treatment Nonoperative Treatment
Primarily for nondisplaced fx Posterior splint immobilization for 3 weeks
Operative Treatment Goal is anatomic reduction ORIF
Indicated for displaced type I fractures Screws placed via lateral approach or posterior with olecranon
osteotomy for trochlea component or medial comminution headless screws may be placed anterior to posterior direction plate added to lateral column for comminution
Fixation should be stable enough to allow early ROM Excision
Contraindicated in the presence of associated elbow fractures Allows for early mobilization and less morbidity but associated
with instability Recommended treatment in old missed fractures with limited
ROM
Distal Humerus Fractures
Capitellum Fractures Complications
Complications Osteonecrosis uncommon
Posttraumatic arthritis increased with failure to restore articular congruity
Cubitus valgus may result with excision of the articular fragment or with associated lateral condylar or radial head fx It is associated with tardy ulnar palsy
Loss of motion (flexion) associated with retained chondral or osseous fragment that may become entrapped in the coronoid or radial fossae
Distal Humerus Fractures Operative
Treatment
Total Elbow Arthroplasty (TEA) Reserved for elderly
patients with poor bone quality low physical demands not amenable to ORIF
Goodexcellent results compared to ORIF in elderly as primary treatment
Distal Humerus Fractures Operative
Treatment
Total Elbow
Arthroplasty (TEA)
Higher rate of
infection nerve
injury implant
failure
Olecranon
Osteotomy
contraindicated
Distal Humerus Fractures
Complications
Ulnar nerve injury Due to initial
trauma or operative treatment
Transposition not proven to beneficial even when nerve is out preoperatively
Decompression recommended when nerve is out preop
Heterotopic Ossification (HO)
After operative fixation
Limits ROM
Prophylactic treatment indications are controversial
Use of indomethacin didnrsquot significantly reduce HO
When prophylaxis used 0-21 clinically significant HO
Distal Humerus Fractures Complications
Heterotopic
Ossification (HO)
1 dose post op
radiation and 2 weeks
indomethacin
treatment 3 rate
clinically significant
HO
Benefits weighted
against risks of union
with prophylactic
treatment
Heterotopic
Ossification (HO)
Risk factors CNS
injury delay in
operative treatment
sx prior to definitive
treatment
Distal Humerus Fractures Complications
Modern dual plate
fixation 89-100
union rates
Failing to adhere to
these principles
increase nonunion
rates
Nonunion treated with
revision ORIF bone
grafting selective
releases
Mean flex-ext arc
ROM 99deg-112deg
Recommended start
ROM at 2 weeks
Functional outcomes
after ORIF 84-100
goodexcellent
Regain 70-75
strength compared
to contra lateral side
DJ 2018 - OleON PPT
Tension Band w K-Wires
65 Cancellous Screw w Tension Band
Lag Screw w Tension Band
Plate Fixation
Current AO product options
Distal Humerus Fractures Fixation
Options of Olecranon Osteotomies
DJ 2018 - OleON PPT
Clinical needs
ndash Improved method to maintain reduction of olecranon osteotomy
ndash Intermedullary solution for fixation of an olecranon osteotomy
Indications The Olecranon Osteotomy Nail is indicated to treat osteotomies of the
olecranon
and simple olecranon fractures
The Olecranon Osteotomy Nail
Overview
DJ 2018 - OleON PPT
Main features and Benefits
Pre-osteotomy fixation ensuring anatomic alignment
Simpler fixation of olecranon osteotomy than current
commonly used techniques after distal humerus
surgery
Simple instrumentation for easy insertion and locking
of nail
Low profile minimizing soft tissue irritation and re-
operation
More stable fixation than current methods
Targeted locking to minimize size of incision
Mechanical testing on file at Synthes
The Olecranon Osteotomy Nail
Overview
Overall
Decision making made on most recent literature
Best available treatment option
Surgeon preference and comfort
Informed decision with patient
Need for prospective multicenter large scale study
Use sound surgical
techinque and use
AO fixation
prinicles
Distal Humerus Fractures
References
Fractures in Adults Rockwood and Wilkins Lippincott William amp Wilkins 2005 6th Edition
Handbook of Fractures Koval and Zuckerman Lippincott William amp Wilkins 2002 2nd Edition
Campbellrsquos Operative Orthopaedics Mosby tenth edition
Chapmans Orthopaedic Surgery 3rd Edition Lippincott Williams amp Wilkins
Distal Humerus Fractures
References Current Concepts Review Distal humerus Fractures in
Adults A Nauth MD M Mckee MD B Ristevski MD JBJS 2011 vol 93-A no 7 4-6-2011
The olecranon osteotomy a six-year experience in the treatment of intraarticular fractures of the distal humerus Coles CP Barei DP Nork SE Taitsman LA Hanel DP Bradford Henley M J Orthop Trauma 2006 Mar20(3)164-71
A true triceps-splitting approach for treatment of distal humerus fractures a preliminary report Ziran BH Smith WR Balk ML Manning CM Agudelo JF J Trauma 2005 Jan58(1)70-5
Distal Humeral Hemiarthroplasty vs Total Elbow Arthroplasty for Acute Distal Humeral Fractures R Rangarajan MD R Papandrea MD A Cil MD Orthopedics JanFeb vol40 no 113-23
Extra Articular fracture Distal Humerus fx
in 67 yo F after someone tried to steal her
purse
SP ORIF Extra Articular fracture with
triceps reflecting
24 yo male GSW
Under went ORIF triceps reflecting
approach
23 yo running from police for no
reasonhellip
SP ORIF with 90-90 plating with
olecranon osteotomy
21 yo SP GSW
SP ORIF with Triceps sparing
approach
2 weeks post op
89 YO SP Mechanical fail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
Distal Humerus Fractures
Mechanism and Assessment Mechanism of Injury
axial load through the elbow with the joint flexed beyond 90 degrees or direct trauma
Clinical Assessment Careful physical and neurovascular exam is
imperative checking for open wounds neurological and arterial injuries
Plain x-ray AP and Lateral while maintaining gentle longitudinal traction
Stress x-rays can help assess ligamentus stability
CT Scan to evaluate articular comminution
Distal Humerus Fractures
Treatment based on AO Classification
Nonoperative Treatment Nondisplaced distal humeral fractures
Patients who canrsquot tolerate anesthesia advanced dementia
Traction with conversion to cast functional brace or hinged brace when fracture is ldquostickyrdquo controlled motion is started
Outcomes of modern operative fixation is indicated in most cases
Other Methods ldquoBag of bonesrdquo arm is placed in a collar and cuff with as much flexion as possible elbow is left hanging free allowing gravity to exert a ligamentotaxis effect
Distal Humerus Fractures Operative
Treatment based on AO Classification
Evidence supports Operative Treatment in patients who can tolerate anesthesia with early ROM if appropriate
Displaced distal humerus fractures Exceptions
Frail or debilitated individuals Open woundsdegloving injury Blast or open crush injury Extreme osteoporosis
Intra-articular fractures
Distal Humerus Fractures Operative
Treatment based on AO Classification
Controversy in approach Triceps splitting
Triceps reflecting Triceps reflecting with anconeus pedicle Triceps sparing with and without olecranon osteotomy
Insufficient evidence to recommend or against ulnar nerve transposition
Speaker preference Triceps sparing or
reflecting for extra-articular or simple intra-articular fractures
Olecranon osteotomy for comminutedcomplex intra-articular fractures
No ulnar nerve transposition
Distal Humerus Fractures Operative
Treatment based on AO Classification
A Triceps splitting
B Triceps reflecting with anconeus pedicle
C Triceps reflecting
D Triceps sparing with amp wo olecranon osteotomy
Distal Humerus Fractures Operative
Treatment based on AO Classification
Triceps sparing Avoids extensor
violation
Utilizes medial and lateral windows on triceps
Good for extra-articular fractures and C-1 2 types
Disadvantage poor visualization of articular surface Can be converted to
olecranon osteotomy or TEA
Distal Humerus Fractures Operative
Treatment based on AO Classification
Triceps splitting Midline incision
leaves triceps tendon intact with extensorflexor fascia
Triceps repaired transosseous to olecranon functional studies equivalent to osteotomy
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon osteotomy Chervon osteotomy
25-3 cm from olecranon tip
Oscillating saw finished with osteotomy
Osteotomy fixated with either tension band intermedullary screw plate or IM nail
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon
osteotomy
Superior
visualization of
articular surface
Retrospective
Studies show no
functional difference
with triceps splitting
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon
osteotomy
6-30 hardware
removal
0-9 nonunion
rates
Distal Humerus Fractures Operative
Treatment based on AO Classification
Plate fixation Since 1970 AO introduction of dual column fixation substantial improvement in surgical outcomes Anatomic articular
reduction Rigid fixation with 2 plates 35 mm minimum
In cases of severe comminution of metaphysis or substantial bone loss Treat with
shortening but maintain alignment
Distal Humerus Fractures Operative
Treatment based on AO Classification
Debate on location of plate placement Perpendicular or
parallel to each other
Most studies show no significant difference in functional outcomes
Parallel plates had slight higher nonunion rate but stronger with metaphyseal comminution
Distal Humerus Fractures Operative
Treatment based on AO Classification
Use of locked
plating has been
controversial
proven superior in
osteoporotic bone
and comminuted
fractures
No data to go
against locked
plating
Distal Humerus Fractures Operative
Treatment based on AO Classification
Coronal Shear fracture OTAAO type B3
Uncommon involves capitellum trochlea or both
Usually associated with elbow dislocation
Often missed on plain x-rays 66 sensitivity CT recommended
Distal Humerus Fractures
Capitellum Fractures
Classification Type I Hahn-Steinthal
Fragment Large osseous component of capitellum sometimes with trochlear involvement
Type II Kocher-Lorenz Fragment Articular cartilage with minimal subcondylar bone attachment ldquo uncapping of the condylerdquo
Type III markedly comminuted
Distal Humerus Fractures
Capitellum Fractures Treatment Nonoperative Treatment
Primarily for nondisplaced fx Posterior splint immobilization for 3 weeks
Operative Treatment Goal is anatomic reduction ORIF
Indicated for displaced type I fractures Screws placed via lateral approach or posterior with olecranon
osteotomy for trochlea component or medial comminution headless screws may be placed anterior to posterior direction plate added to lateral column for comminution
Fixation should be stable enough to allow early ROM Excision
Contraindicated in the presence of associated elbow fractures Allows for early mobilization and less morbidity but associated
with instability Recommended treatment in old missed fractures with limited
ROM
Distal Humerus Fractures
Capitellum Fractures Complications
Complications Osteonecrosis uncommon
Posttraumatic arthritis increased with failure to restore articular congruity
Cubitus valgus may result with excision of the articular fragment or with associated lateral condylar or radial head fx It is associated with tardy ulnar palsy
Loss of motion (flexion) associated with retained chondral or osseous fragment that may become entrapped in the coronoid or radial fossae
Distal Humerus Fractures Operative
Treatment
Total Elbow Arthroplasty (TEA) Reserved for elderly
patients with poor bone quality low physical demands not amenable to ORIF
Goodexcellent results compared to ORIF in elderly as primary treatment
Distal Humerus Fractures Operative
Treatment
Total Elbow
Arthroplasty (TEA)
Higher rate of
infection nerve
injury implant
failure
Olecranon
Osteotomy
contraindicated
Distal Humerus Fractures
Complications
Ulnar nerve injury Due to initial
trauma or operative treatment
Transposition not proven to beneficial even when nerve is out preoperatively
Decompression recommended when nerve is out preop
Heterotopic Ossification (HO)
After operative fixation
Limits ROM
Prophylactic treatment indications are controversial
Use of indomethacin didnrsquot significantly reduce HO
When prophylaxis used 0-21 clinically significant HO
Distal Humerus Fractures Complications
Heterotopic
Ossification (HO)
1 dose post op
radiation and 2 weeks
indomethacin
treatment 3 rate
clinically significant
HO
Benefits weighted
against risks of union
with prophylactic
treatment
Heterotopic
Ossification (HO)
Risk factors CNS
injury delay in
operative treatment
sx prior to definitive
treatment
Distal Humerus Fractures Complications
Modern dual plate
fixation 89-100
union rates
Failing to adhere to
these principles
increase nonunion
rates
Nonunion treated with
revision ORIF bone
grafting selective
releases
Mean flex-ext arc
ROM 99deg-112deg
Recommended start
ROM at 2 weeks
Functional outcomes
after ORIF 84-100
goodexcellent
Regain 70-75
strength compared
to contra lateral side
DJ 2018 - OleON PPT
Tension Band w K-Wires
65 Cancellous Screw w Tension Band
Lag Screw w Tension Band
Plate Fixation
Current AO product options
Distal Humerus Fractures Fixation
Options of Olecranon Osteotomies
DJ 2018 - OleON PPT
Clinical needs
ndash Improved method to maintain reduction of olecranon osteotomy
ndash Intermedullary solution for fixation of an olecranon osteotomy
Indications The Olecranon Osteotomy Nail is indicated to treat osteotomies of the
olecranon
and simple olecranon fractures
The Olecranon Osteotomy Nail
Overview
DJ 2018 - OleON PPT
Main features and Benefits
Pre-osteotomy fixation ensuring anatomic alignment
Simpler fixation of olecranon osteotomy than current
commonly used techniques after distal humerus
surgery
Simple instrumentation for easy insertion and locking
of nail
Low profile minimizing soft tissue irritation and re-
operation
More stable fixation than current methods
Targeted locking to minimize size of incision
Mechanical testing on file at Synthes
The Olecranon Osteotomy Nail
Overview
Overall
Decision making made on most recent literature
Best available treatment option
Surgeon preference and comfort
Informed decision with patient
Need for prospective multicenter large scale study
Use sound surgical
techinque and use
AO fixation
prinicles
Distal Humerus Fractures
References
Fractures in Adults Rockwood and Wilkins Lippincott William amp Wilkins 2005 6th Edition
Handbook of Fractures Koval and Zuckerman Lippincott William amp Wilkins 2002 2nd Edition
Campbellrsquos Operative Orthopaedics Mosby tenth edition
Chapmans Orthopaedic Surgery 3rd Edition Lippincott Williams amp Wilkins
Distal Humerus Fractures
References Current Concepts Review Distal humerus Fractures in
Adults A Nauth MD M Mckee MD B Ristevski MD JBJS 2011 vol 93-A no 7 4-6-2011
The olecranon osteotomy a six-year experience in the treatment of intraarticular fractures of the distal humerus Coles CP Barei DP Nork SE Taitsman LA Hanel DP Bradford Henley M J Orthop Trauma 2006 Mar20(3)164-71
A true triceps-splitting approach for treatment of distal humerus fractures a preliminary report Ziran BH Smith WR Balk ML Manning CM Agudelo JF J Trauma 2005 Jan58(1)70-5
Distal Humeral Hemiarthroplasty vs Total Elbow Arthroplasty for Acute Distal Humeral Fractures R Rangarajan MD R Papandrea MD A Cil MD Orthopedics JanFeb vol40 no 113-23
Extra Articular fracture Distal Humerus fx
in 67 yo F after someone tried to steal her
purse
SP ORIF Extra Articular fracture with
triceps reflecting
24 yo male GSW
Under went ORIF triceps reflecting
approach
23 yo running from police for no
reasonhellip
SP ORIF with 90-90 plating with
olecranon osteotomy
21 yo SP GSW
SP ORIF with Triceps sparing
approach
2 weeks post op
89 YO SP Mechanical fail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
Distal Humerus Fractures
Treatment based on AO Classification
Nonoperative Treatment Nondisplaced distal humeral fractures
Patients who canrsquot tolerate anesthesia advanced dementia
Traction with conversion to cast functional brace or hinged brace when fracture is ldquostickyrdquo controlled motion is started
Outcomes of modern operative fixation is indicated in most cases
Other Methods ldquoBag of bonesrdquo arm is placed in a collar and cuff with as much flexion as possible elbow is left hanging free allowing gravity to exert a ligamentotaxis effect
Distal Humerus Fractures Operative
Treatment based on AO Classification
Evidence supports Operative Treatment in patients who can tolerate anesthesia with early ROM if appropriate
Displaced distal humerus fractures Exceptions
Frail or debilitated individuals Open woundsdegloving injury Blast or open crush injury Extreme osteoporosis
Intra-articular fractures
Distal Humerus Fractures Operative
Treatment based on AO Classification
Controversy in approach Triceps splitting
Triceps reflecting Triceps reflecting with anconeus pedicle Triceps sparing with and without olecranon osteotomy
Insufficient evidence to recommend or against ulnar nerve transposition
Speaker preference Triceps sparing or
reflecting for extra-articular or simple intra-articular fractures
Olecranon osteotomy for comminutedcomplex intra-articular fractures
No ulnar nerve transposition
Distal Humerus Fractures Operative
Treatment based on AO Classification
A Triceps splitting
B Triceps reflecting with anconeus pedicle
C Triceps reflecting
D Triceps sparing with amp wo olecranon osteotomy
Distal Humerus Fractures Operative
Treatment based on AO Classification
Triceps sparing Avoids extensor
violation
Utilizes medial and lateral windows on triceps
Good for extra-articular fractures and C-1 2 types
Disadvantage poor visualization of articular surface Can be converted to
olecranon osteotomy or TEA
Distal Humerus Fractures Operative
Treatment based on AO Classification
Triceps splitting Midline incision
leaves triceps tendon intact with extensorflexor fascia
Triceps repaired transosseous to olecranon functional studies equivalent to osteotomy
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon osteotomy Chervon osteotomy
25-3 cm from olecranon tip
Oscillating saw finished with osteotomy
Osteotomy fixated with either tension band intermedullary screw plate or IM nail
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon
osteotomy
Superior
visualization of
articular surface
Retrospective
Studies show no
functional difference
with triceps splitting
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon
osteotomy
6-30 hardware
removal
0-9 nonunion
rates
Distal Humerus Fractures Operative
Treatment based on AO Classification
Plate fixation Since 1970 AO introduction of dual column fixation substantial improvement in surgical outcomes Anatomic articular
reduction Rigid fixation with 2 plates 35 mm minimum
In cases of severe comminution of metaphysis or substantial bone loss Treat with
shortening but maintain alignment
Distal Humerus Fractures Operative
Treatment based on AO Classification
Debate on location of plate placement Perpendicular or
parallel to each other
Most studies show no significant difference in functional outcomes
Parallel plates had slight higher nonunion rate but stronger with metaphyseal comminution
Distal Humerus Fractures Operative
Treatment based on AO Classification
Use of locked
plating has been
controversial
proven superior in
osteoporotic bone
and comminuted
fractures
No data to go
against locked
plating
Distal Humerus Fractures Operative
Treatment based on AO Classification
Coronal Shear fracture OTAAO type B3
Uncommon involves capitellum trochlea or both
Usually associated with elbow dislocation
Often missed on plain x-rays 66 sensitivity CT recommended
Distal Humerus Fractures
Capitellum Fractures
Classification Type I Hahn-Steinthal
Fragment Large osseous component of capitellum sometimes with trochlear involvement
Type II Kocher-Lorenz Fragment Articular cartilage with minimal subcondylar bone attachment ldquo uncapping of the condylerdquo
Type III markedly comminuted
Distal Humerus Fractures
Capitellum Fractures Treatment Nonoperative Treatment
Primarily for nondisplaced fx Posterior splint immobilization for 3 weeks
Operative Treatment Goal is anatomic reduction ORIF
Indicated for displaced type I fractures Screws placed via lateral approach or posterior with olecranon
osteotomy for trochlea component or medial comminution headless screws may be placed anterior to posterior direction plate added to lateral column for comminution
Fixation should be stable enough to allow early ROM Excision
Contraindicated in the presence of associated elbow fractures Allows for early mobilization and less morbidity but associated
with instability Recommended treatment in old missed fractures with limited
ROM
Distal Humerus Fractures
Capitellum Fractures Complications
Complications Osteonecrosis uncommon
Posttraumatic arthritis increased with failure to restore articular congruity
Cubitus valgus may result with excision of the articular fragment or with associated lateral condylar or radial head fx It is associated with tardy ulnar palsy
Loss of motion (flexion) associated with retained chondral or osseous fragment that may become entrapped in the coronoid or radial fossae
Distal Humerus Fractures Operative
Treatment
Total Elbow Arthroplasty (TEA) Reserved for elderly
patients with poor bone quality low physical demands not amenable to ORIF
Goodexcellent results compared to ORIF in elderly as primary treatment
Distal Humerus Fractures Operative
Treatment
Total Elbow
Arthroplasty (TEA)
Higher rate of
infection nerve
injury implant
failure
Olecranon
Osteotomy
contraindicated
Distal Humerus Fractures
Complications
Ulnar nerve injury Due to initial
trauma or operative treatment
Transposition not proven to beneficial even when nerve is out preoperatively
Decompression recommended when nerve is out preop
Heterotopic Ossification (HO)
After operative fixation
Limits ROM
Prophylactic treatment indications are controversial
Use of indomethacin didnrsquot significantly reduce HO
When prophylaxis used 0-21 clinically significant HO
Distal Humerus Fractures Complications
Heterotopic
Ossification (HO)
1 dose post op
radiation and 2 weeks
indomethacin
treatment 3 rate
clinically significant
HO
Benefits weighted
against risks of union
with prophylactic
treatment
Heterotopic
Ossification (HO)
Risk factors CNS
injury delay in
operative treatment
sx prior to definitive
treatment
Distal Humerus Fractures Complications
Modern dual plate
fixation 89-100
union rates
Failing to adhere to
these principles
increase nonunion
rates
Nonunion treated with
revision ORIF bone
grafting selective
releases
Mean flex-ext arc
ROM 99deg-112deg
Recommended start
ROM at 2 weeks
Functional outcomes
after ORIF 84-100
goodexcellent
Regain 70-75
strength compared
to contra lateral side
DJ 2018 - OleON PPT
Tension Band w K-Wires
65 Cancellous Screw w Tension Band
Lag Screw w Tension Band
Plate Fixation
Current AO product options
Distal Humerus Fractures Fixation
Options of Olecranon Osteotomies
DJ 2018 - OleON PPT
Clinical needs
ndash Improved method to maintain reduction of olecranon osteotomy
ndash Intermedullary solution for fixation of an olecranon osteotomy
Indications The Olecranon Osteotomy Nail is indicated to treat osteotomies of the
olecranon
and simple olecranon fractures
The Olecranon Osteotomy Nail
Overview
DJ 2018 - OleON PPT
Main features and Benefits
Pre-osteotomy fixation ensuring anatomic alignment
Simpler fixation of olecranon osteotomy than current
commonly used techniques after distal humerus
surgery
Simple instrumentation for easy insertion and locking
of nail
Low profile minimizing soft tissue irritation and re-
operation
More stable fixation than current methods
Targeted locking to minimize size of incision
Mechanical testing on file at Synthes
The Olecranon Osteotomy Nail
Overview
Overall
Decision making made on most recent literature
Best available treatment option
Surgeon preference and comfort
Informed decision with patient
Need for prospective multicenter large scale study
Use sound surgical
techinque and use
AO fixation
prinicles
Distal Humerus Fractures
References
Fractures in Adults Rockwood and Wilkins Lippincott William amp Wilkins 2005 6th Edition
Handbook of Fractures Koval and Zuckerman Lippincott William amp Wilkins 2002 2nd Edition
Campbellrsquos Operative Orthopaedics Mosby tenth edition
Chapmans Orthopaedic Surgery 3rd Edition Lippincott Williams amp Wilkins
Distal Humerus Fractures
References Current Concepts Review Distal humerus Fractures in
Adults A Nauth MD M Mckee MD B Ristevski MD JBJS 2011 vol 93-A no 7 4-6-2011
The olecranon osteotomy a six-year experience in the treatment of intraarticular fractures of the distal humerus Coles CP Barei DP Nork SE Taitsman LA Hanel DP Bradford Henley M J Orthop Trauma 2006 Mar20(3)164-71
A true triceps-splitting approach for treatment of distal humerus fractures a preliminary report Ziran BH Smith WR Balk ML Manning CM Agudelo JF J Trauma 2005 Jan58(1)70-5
Distal Humeral Hemiarthroplasty vs Total Elbow Arthroplasty for Acute Distal Humeral Fractures R Rangarajan MD R Papandrea MD A Cil MD Orthopedics JanFeb vol40 no 113-23
Extra Articular fracture Distal Humerus fx
in 67 yo F after someone tried to steal her
purse
SP ORIF Extra Articular fracture with
triceps reflecting
24 yo male GSW
Under went ORIF triceps reflecting
approach
23 yo running from police for no
reasonhellip
SP ORIF with 90-90 plating with
olecranon osteotomy
21 yo SP GSW
SP ORIF with Triceps sparing
approach
2 weeks post op
89 YO SP Mechanical fail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
Distal Humerus Fractures Operative
Treatment based on AO Classification
Evidence supports Operative Treatment in patients who can tolerate anesthesia with early ROM if appropriate
Displaced distal humerus fractures Exceptions
Frail or debilitated individuals Open woundsdegloving injury Blast or open crush injury Extreme osteoporosis
Intra-articular fractures
Distal Humerus Fractures Operative
Treatment based on AO Classification
Controversy in approach Triceps splitting
Triceps reflecting Triceps reflecting with anconeus pedicle Triceps sparing with and without olecranon osteotomy
Insufficient evidence to recommend or against ulnar nerve transposition
Speaker preference Triceps sparing or
reflecting for extra-articular or simple intra-articular fractures
Olecranon osteotomy for comminutedcomplex intra-articular fractures
No ulnar nerve transposition
Distal Humerus Fractures Operative
Treatment based on AO Classification
A Triceps splitting
B Triceps reflecting with anconeus pedicle
C Triceps reflecting
D Triceps sparing with amp wo olecranon osteotomy
Distal Humerus Fractures Operative
Treatment based on AO Classification
Triceps sparing Avoids extensor
violation
Utilizes medial and lateral windows on triceps
Good for extra-articular fractures and C-1 2 types
Disadvantage poor visualization of articular surface Can be converted to
olecranon osteotomy or TEA
Distal Humerus Fractures Operative
Treatment based on AO Classification
Triceps splitting Midline incision
leaves triceps tendon intact with extensorflexor fascia
Triceps repaired transosseous to olecranon functional studies equivalent to osteotomy
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon osteotomy Chervon osteotomy
25-3 cm from olecranon tip
Oscillating saw finished with osteotomy
Osteotomy fixated with either tension band intermedullary screw plate or IM nail
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon
osteotomy
Superior
visualization of
articular surface
Retrospective
Studies show no
functional difference
with triceps splitting
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon
osteotomy
6-30 hardware
removal
0-9 nonunion
rates
Distal Humerus Fractures Operative
Treatment based on AO Classification
Plate fixation Since 1970 AO introduction of dual column fixation substantial improvement in surgical outcomes Anatomic articular
reduction Rigid fixation with 2 plates 35 mm minimum
In cases of severe comminution of metaphysis or substantial bone loss Treat with
shortening but maintain alignment
Distal Humerus Fractures Operative
Treatment based on AO Classification
Debate on location of plate placement Perpendicular or
parallel to each other
Most studies show no significant difference in functional outcomes
Parallel plates had slight higher nonunion rate but stronger with metaphyseal comminution
Distal Humerus Fractures Operative
Treatment based on AO Classification
Use of locked
plating has been
controversial
proven superior in
osteoporotic bone
and comminuted
fractures
No data to go
against locked
plating
Distal Humerus Fractures Operative
Treatment based on AO Classification
Coronal Shear fracture OTAAO type B3
Uncommon involves capitellum trochlea or both
Usually associated with elbow dislocation
Often missed on plain x-rays 66 sensitivity CT recommended
Distal Humerus Fractures
Capitellum Fractures
Classification Type I Hahn-Steinthal
Fragment Large osseous component of capitellum sometimes with trochlear involvement
Type II Kocher-Lorenz Fragment Articular cartilage with minimal subcondylar bone attachment ldquo uncapping of the condylerdquo
Type III markedly comminuted
Distal Humerus Fractures
Capitellum Fractures Treatment Nonoperative Treatment
Primarily for nondisplaced fx Posterior splint immobilization for 3 weeks
Operative Treatment Goal is anatomic reduction ORIF
Indicated for displaced type I fractures Screws placed via lateral approach or posterior with olecranon
osteotomy for trochlea component or medial comminution headless screws may be placed anterior to posterior direction plate added to lateral column for comminution
Fixation should be stable enough to allow early ROM Excision
Contraindicated in the presence of associated elbow fractures Allows for early mobilization and less morbidity but associated
with instability Recommended treatment in old missed fractures with limited
ROM
Distal Humerus Fractures
Capitellum Fractures Complications
Complications Osteonecrosis uncommon
Posttraumatic arthritis increased with failure to restore articular congruity
Cubitus valgus may result with excision of the articular fragment or with associated lateral condylar or radial head fx It is associated with tardy ulnar palsy
Loss of motion (flexion) associated with retained chondral or osseous fragment that may become entrapped in the coronoid or radial fossae
Distal Humerus Fractures Operative
Treatment
Total Elbow Arthroplasty (TEA) Reserved for elderly
patients with poor bone quality low physical demands not amenable to ORIF
Goodexcellent results compared to ORIF in elderly as primary treatment
Distal Humerus Fractures Operative
Treatment
Total Elbow
Arthroplasty (TEA)
Higher rate of
infection nerve
injury implant
failure
Olecranon
Osteotomy
contraindicated
Distal Humerus Fractures
Complications
Ulnar nerve injury Due to initial
trauma or operative treatment
Transposition not proven to beneficial even when nerve is out preoperatively
Decompression recommended when nerve is out preop
Heterotopic Ossification (HO)
After operative fixation
Limits ROM
Prophylactic treatment indications are controversial
Use of indomethacin didnrsquot significantly reduce HO
When prophylaxis used 0-21 clinically significant HO
Distal Humerus Fractures Complications
Heterotopic
Ossification (HO)
1 dose post op
radiation and 2 weeks
indomethacin
treatment 3 rate
clinically significant
HO
Benefits weighted
against risks of union
with prophylactic
treatment
Heterotopic
Ossification (HO)
Risk factors CNS
injury delay in
operative treatment
sx prior to definitive
treatment
Distal Humerus Fractures Complications
Modern dual plate
fixation 89-100
union rates
Failing to adhere to
these principles
increase nonunion
rates
Nonunion treated with
revision ORIF bone
grafting selective
releases
Mean flex-ext arc
ROM 99deg-112deg
Recommended start
ROM at 2 weeks
Functional outcomes
after ORIF 84-100
goodexcellent
Regain 70-75
strength compared
to contra lateral side
DJ 2018 - OleON PPT
Tension Band w K-Wires
65 Cancellous Screw w Tension Band
Lag Screw w Tension Band
Plate Fixation
Current AO product options
Distal Humerus Fractures Fixation
Options of Olecranon Osteotomies
DJ 2018 - OleON PPT
Clinical needs
ndash Improved method to maintain reduction of olecranon osteotomy
ndash Intermedullary solution for fixation of an olecranon osteotomy
Indications The Olecranon Osteotomy Nail is indicated to treat osteotomies of the
olecranon
and simple olecranon fractures
The Olecranon Osteotomy Nail
Overview
DJ 2018 - OleON PPT
Main features and Benefits
Pre-osteotomy fixation ensuring anatomic alignment
Simpler fixation of olecranon osteotomy than current
commonly used techniques after distal humerus
surgery
Simple instrumentation for easy insertion and locking
of nail
Low profile minimizing soft tissue irritation and re-
operation
More stable fixation than current methods
Targeted locking to minimize size of incision
Mechanical testing on file at Synthes
The Olecranon Osteotomy Nail
Overview
Overall
Decision making made on most recent literature
Best available treatment option
Surgeon preference and comfort
Informed decision with patient
Need for prospective multicenter large scale study
Use sound surgical
techinque and use
AO fixation
prinicles
Distal Humerus Fractures
References
Fractures in Adults Rockwood and Wilkins Lippincott William amp Wilkins 2005 6th Edition
Handbook of Fractures Koval and Zuckerman Lippincott William amp Wilkins 2002 2nd Edition
Campbellrsquos Operative Orthopaedics Mosby tenth edition
Chapmans Orthopaedic Surgery 3rd Edition Lippincott Williams amp Wilkins
Distal Humerus Fractures
References Current Concepts Review Distal humerus Fractures in
Adults A Nauth MD M Mckee MD B Ristevski MD JBJS 2011 vol 93-A no 7 4-6-2011
The olecranon osteotomy a six-year experience in the treatment of intraarticular fractures of the distal humerus Coles CP Barei DP Nork SE Taitsman LA Hanel DP Bradford Henley M J Orthop Trauma 2006 Mar20(3)164-71
A true triceps-splitting approach for treatment of distal humerus fractures a preliminary report Ziran BH Smith WR Balk ML Manning CM Agudelo JF J Trauma 2005 Jan58(1)70-5
Distal Humeral Hemiarthroplasty vs Total Elbow Arthroplasty for Acute Distal Humeral Fractures R Rangarajan MD R Papandrea MD A Cil MD Orthopedics JanFeb vol40 no 113-23
Extra Articular fracture Distal Humerus fx
in 67 yo F after someone tried to steal her
purse
SP ORIF Extra Articular fracture with
triceps reflecting
24 yo male GSW
Under went ORIF triceps reflecting
approach
23 yo running from police for no
reasonhellip
SP ORIF with 90-90 plating with
olecranon osteotomy
21 yo SP GSW
SP ORIF with Triceps sparing
approach
2 weeks post op
89 YO SP Mechanical fail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
Distal Humerus Fractures Operative
Treatment based on AO Classification
Controversy in approach Triceps splitting
Triceps reflecting Triceps reflecting with anconeus pedicle Triceps sparing with and without olecranon osteotomy
Insufficient evidence to recommend or against ulnar nerve transposition
Speaker preference Triceps sparing or
reflecting for extra-articular or simple intra-articular fractures
Olecranon osteotomy for comminutedcomplex intra-articular fractures
No ulnar nerve transposition
Distal Humerus Fractures Operative
Treatment based on AO Classification
A Triceps splitting
B Triceps reflecting with anconeus pedicle
C Triceps reflecting
D Triceps sparing with amp wo olecranon osteotomy
Distal Humerus Fractures Operative
Treatment based on AO Classification
Triceps sparing Avoids extensor
violation
Utilizes medial and lateral windows on triceps
Good for extra-articular fractures and C-1 2 types
Disadvantage poor visualization of articular surface Can be converted to
olecranon osteotomy or TEA
Distal Humerus Fractures Operative
Treatment based on AO Classification
Triceps splitting Midline incision
leaves triceps tendon intact with extensorflexor fascia
Triceps repaired transosseous to olecranon functional studies equivalent to osteotomy
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon osteotomy Chervon osteotomy
25-3 cm from olecranon tip
Oscillating saw finished with osteotomy
Osteotomy fixated with either tension band intermedullary screw plate or IM nail
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon
osteotomy
Superior
visualization of
articular surface
Retrospective
Studies show no
functional difference
with triceps splitting
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon
osteotomy
6-30 hardware
removal
0-9 nonunion
rates
Distal Humerus Fractures Operative
Treatment based on AO Classification
Plate fixation Since 1970 AO introduction of dual column fixation substantial improvement in surgical outcomes Anatomic articular
reduction Rigid fixation with 2 plates 35 mm minimum
In cases of severe comminution of metaphysis or substantial bone loss Treat with
shortening but maintain alignment
Distal Humerus Fractures Operative
Treatment based on AO Classification
Debate on location of plate placement Perpendicular or
parallel to each other
Most studies show no significant difference in functional outcomes
Parallel plates had slight higher nonunion rate but stronger with metaphyseal comminution
Distal Humerus Fractures Operative
Treatment based on AO Classification
Use of locked
plating has been
controversial
proven superior in
osteoporotic bone
and comminuted
fractures
No data to go
against locked
plating
Distal Humerus Fractures Operative
Treatment based on AO Classification
Coronal Shear fracture OTAAO type B3
Uncommon involves capitellum trochlea or both
Usually associated with elbow dislocation
Often missed on plain x-rays 66 sensitivity CT recommended
Distal Humerus Fractures
Capitellum Fractures
Classification Type I Hahn-Steinthal
Fragment Large osseous component of capitellum sometimes with trochlear involvement
Type II Kocher-Lorenz Fragment Articular cartilage with minimal subcondylar bone attachment ldquo uncapping of the condylerdquo
Type III markedly comminuted
Distal Humerus Fractures
Capitellum Fractures Treatment Nonoperative Treatment
Primarily for nondisplaced fx Posterior splint immobilization for 3 weeks
Operative Treatment Goal is anatomic reduction ORIF
Indicated for displaced type I fractures Screws placed via lateral approach or posterior with olecranon
osteotomy for trochlea component or medial comminution headless screws may be placed anterior to posterior direction plate added to lateral column for comminution
Fixation should be stable enough to allow early ROM Excision
Contraindicated in the presence of associated elbow fractures Allows for early mobilization and less morbidity but associated
with instability Recommended treatment in old missed fractures with limited
ROM
Distal Humerus Fractures
Capitellum Fractures Complications
Complications Osteonecrosis uncommon
Posttraumatic arthritis increased with failure to restore articular congruity
Cubitus valgus may result with excision of the articular fragment or with associated lateral condylar or radial head fx It is associated with tardy ulnar palsy
Loss of motion (flexion) associated with retained chondral or osseous fragment that may become entrapped in the coronoid or radial fossae
Distal Humerus Fractures Operative
Treatment
Total Elbow Arthroplasty (TEA) Reserved for elderly
patients with poor bone quality low physical demands not amenable to ORIF
Goodexcellent results compared to ORIF in elderly as primary treatment
Distal Humerus Fractures Operative
Treatment
Total Elbow
Arthroplasty (TEA)
Higher rate of
infection nerve
injury implant
failure
Olecranon
Osteotomy
contraindicated
Distal Humerus Fractures
Complications
Ulnar nerve injury Due to initial
trauma or operative treatment
Transposition not proven to beneficial even when nerve is out preoperatively
Decompression recommended when nerve is out preop
Heterotopic Ossification (HO)
After operative fixation
Limits ROM
Prophylactic treatment indications are controversial
Use of indomethacin didnrsquot significantly reduce HO
When prophylaxis used 0-21 clinically significant HO
Distal Humerus Fractures Complications
Heterotopic
Ossification (HO)
1 dose post op
radiation and 2 weeks
indomethacin
treatment 3 rate
clinically significant
HO
Benefits weighted
against risks of union
with prophylactic
treatment
Heterotopic
Ossification (HO)
Risk factors CNS
injury delay in
operative treatment
sx prior to definitive
treatment
Distal Humerus Fractures Complications
Modern dual plate
fixation 89-100
union rates
Failing to adhere to
these principles
increase nonunion
rates
Nonunion treated with
revision ORIF bone
grafting selective
releases
Mean flex-ext arc
ROM 99deg-112deg
Recommended start
ROM at 2 weeks
Functional outcomes
after ORIF 84-100
goodexcellent
Regain 70-75
strength compared
to contra lateral side
DJ 2018 - OleON PPT
Tension Band w K-Wires
65 Cancellous Screw w Tension Band
Lag Screw w Tension Band
Plate Fixation
Current AO product options
Distal Humerus Fractures Fixation
Options of Olecranon Osteotomies
DJ 2018 - OleON PPT
Clinical needs
ndash Improved method to maintain reduction of olecranon osteotomy
ndash Intermedullary solution for fixation of an olecranon osteotomy
Indications The Olecranon Osteotomy Nail is indicated to treat osteotomies of the
olecranon
and simple olecranon fractures
The Olecranon Osteotomy Nail
Overview
DJ 2018 - OleON PPT
Main features and Benefits
Pre-osteotomy fixation ensuring anatomic alignment
Simpler fixation of olecranon osteotomy than current
commonly used techniques after distal humerus
surgery
Simple instrumentation for easy insertion and locking
of nail
Low profile minimizing soft tissue irritation and re-
operation
More stable fixation than current methods
Targeted locking to minimize size of incision
Mechanical testing on file at Synthes
The Olecranon Osteotomy Nail
Overview
Overall
Decision making made on most recent literature
Best available treatment option
Surgeon preference and comfort
Informed decision with patient
Need for prospective multicenter large scale study
Use sound surgical
techinque and use
AO fixation
prinicles
Distal Humerus Fractures
References
Fractures in Adults Rockwood and Wilkins Lippincott William amp Wilkins 2005 6th Edition
Handbook of Fractures Koval and Zuckerman Lippincott William amp Wilkins 2002 2nd Edition
Campbellrsquos Operative Orthopaedics Mosby tenth edition
Chapmans Orthopaedic Surgery 3rd Edition Lippincott Williams amp Wilkins
Distal Humerus Fractures
References Current Concepts Review Distal humerus Fractures in
Adults A Nauth MD M Mckee MD B Ristevski MD JBJS 2011 vol 93-A no 7 4-6-2011
The olecranon osteotomy a six-year experience in the treatment of intraarticular fractures of the distal humerus Coles CP Barei DP Nork SE Taitsman LA Hanel DP Bradford Henley M J Orthop Trauma 2006 Mar20(3)164-71
A true triceps-splitting approach for treatment of distal humerus fractures a preliminary report Ziran BH Smith WR Balk ML Manning CM Agudelo JF J Trauma 2005 Jan58(1)70-5
Distal Humeral Hemiarthroplasty vs Total Elbow Arthroplasty for Acute Distal Humeral Fractures R Rangarajan MD R Papandrea MD A Cil MD Orthopedics JanFeb vol40 no 113-23
Extra Articular fracture Distal Humerus fx
in 67 yo F after someone tried to steal her
purse
SP ORIF Extra Articular fracture with
triceps reflecting
24 yo male GSW
Under went ORIF triceps reflecting
approach
23 yo running from police for no
reasonhellip
SP ORIF with 90-90 plating with
olecranon osteotomy
21 yo SP GSW
SP ORIF with Triceps sparing
approach
2 weeks post op
89 YO SP Mechanical fail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
Distal Humerus Fractures Operative
Treatment based on AO Classification
A Triceps splitting
B Triceps reflecting with anconeus pedicle
C Triceps reflecting
D Triceps sparing with amp wo olecranon osteotomy
Distal Humerus Fractures Operative
Treatment based on AO Classification
Triceps sparing Avoids extensor
violation
Utilizes medial and lateral windows on triceps
Good for extra-articular fractures and C-1 2 types
Disadvantage poor visualization of articular surface Can be converted to
olecranon osteotomy or TEA
Distal Humerus Fractures Operative
Treatment based on AO Classification
Triceps splitting Midline incision
leaves triceps tendon intact with extensorflexor fascia
Triceps repaired transosseous to olecranon functional studies equivalent to osteotomy
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon osteotomy Chervon osteotomy
25-3 cm from olecranon tip
Oscillating saw finished with osteotomy
Osteotomy fixated with either tension band intermedullary screw plate or IM nail
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon
osteotomy
Superior
visualization of
articular surface
Retrospective
Studies show no
functional difference
with triceps splitting
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon
osteotomy
6-30 hardware
removal
0-9 nonunion
rates
Distal Humerus Fractures Operative
Treatment based on AO Classification
Plate fixation Since 1970 AO introduction of dual column fixation substantial improvement in surgical outcomes Anatomic articular
reduction Rigid fixation with 2 plates 35 mm minimum
In cases of severe comminution of metaphysis or substantial bone loss Treat with
shortening but maintain alignment
Distal Humerus Fractures Operative
Treatment based on AO Classification
Debate on location of plate placement Perpendicular or
parallel to each other
Most studies show no significant difference in functional outcomes
Parallel plates had slight higher nonunion rate but stronger with metaphyseal comminution
Distal Humerus Fractures Operative
Treatment based on AO Classification
Use of locked
plating has been
controversial
proven superior in
osteoporotic bone
and comminuted
fractures
No data to go
against locked
plating
Distal Humerus Fractures Operative
Treatment based on AO Classification
Coronal Shear fracture OTAAO type B3
Uncommon involves capitellum trochlea or both
Usually associated with elbow dislocation
Often missed on plain x-rays 66 sensitivity CT recommended
Distal Humerus Fractures
Capitellum Fractures
Classification Type I Hahn-Steinthal
Fragment Large osseous component of capitellum sometimes with trochlear involvement
Type II Kocher-Lorenz Fragment Articular cartilage with minimal subcondylar bone attachment ldquo uncapping of the condylerdquo
Type III markedly comminuted
Distal Humerus Fractures
Capitellum Fractures Treatment Nonoperative Treatment
Primarily for nondisplaced fx Posterior splint immobilization for 3 weeks
Operative Treatment Goal is anatomic reduction ORIF
Indicated for displaced type I fractures Screws placed via lateral approach or posterior with olecranon
osteotomy for trochlea component or medial comminution headless screws may be placed anterior to posterior direction plate added to lateral column for comminution
Fixation should be stable enough to allow early ROM Excision
Contraindicated in the presence of associated elbow fractures Allows for early mobilization and less morbidity but associated
with instability Recommended treatment in old missed fractures with limited
ROM
Distal Humerus Fractures
Capitellum Fractures Complications
Complications Osteonecrosis uncommon
Posttraumatic arthritis increased with failure to restore articular congruity
Cubitus valgus may result with excision of the articular fragment or with associated lateral condylar or radial head fx It is associated with tardy ulnar palsy
Loss of motion (flexion) associated with retained chondral or osseous fragment that may become entrapped in the coronoid or radial fossae
Distal Humerus Fractures Operative
Treatment
Total Elbow Arthroplasty (TEA) Reserved for elderly
patients with poor bone quality low physical demands not amenable to ORIF
Goodexcellent results compared to ORIF in elderly as primary treatment
Distal Humerus Fractures Operative
Treatment
Total Elbow
Arthroplasty (TEA)
Higher rate of
infection nerve
injury implant
failure
Olecranon
Osteotomy
contraindicated
Distal Humerus Fractures
Complications
Ulnar nerve injury Due to initial
trauma or operative treatment
Transposition not proven to beneficial even when nerve is out preoperatively
Decompression recommended when nerve is out preop
Heterotopic Ossification (HO)
After operative fixation
Limits ROM
Prophylactic treatment indications are controversial
Use of indomethacin didnrsquot significantly reduce HO
When prophylaxis used 0-21 clinically significant HO
Distal Humerus Fractures Complications
Heterotopic
Ossification (HO)
1 dose post op
radiation and 2 weeks
indomethacin
treatment 3 rate
clinically significant
HO
Benefits weighted
against risks of union
with prophylactic
treatment
Heterotopic
Ossification (HO)
Risk factors CNS
injury delay in
operative treatment
sx prior to definitive
treatment
Distal Humerus Fractures Complications
Modern dual plate
fixation 89-100
union rates
Failing to adhere to
these principles
increase nonunion
rates
Nonunion treated with
revision ORIF bone
grafting selective
releases
Mean flex-ext arc
ROM 99deg-112deg
Recommended start
ROM at 2 weeks
Functional outcomes
after ORIF 84-100
goodexcellent
Regain 70-75
strength compared
to contra lateral side
DJ 2018 - OleON PPT
Tension Band w K-Wires
65 Cancellous Screw w Tension Band
Lag Screw w Tension Band
Plate Fixation
Current AO product options
Distal Humerus Fractures Fixation
Options of Olecranon Osteotomies
DJ 2018 - OleON PPT
Clinical needs
ndash Improved method to maintain reduction of olecranon osteotomy
ndash Intermedullary solution for fixation of an olecranon osteotomy
Indications The Olecranon Osteotomy Nail is indicated to treat osteotomies of the
olecranon
and simple olecranon fractures
The Olecranon Osteotomy Nail
Overview
DJ 2018 - OleON PPT
Main features and Benefits
Pre-osteotomy fixation ensuring anatomic alignment
Simpler fixation of olecranon osteotomy than current
commonly used techniques after distal humerus
surgery
Simple instrumentation for easy insertion and locking
of nail
Low profile minimizing soft tissue irritation and re-
operation
More stable fixation than current methods
Targeted locking to minimize size of incision
Mechanical testing on file at Synthes
The Olecranon Osteotomy Nail
Overview
Overall
Decision making made on most recent literature
Best available treatment option
Surgeon preference and comfort
Informed decision with patient
Need for prospective multicenter large scale study
Use sound surgical
techinque and use
AO fixation
prinicles
Distal Humerus Fractures
References
Fractures in Adults Rockwood and Wilkins Lippincott William amp Wilkins 2005 6th Edition
Handbook of Fractures Koval and Zuckerman Lippincott William amp Wilkins 2002 2nd Edition
Campbellrsquos Operative Orthopaedics Mosby tenth edition
Chapmans Orthopaedic Surgery 3rd Edition Lippincott Williams amp Wilkins
Distal Humerus Fractures
References Current Concepts Review Distal humerus Fractures in
Adults A Nauth MD M Mckee MD B Ristevski MD JBJS 2011 vol 93-A no 7 4-6-2011
The olecranon osteotomy a six-year experience in the treatment of intraarticular fractures of the distal humerus Coles CP Barei DP Nork SE Taitsman LA Hanel DP Bradford Henley M J Orthop Trauma 2006 Mar20(3)164-71
A true triceps-splitting approach for treatment of distal humerus fractures a preliminary report Ziran BH Smith WR Balk ML Manning CM Agudelo JF J Trauma 2005 Jan58(1)70-5
Distal Humeral Hemiarthroplasty vs Total Elbow Arthroplasty for Acute Distal Humeral Fractures R Rangarajan MD R Papandrea MD A Cil MD Orthopedics JanFeb vol40 no 113-23
Extra Articular fracture Distal Humerus fx
in 67 yo F after someone tried to steal her
purse
SP ORIF Extra Articular fracture with
triceps reflecting
24 yo male GSW
Under went ORIF triceps reflecting
approach
23 yo running from police for no
reasonhellip
SP ORIF with 90-90 plating with
olecranon osteotomy
21 yo SP GSW
SP ORIF with Triceps sparing
approach
2 weeks post op
89 YO SP Mechanical fail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
Distal Humerus Fractures Operative
Treatment based on AO Classification
Triceps sparing Avoids extensor
violation
Utilizes medial and lateral windows on triceps
Good for extra-articular fractures and C-1 2 types
Disadvantage poor visualization of articular surface Can be converted to
olecranon osteotomy or TEA
Distal Humerus Fractures Operative
Treatment based on AO Classification
Triceps splitting Midline incision
leaves triceps tendon intact with extensorflexor fascia
Triceps repaired transosseous to olecranon functional studies equivalent to osteotomy
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon osteotomy Chervon osteotomy
25-3 cm from olecranon tip
Oscillating saw finished with osteotomy
Osteotomy fixated with either tension band intermedullary screw plate or IM nail
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon
osteotomy
Superior
visualization of
articular surface
Retrospective
Studies show no
functional difference
with triceps splitting
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon
osteotomy
6-30 hardware
removal
0-9 nonunion
rates
Distal Humerus Fractures Operative
Treatment based on AO Classification
Plate fixation Since 1970 AO introduction of dual column fixation substantial improvement in surgical outcomes Anatomic articular
reduction Rigid fixation with 2 plates 35 mm minimum
In cases of severe comminution of metaphysis or substantial bone loss Treat with
shortening but maintain alignment
Distal Humerus Fractures Operative
Treatment based on AO Classification
Debate on location of plate placement Perpendicular or
parallel to each other
Most studies show no significant difference in functional outcomes
Parallel plates had slight higher nonunion rate but stronger with metaphyseal comminution
Distal Humerus Fractures Operative
Treatment based on AO Classification
Use of locked
plating has been
controversial
proven superior in
osteoporotic bone
and comminuted
fractures
No data to go
against locked
plating
Distal Humerus Fractures Operative
Treatment based on AO Classification
Coronal Shear fracture OTAAO type B3
Uncommon involves capitellum trochlea or both
Usually associated with elbow dislocation
Often missed on plain x-rays 66 sensitivity CT recommended
Distal Humerus Fractures
Capitellum Fractures
Classification Type I Hahn-Steinthal
Fragment Large osseous component of capitellum sometimes with trochlear involvement
Type II Kocher-Lorenz Fragment Articular cartilage with minimal subcondylar bone attachment ldquo uncapping of the condylerdquo
Type III markedly comminuted
Distal Humerus Fractures
Capitellum Fractures Treatment Nonoperative Treatment
Primarily for nondisplaced fx Posterior splint immobilization for 3 weeks
Operative Treatment Goal is anatomic reduction ORIF
Indicated for displaced type I fractures Screws placed via lateral approach or posterior with olecranon
osteotomy for trochlea component or medial comminution headless screws may be placed anterior to posterior direction plate added to lateral column for comminution
Fixation should be stable enough to allow early ROM Excision
Contraindicated in the presence of associated elbow fractures Allows for early mobilization and less morbidity but associated
with instability Recommended treatment in old missed fractures with limited
ROM
Distal Humerus Fractures
Capitellum Fractures Complications
Complications Osteonecrosis uncommon
Posttraumatic arthritis increased with failure to restore articular congruity
Cubitus valgus may result with excision of the articular fragment or with associated lateral condylar or radial head fx It is associated with tardy ulnar palsy
Loss of motion (flexion) associated with retained chondral or osseous fragment that may become entrapped in the coronoid or radial fossae
Distal Humerus Fractures Operative
Treatment
Total Elbow Arthroplasty (TEA) Reserved for elderly
patients with poor bone quality low physical demands not amenable to ORIF
Goodexcellent results compared to ORIF in elderly as primary treatment
Distal Humerus Fractures Operative
Treatment
Total Elbow
Arthroplasty (TEA)
Higher rate of
infection nerve
injury implant
failure
Olecranon
Osteotomy
contraindicated
Distal Humerus Fractures
Complications
Ulnar nerve injury Due to initial
trauma or operative treatment
Transposition not proven to beneficial even when nerve is out preoperatively
Decompression recommended when nerve is out preop
Heterotopic Ossification (HO)
After operative fixation
Limits ROM
Prophylactic treatment indications are controversial
Use of indomethacin didnrsquot significantly reduce HO
When prophylaxis used 0-21 clinically significant HO
Distal Humerus Fractures Complications
Heterotopic
Ossification (HO)
1 dose post op
radiation and 2 weeks
indomethacin
treatment 3 rate
clinically significant
HO
Benefits weighted
against risks of union
with prophylactic
treatment
Heterotopic
Ossification (HO)
Risk factors CNS
injury delay in
operative treatment
sx prior to definitive
treatment
Distal Humerus Fractures Complications
Modern dual plate
fixation 89-100
union rates
Failing to adhere to
these principles
increase nonunion
rates
Nonunion treated with
revision ORIF bone
grafting selective
releases
Mean flex-ext arc
ROM 99deg-112deg
Recommended start
ROM at 2 weeks
Functional outcomes
after ORIF 84-100
goodexcellent
Regain 70-75
strength compared
to contra lateral side
DJ 2018 - OleON PPT
Tension Band w K-Wires
65 Cancellous Screw w Tension Band
Lag Screw w Tension Band
Plate Fixation
Current AO product options
Distal Humerus Fractures Fixation
Options of Olecranon Osteotomies
DJ 2018 - OleON PPT
Clinical needs
ndash Improved method to maintain reduction of olecranon osteotomy
ndash Intermedullary solution for fixation of an olecranon osteotomy
Indications The Olecranon Osteotomy Nail is indicated to treat osteotomies of the
olecranon
and simple olecranon fractures
The Olecranon Osteotomy Nail
Overview
DJ 2018 - OleON PPT
Main features and Benefits
Pre-osteotomy fixation ensuring anatomic alignment
Simpler fixation of olecranon osteotomy than current
commonly used techniques after distal humerus
surgery
Simple instrumentation for easy insertion and locking
of nail
Low profile minimizing soft tissue irritation and re-
operation
More stable fixation than current methods
Targeted locking to minimize size of incision
Mechanical testing on file at Synthes
The Olecranon Osteotomy Nail
Overview
Overall
Decision making made on most recent literature
Best available treatment option
Surgeon preference and comfort
Informed decision with patient
Need for prospective multicenter large scale study
Use sound surgical
techinque and use
AO fixation
prinicles
Distal Humerus Fractures
References
Fractures in Adults Rockwood and Wilkins Lippincott William amp Wilkins 2005 6th Edition
Handbook of Fractures Koval and Zuckerman Lippincott William amp Wilkins 2002 2nd Edition
Campbellrsquos Operative Orthopaedics Mosby tenth edition
Chapmans Orthopaedic Surgery 3rd Edition Lippincott Williams amp Wilkins
Distal Humerus Fractures
References Current Concepts Review Distal humerus Fractures in
Adults A Nauth MD M Mckee MD B Ristevski MD JBJS 2011 vol 93-A no 7 4-6-2011
The olecranon osteotomy a six-year experience in the treatment of intraarticular fractures of the distal humerus Coles CP Barei DP Nork SE Taitsman LA Hanel DP Bradford Henley M J Orthop Trauma 2006 Mar20(3)164-71
A true triceps-splitting approach for treatment of distal humerus fractures a preliminary report Ziran BH Smith WR Balk ML Manning CM Agudelo JF J Trauma 2005 Jan58(1)70-5
Distal Humeral Hemiarthroplasty vs Total Elbow Arthroplasty for Acute Distal Humeral Fractures R Rangarajan MD R Papandrea MD A Cil MD Orthopedics JanFeb vol40 no 113-23
Extra Articular fracture Distal Humerus fx
in 67 yo F after someone tried to steal her
purse
SP ORIF Extra Articular fracture with
triceps reflecting
24 yo male GSW
Under went ORIF triceps reflecting
approach
23 yo running from police for no
reasonhellip
SP ORIF with 90-90 plating with
olecranon osteotomy
21 yo SP GSW
SP ORIF with Triceps sparing
approach
2 weeks post op
89 YO SP Mechanical fail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
Distal Humerus Fractures Operative
Treatment based on AO Classification
Triceps splitting Midline incision
leaves triceps tendon intact with extensorflexor fascia
Triceps repaired transosseous to olecranon functional studies equivalent to osteotomy
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon osteotomy Chervon osteotomy
25-3 cm from olecranon tip
Oscillating saw finished with osteotomy
Osteotomy fixated with either tension band intermedullary screw plate or IM nail
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon
osteotomy
Superior
visualization of
articular surface
Retrospective
Studies show no
functional difference
with triceps splitting
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon
osteotomy
6-30 hardware
removal
0-9 nonunion
rates
Distal Humerus Fractures Operative
Treatment based on AO Classification
Plate fixation Since 1970 AO introduction of dual column fixation substantial improvement in surgical outcomes Anatomic articular
reduction Rigid fixation with 2 plates 35 mm minimum
In cases of severe comminution of metaphysis or substantial bone loss Treat with
shortening but maintain alignment
Distal Humerus Fractures Operative
Treatment based on AO Classification
Debate on location of plate placement Perpendicular or
parallel to each other
Most studies show no significant difference in functional outcomes
Parallel plates had slight higher nonunion rate but stronger with metaphyseal comminution
Distal Humerus Fractures Operative
Treatment based on AO Classification
Use of locked
plating has been
controversial
proven superior in
osteoporotic bone
and comminuted
fractures
No data to go
against locked
plating
Distal Humerus Fractures Operative
Treatment based on AO Classification
Coronal Shear fracture OTAAO type B3
Uncommon involves capitellum trochlea or both
Usually associated with elbow dislocation
Often missed on plain x-rays 66 sensitivity CT recommended
Distal Humerus Fractures
Capitellum Fractures
Classification Type I Hahn-Steinthal
Fragment Large osseous component of capitellum sometimes with trochlear involvement
Type II Kocher-Lorenz Fragment Articular cartilage with minimal subcondylar bone attachment ldquo uncapping of the condylerdquo
Type III markedly comminuted
Distal Humerus Fractures
Capitellum Fractures Treatment Nonoperative Treatment
Primarily for nondisplaced fx Posterior splint immobilization for 3 weeks
Operative Treatment Goal is anatomic reduction ORIF
Indicated for displaced type I fractures Screws placed via lateral approach or posterior with olecranon
osteotomy for trochlea component or medial comminution headless screws may be placed anterior to posterior direction plate added to lateral column for comminution
Fixation should be stable enough to allow early ROM Excision
Contraindicated in the presence of associated elbow fractures Allows for early mobilization and less morbidity but associated
with instability Recommended treatment in old missed fractures with limited
ROM
Distal Humerus Fractures
Capitellum Fractures Complications
Complications Osteonecrosis uncommon
Posttraumatic arthritis increased with failure to restore articular congruity
Cubitus valgus may result with excision of the articular fragment or with associated lateral condylar or radial head fx It is associated with tardy ulnar palsy
Loss of motion (flexion) associated with retained chondral or osseous fragment that may become entrapped in the coronoid or radial fossae
Distal Humerus Fractures Operative
Treatment
Total Elbow Arthroplasty (TEA) Reserved for elderly
patients with poor bone quality low physical demands not amenable to ORIF
Goodexcellent results compared to ORIF in elderly as primary treatment
Distal Humerus Fractures Operative
Treatment
Total Elbow
Arthroplasty (TEA)
Higher rate of
infection nerve
injury implant
failure
Olecranon
Osteotomy
contraindicated
Distal Humerus Fractures
Complications
Ulnar nerve injury Due to initial
trauma or operative treatment
Transposition not proven to beneficial even when nerve is out preoperatively
Decompression recommended when nerve is out preop
Heterotopic Ossification (HO)
After operative fixation
Limits ROM
Prophylactic treatment indications are controversial
Use of indomethacin didnrsquot significantly reduce HO
When prophylaxis used 0-21 clinically significant HO
Distal Humerus Fractures Complications
Heterotopic
Ossification (HO)
1 dose post op
radiation and 2 weeks
indomethacin
treatment 3 rate
clinically significant
HO
Benefits weighted
against risks of union
with prophylactic
treatment
Heterotopic
Ossification (HO)
Risk factors CNS
injury delay in
operative treatment
sx prior to definitive
treatment
Distal Humerus Fractures Complications
Modern dual plate
fixation 89-100
union rates
Failing to adhere to
these principles
increase nonunion
rates
Nonunion treated with
revision ORIF bone
grafting selective
releases
Mean flex-ext arc
ROM 99deg-112deg
Recommended start
ROM at 2 weeks
Functional outcomes
after ORIF 84-100
goodexcellent
Regain 70-75
strength compared
to contra lateral side
DJ 2018 - OleON PPT
Tension Band w K-Wires
65 Cancellous Screw w Tension Band
Lag Screw w Tension Band
Plate Fixation
Current AO product options
Distal Humerus Fractures Fixation
Options of Olecranon Osteotomies
DJ 2018 - OleON PPT
Clinical needs
ndash Improved method to maintain reduction of olecranon osteotomy
ndash Intermedullary solution for fixation of an olecranon osteotomy
Indications The Olecranon Osteotomy Nail is indicated to treat osteotomies of the
olecranon
and simple olecranon fractures
The Olecranon Osteotomy Nail
Overview
DJ 2018 - OleON PPT
Main features and Benefits
Pre-osteotomy fixation ensuring anatomic alignment
Simpler fixation of olecranon osteotomy than current
commonly used techniques after distal humerus
surgery
Simple instrumentation for easy insertion and locking
of nail
Low profile minimizing soft tissue irritation and re-
operation
More stable fixation than current methods
Targeted locking to minimize size of incision
Mechanical testing on file at Synthes
The Olecranon Osteotomy Nail
Overview
Overall
Decision making made on most recent literature
Best available treatment option
Surgeon preference and comfort
Informed decision with patient
Need for prospective multicenter large scale study
Use sound surgical
techinque and use
AO fixation
prinicles
Distal Humerus Fractures
References
Fractures in Adults Rockwood and Wilkins Lippincott William amp Wilkins 2005 6th Edition
Handbook of Fractures Koval and Zuckerman Lippincott William amp Wilkins 2002 2nd Edition
Campbellrsquos Operative Orthopaedics Mosby tenth edition
Chapmans Orthopaedic Surgery 3rd Edition Lippincott Williams amp Wilkins
Distal Humerus Fractures
References Current Concepts Review Distal humerus Fractures in
Adults A Nauth MD M Mckee MD B Ristevski MD JBJS 2011 vol 93-A no 7 4-6-2011
The olecranon osteotomy a six-year experience in the treatment of intraarticular fractures of the distal humerus Coles CP Barei DP Nork SE Taitsman LA Hanel DP Bradford Henley M J Orthop Trauma 2006 Mar20(3)164-71
A true triceps-splitting approach for treatment of distal humerus fractures a preliminary report Ziran BH Smith WR Balk ML Manning CM Agudelo JF J Trauma 2005 Jan58(1)70-5
Distal Humeral Hemiarthroplasty vs Total Elbow Arthroplasty for Acute Distal Humeral Fractures R Rangarajan MD R Papandrea MD A Cil MD Orthopedics JanFeb vol40 no 113-23
Extra Articular fracture Distal Humerus fx
in 67 yo F after someone tried to steal her
purse
SP ORIF Extra Articular fracture with
triceps reflecting
24 yo male GSW
Under went ORIF triceps reflecting
approach
23 yo running from police for no
reasonhellip
SP ORIF with 90-90 plating with
olecranon osteotomy
21 yo SP GSW
SP ORIF with Triceps sparing
approach
2 weeks post op
89 YO SP Mechanical fail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon osteotomy Chervon osteotomy
25-3 cm from olecranon tip
Oscillating saw finished with osteotomy
Osteotomy fixated with either tension band intermedullary screw plate or IM nail
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon
osteotomy
Superior
visualization of
articular surface
Retrospective
Studies show no
functional difference
with triceps splitting
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon
osteotomy
6-30 hardware
removal
0-9 nonunion
rates
Distal Humerus Fractures Operative
Treatment based on AO Classification
Plate fixation Since 1970 AO introduction of dual column fixation substantial improvement in surgical outcomes Anatomic articular
reduction Rigid fixation with 2 plates 35 mm minimum
In cases of severe comminution of metaphysis or substantial bone loss Treat with
shortening but maintain alignment
Distal Humerus Fractures Operative
Treatment based on AO Classification
Debate on location of plate placement Perpendicular or
parallel to each other
Most studies show no significant difference in functional outcomes
Parallel plates had slight higher nonunion rate but stronger with metaphyseal comminution
Distal Humerus Fractures Operative
Treatment based on AO Classification
Use of locked
plating has been
controversial
proven superior in
osteoporotic bone
and comminuted
fractures
No data to go
against locked
plating
Distal Humerus Fractures Operative
Treatment based on AO Classification
Coronal Shear fracture OTAAO type B3
Uncommon involves capitellum trochlea or both
Usually associated with elbow dislocation
Often missed on plain x-rays 66 sensitivity CT recommended
Distal Humerus Fractures
Capitellum Fractures
Classification Type I Hahn-Steinthal
Fragment Large osseous component of capitellum sometimes with trochlear involvement
Type II Kocher-Lorenz Fragment Articular cartilage with minimal subcondylar bone attachment ldquo uncapping of the condylerdquo
Type III markedly comminuted
Distal Humerus Fractures
Capitellum Fractures Treatment Nonoperative Treatment
Primarily for nondisplaced fx Posterior splint immobilization for 3 weeks
Operative Treatment Goal is anatomic reduction ORIF
Indicated for displaced type I fractures Screws placed via lateral approach or posterior with olecranon
osteotomy for trochlea component or medial comminution headless screws may be placed anterior to posterior direction plate added to lateral column for comminution
Fixation should be stable enough to allow early ROM Excision
Contraindicated in the presence of associated elbow fractures Allows for early mobilization and less morbidity but associated
with instability Recommended treatment in old missed fractures with limited
ROM
Distal Humerus Fractures
Capitellum Fractures Complications
Complications Osteonecrosis uncommon
Posttraumatic arthritis increased with failure to restore articular congruity
Cubitus valgus may result with excision of the articular fragment or with associated lateral condylar or radial head fx It is associated with tardy ulnar palsy
Loss of motion (flexion) associated with retained chondral or osseous fragment that may become entrapped in the coronoid or radial fossae
Distal Humerus Fractures Operative
Treatment
Total Elbow Arthroplasty (TEA) Reserved for elderly
patients with poor bone quality low physical demands not amenable to ORIF
Goodexcellent results compared to ORIF in elderly as primary treatment
Distal Humerus Fractures Operative
Treatment
Total Elbow
Arthroplasty (TEA)
Higher rate of
infection nerve
injury implant
failure
Olecranon
Osteotomy
contraindicated
Distal Humerus Fractures
Complications
Ulnar nerve injury Due to initial
trauma or operative treatment
Transposition not proven to beneficial even when nerve is out preoperatively
Decompression recommended when nerve is out preop
Heterotopic Ossification (HO)
After operative fixation
Limits ROM
Prophylactic treatment indications are controversial
Use of indomethacin didnrsquot significantly reduce HO
When prophylaxis used 0-21 clinically significant HO
Distal Humerus Fractures Complications
Heterotopic
Ossification (HO)
1 dose post op
radiation and 2 weeks
indomethacin
treatment 3 rate
clinically significant
HO
Benefits weighted
against risks of union
with prophylactic
treatment
Heterotopic
Ossification (HO)
Risk factors CNS
injury delay in
operative treatment
sx prior to definitive
treatment
Distal Humerus Fractures Complications
Modern dual plate
fixation 89-100
union rates
Failing to adhere to
these principles
increase nonunion
rates
Nonunion treated with
revision ORIF bone
grafting selective
releases
Mean flex-ext arc
ROM 99deg-112deg
Recommended start
ROM at 2 weeks
Functional outcomes
after ORIF 84-100
goodexcellent
Regain 70-75
strength compared
to contra lateral side
DJ 2018 - OleON PPT
Tension Band w K-Wires
65 Cancellous Screw w Tension Band
Lag Screw w Tension Band
Plate Fixation
Current AO product options
Distal Humerus Fractures Fixation
Options of Olecranon Osteotomies
DJ 2018 - OleON PPT
Clinical needs
ndash Improved method to maintain reduction of olecranon osteotomy
ndash Intermedullary solution for fixation of an olecranon osteotomy
Indications The Olecranon Osteotomy Nail is indicated to treat osteotomies of the
olecranon
and simple olecranon fractures
The Olecranon Osteotomy Nail
Overview
DJ 2018 - OleON PPT
Main features and Benefits
Pre-osteotomy fixation ensuring anatomic alignment
Simpler fixation of olecranon osteotomy than current
commonly used techniques after distal humerus
surgery
Simple instrumentation for easy insertion and locking
of nail
Low profile minimizing soft tissue irritation and re-
operation
More stable fixation than current methods
Targeted locking to minimize size of incision
Mechanical testing on file at Synthes
The Olecranon Osteotomy Nail
Overview
Overall
Decision making made on most recent literature
Best available treatment option
Surgeon preference and comfort
Informed decision with patient
Need for prospective multicenter large scale study
Use sound surgical
techinque and use
AO fixation
prinicles
Distal Humerus Fractures
References
Fractures in Adults Rockwood and Wilkins Lippincott William amp Wilkins 2005 6th Edition
Handbook of Fractures Koval and Zuckerman Lippincott William amp Wilkins 2002 2nd Edition
Campbellrsquos Operative Orthopaedics Mosby tenth edition
Chapmans Orthopaedic Surgery 3rd Edition Lippincott Williams amp Wilkins
Distal Humerus Fractures
References Current Concepts Review Distal humerus Fractures in
Adults A Nauth MD M Mckee MD B Ristevski MD JBJS 2011 vol 93-A no 7 4-6-2011
The olecranon osteotomy a six-year experience in the treatment of intraarticular fractures of the distal humerus Coles CP Barei DP Nork SE Taitsman LA Hanel DP Bradford Henley M J Orthop Trauma 2006 Mar20(3)164-71
A true triceps-splitting approach for treatment of distal humerus fractures a preliminary report Ziran BH Smith WR Balk ML Manning CM Agudelo JF J Trauma 2005 Jan58(1)70-5
Distal Humeral Hemiarthroplasty vs Total Elbow Arthroplasty for Acute Distal Humeral Fractures R Rangarajan MD R Papandrea MD A Cil MD Orthopedics JanFeb vol40 no 113-23
Extra Articular fracture Distal Humerus fx
in 67 yo F after someone tried to steal her
purse
SP ORIF Extra Articular fracture with
triceps reflecting
24 yo male GSW
Under went ORIF triceps reflecting
approach
23 yo running from police for no
reasonhellip
SP ORIF with 90-90 plating with
olecranon osteotomy
21 yo SP GSW
SP ORIF with Triceps sparing
approach
2 weeks post op
89 YO SP Mechanical fail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon
osteotomy
Superior
visualization of
articular surface
Retrospective
Studies show no
functional difference
with triceps splitting
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon
osteotomy
6-30 hardware
removal
0-9 nonunion
rates
Distal Humerus Fractures Operative
Treatment based on AO Classification
Plate fixation Since 1970 AO introduction of dual column fixation substantial improvement in surgical outcomes Anatomic articular
reduction Rigid fixation with 2 plates 35 mm minimum
In cases of severe comminution of metaphysis or substantial bone loss Treat with
shortening but maintain alignment
Distal Humerus Fractures Operative
Treatment based on AO Classification
Debate on location of plate placement Perpendicular or
parallel to each other
Most studies show no significant difference in functional outcomes
Parallel plates had slight higher nonunion rate but stronger with metaphyseal comminution
Distal Humerus Fractures Operative
Treatment based on AO Classification
Use of locked
plating has been
controversial
proven superior in
osteoporotic bone
and comminuted
fractures
No data to go
against locked
plating
Distal Humerus Fractures Operative
Treatment based on AO Classification
Coronal Shear fracture OTAAO type B3
Uncommon involves capitellum trochlea or both
Usually associated with elbow dislocation
Often missed on plain x-rays 66 sensitivity CT recommended
Distal Humerus Fractures
Capitellum Fractures
Classification Type I Hahn-Steinthal
Fragment Large osseous component of capitellum sometimes with trochlear involvement
Type II Kocher-Lorenz Fragment Articular cartilage with minimal subcondylar bone attachment ldquo uncapping of the condylerdquo
Type III markedly comminuted
Distal Humerus Fractures
Capitellum Fractures Treatment Nonoperative Treatment
Primarily for nondisplaced fx Posterior splint immobilization for 3 weeks
Operative Treatment Goal is anatomic reduction ORIF
Indicated for displaced type I fractures Screws placed via lateral approach or posterior with olecranon
osteotomy for trochlea component or medial comminution headless screws may be placed anterior to posterior direction plate added to lateral column for comminution
Fixation should be stable enough to allow early ROM Excision
Contraindicated in the presence of associated elbow fractures Allows for early mobilization and less morbidity but associated
with instability Recommended treatment in old missed fractures with limited
ROM
Distal Humerus Fractures
Capitellum Fractures Complications
Complications Osteonecrosis uncommon
Posttraumatic arthritis increased with failure to restore articular congruity
Cubitus valgus may result with excision of the articular fragment or with associated lateral condylar or radial head fx It is associated with tardy ulnar palsy
Loss of motion (flexion) associated with retained chondral or osseous fragment that may become entrapped in the coronoid or radial fossae
Distal Humerus Fractures Operative
Treatment
Total Elbow Arthroplasty (TEA) Reserved for elderly
patients with poor bone quality low physical demands not amenable to ORIF
Goodexcellent results compared to ORIF in elderly as primary treatment
Distal Humerus Fractures Operative
Treatment
Total Elbow
Arthroplasty (TEA)
Higher rate of
infection nerve
injury implant
failure
Olecranon
Osteotomy
contraindicated
Distal Humerus Fractures
Complications
Ulnar nerve injury Due to initial
trauma or operative treatment
Transposition not proven to beneficial even when nerve is out preoperatively
Decompression recommended when nerve is out preop
Heterotopic Ossification (HO)
After operative fixation
Limits ROM
Prophylactic treatment indications are controversial
Use of indomethacin didnrsquot significantly reduce HO
When prophylaxis used 0-21 clinically significant HO
Distal Humerus Fractures Complications
Heterotopic
Ossification (HO)
1 dose post op
radiation and 2 weeks
indomethacin
treatment 3 rate
clinically significant
HO
Benefits weighted
against risks of union
with prophylactic
treatment
Heterotopic
Ossification (HO)
Risk factors CNS
injury delay in
operative treatment
sx prior to definitive
treatment
Distal Humerus Fractures Complications
Modern dual plate
fixation 89-100
union rates
Failing to adhere to
these principles
increase nonunion
rates
Nonunion treated with
revision ORIF bone
grafting selective
releases
Mean flex-ext arc
ROM 99deg-112deg
Recommended start
ROM at 2 weeks
Functional outcomes
after ORIF 84-100
goodexcellent
Regain 70-75
strength compared
to contra lateral side
DJ 2018 - OleON PPT
Tension Band w K-Wires
65 Cancellous Screw w Tension Band
Lag Screw w Tension Band
Plate Fixation
Current AO product options
Distal Humerus Fractures Fixation
Options of Olecranon Osteotomies
DJ 2018 - OleON PPT
Clinical needs
ndash Improved method to maintain reduction of olecranon osteotomy
ndash Intermedullary solution for fixation of an olecranon osteotomy
Indications The Olecranon Osteotomy Nail is indicated to treat osteotomies of the
olecranon
and simple olecranon fractures
The Olecranon Osteotomy Nail
Overview
DJ 2018 - OleON PPT
Main features and Benefits
Pre-osteotomy fixation ensuring anatomic alignment
Simpler fixation of olecranon osteotomy than current
commonly used techniques after distal humerus
surgery
Simple instrumentation for easy insertion and locking
of nail
Low profile minimizing soft tissue irritation and re-
operation
More stable fixation than current methods
Targeted locking to minimize size of incision
Mechanical testing on file at Synthes
The Olecranon Osteotomy Nail
Overview
Overall
Decision making made on most recent literature
Best available treatment option
Surgeon preference and comfort
Informed decision with patient
Need for prospective multicenter large scale study
Use sound surgical
techinque and use
AO fixation
prinicles
Distal Humerus Fractures
References
Fractures in Adults Rockwood and Wilkins Lippincott William amp Wilkins 2005 6th Edition
Handbook of Fractures Koval and Zuckerman Lippincott William amp Wilkins 2002 2nd Edition
Campbellrsquos Operative Orthopaedics Mosby tenth edition
Chapmans Orthopaedic Surgery 3rd Edition Lippincott Williams amp Wilkins
Distal Humerus Fractures
References Current Concepts Review Distal humerus Fractures in
Adults A Nauth MD M Mckee MD B Ristevski MD JBJS 2011 vol 93-A no 7 4-6-2011
The olecranon osteotomy a six-year experience in the treatment of intraarticular fractures of the distal humerus Coles CP Barei DP Nork SE Taitsman LA Hanel DP Bradford Henley M J Orthop Trauma 2006 Mar20(3)164-71
A true triceps-splitting approach for treatment of distal humerus fractures a preliminary report Ziran BH Smith WR Balk ML Manning CM Agudelo JF J Trauma 2005 Jan58(1)70-5
Distal Humeral Hemiarthroplasty vs Total Elbow Arthroplasty for Acute Distal Humeral Fractures R Rangarajan MD R Papandrea MD A Cil MD Orthopedics JanFeb vol40 no 113-23
Extra Articular fracture Distal Humerus fx
in 67 yo F after someone tried to steal her
purse
SP ORIF Extra Articular fracture with
triceps reflecting
24 yo male GSW
Under went ORIF triceps reflecting
approach
23 yo running from police for no
reasonhellip
SP ORIF with 90-90 plating with
olecranon osteotomy
21 yo SP GSW
SP ORIF with Triceps sparing
approach
2 weeks post op
89 YO SP Mechanical fail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
Distal Humerus Fractures Operative
Treatment based on AO Classification
Olecranon
osteotomy
6-30 hardware
removal
0-9 nonunion
rates
Distal Humerus Fractures Operative
Treatment based on AO Classification
Plate fixation Since 1970 AO introduction of dual column fixation substantial improvement in surgical outcomes Anatomic articular
reduction Rigid fixation with 2 plates 35 mm minimum
In cases of severe comminution of metaphysis or substantial bone loss Treat with
shortening but maintain alignment
Distal Humerus Fractures Operative
Treatment based on AO Classification
Debate on location of plate placement Perpendicular or
parallel to each other
Most studies show no significant difference in functional outcomes
Parallel plates had slight higher nonunion rate but stronger with metaphyseal comminution
Distal Humerus Fractures Operative
Treatment based on AO Classification
Use of locked
plating has been
controversial
proven superior in
osteoporotic bone
and comminuted
fractures
No data to go
against locked
plating
Distal Humerus Fractures Operative
Treatment based on AO Classification
Coronal Shear fracture OTAAO type B3
Uncommon involves capitellum trochlea or both
Usually associated with elbow dislocation
Often missed on plain x-rays 66 sensitivity CT recommended
Distal Humerus Fractures
Capitellum Fractures
Classification Type I Hahn-Steinthal
Fragment Large osseous component of capitellum sometimes with trochlear involvement
Type II Kocher-Lorenz Fragment Articular cartilage with minimal subcondylar bone attachment ldquo uncapping of the condylerdquo
Type III markedly comminuted
Distal Humerus Fractures
Capitellum Fractures Treatment Nonoperative Treatment
Primarily for nondisplaced fx Posterior splint immobilization for 3 weeks
Operative Treatment Goal is anatomic reduction ORIF
Indicated for displaced type I fractures Screws placed via lateral approach or posterior with olecranon
osteotomy for trochlea component or medial comminution headless screws may be placed anterior to posterior direction plate added to lateral column for comminution
Fixation should be stable enough to allow early ROM Excision
Contraindicated in the presence of associated elbow fractures Allows for early mobilization and less morbidity but associated
with instability Recommended treatment in old missed fractures with limited
ROM
Distal Humerus Fractures
Capitellum Fractures Complications
Complications Osteonecrosis uncommon
Posttraumatic arthritis increased with failure to restore articular congruity
Cubitus valgus may result with excision of the articular fragment or with associated lateral condylar or radial head fx It is associated with tardy ulnar palsy
Loss of motion (flexion) associated with retained chondral or osseous fragment that may become entrapped in the coronoid or radial fossae
Distal Humerus Fractures Operative
Treatment
Total Elbow Arthroplasty (TEA) Reserved for elderly
patients with poor bone quality low physical demands not amenable to ORIF
Goodexcellent results compared to ORIF in elderly as primary treatment
Distal Humerus Fractures Operative
Treatment
Total Elbow
Arthroplasty (TEA)
Higher rate of
infection nerve
injury implant
failure
Olecranon
Osteotomy
contraindicated
Distal Humerus Fractures
Complications
Ulnar nerve injury Due to initial
trauma or operative treatment
Transposition not proven to beneficial even when nerve is out preoperatively
Decompression recommended when nerve is out preop
Heterotopic Ossification (HO)
After operative fixation
Limits ROM
Prophylactic treatment indications are controversial
Use of indomethacin didnrsquot significantly reduce HO
When prophylaxis used 0-21 clinically significant HO
Distal Humerus Fractures Complications
Heterotopic
Ossification (HO)
1 dose post op
radiation and 2 weeks
indomethacin
treatment 3 rate
clinically significant
HO
Benefits weighted
against risks of union
with prophylactic
treatment
Heterotopic
Ossification (HO)
Risk factors CNS
injury delay in
operative treatment
sx prior to definitive
treatment
Distal Humerus Fractures Complications
Modern dual plate
fixation 89-100
union rates
Failing to adhere to
these principles
increase nonunion
rates
Nonunion treated with
revision ORIF bone
grafting selective
releases
Mean flex-ext arc
ROM 99deg-112deg
Recommended start
ROM at 2 weeks
Functional outcomes
after ORIF 84-100
goodexcellent
Regain 70-75
strength compared
to contra lateral side
DJ 2018 - OleON PPT
Tension Band w K-Wires
65 Cancellous Screw w Tension Band
Lag Screw w Tension Band
Plate Fixation
Current AO product options
Distal Humerus Fractures Fixation
Options of Olecranon Osteotomies
DJ 2018 - OleON PPT
Clinical needs
ndash Improved method to maintain reduction of olecranon osteotomy
ndash Intermedullary solution for fixation of an olecranon osteotomy
Indications The Olecranon Osteotomy Nail is indicated to treat osteotomies of the
olecranon
and simple olecranon fractures
The Olecranon Osteotomy Nail
Overview
DJ 2018 - OleON PPT
Main features and Benefits
Pre-osteotomy fixation ensuring anatomic alignment
Simpler fixation of olecranon osteotomy than current
commonly used techniques after distal humerus
surgery
Simple instrumentation for easy insertion and locking
of nail
Low profile minimizing soft tissue irritation and re-
operation
More stable fixation than current methods
Targeted locking to minimize size of incision
Mechanical testing on file at Synthes
The Olecranon Osteotomy Nail
Overview
Overall
Decision making made on most recent literature
Best available treatment option
Surgeon preference and comfort
Informed decision with patient
Need for prospective multicenter large scale study
Use sound surgical
techinque and use
AO fixation
prinicles
Distal Humerus Fractures
References
Fractures in Adults Rockwood and Wilkins Lippincott William amp Wilkins 2005 6th Edition
Handbook of Fractures Koval and Zuckerman Lippincott William amp Wilkins 2002 2nd Edition
Campbellrsquos Operative Orthopaedics Mosby tenth edition
Chapmans Orthopaedic Surgery 3rd Edition Lippincott Williams amp Wilkins
Distal Humerus Fractures
References Current Concepts Review Distal humerus Fractures in
Adults A Nauth MD M Mckee MD B Ristevski MD JBJS 2011 vol 93-A no 7 4-6-2011
The olecranon osteotomy a six-year experience in the treatment of intraarticular fractures of the distal humerus Coles CP Barei DP Nork SE Taitsman LA Hanel DP Bradford Henley M J Orthop Trauma 2006 Mar20(3)164-71
A true triceps-splitting approach for treatment of distal humerus fractures a preliminary report Ziran BH Smith WR Balk ML Manning CM Agudelo JF J Trauma 2005 Jan58(1)70-5
Distal Humeral Hemiarthroplasty vs Total Elbow Arthroplasty for Acute Distal Humeral Fractures R Rangarajan MD R Papandrea MD A Cil MD Orthopedics JanFeb vol40 no 113-23
Extra Articular fracture Distal Humerus fx
in 67 yo F after someone tried to steal her
purse
SP ORIF Extra Articular fracture with
triceps reflecting
24 yo male GSW
Under went ORIF triceps reflecting
approach
23 yo running from police for no
reasonhellip
SP ORIF with 90-90 plating with
olecranon osteotomy
21 yo SP GSW
SP ORIF with Triceps sparing
approach
2 weeks post op
89 YO SP Mechanical fail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
Distal Humerus Fractures Operative
Treatment based on AO Classification
Plate fixation Since 1970 AO introduction of dual column fixation substantial improvement in surgical outcomes Anatomic articular
reduction Rigid fixation with 2 plates 35 mm minimum
In cases of severe comminution of metaphysis or substantial bone loss Treat with
shortening but maintain alignment
Distal Humerus Fractures Operative
Treatment based on AO Classification
Debate on location of plate placement Perpendicular or
parallel to each other
Most studies show no significant difference in functional outcomes
Parallel plates had slight higher nonunion rate but stronger with metaphyseal comminution
Distal Humerus Fractures Operative
Treatment based on AO Classification
Use of locked
plating has been
controversial
proven superior in
osteoporotic bone
and comminuted
fractures
No data to go
against locked
plating
Distal Humerus Fractures Operative
Treatment based on AO Classification
Coronal Shear fracture OTAAO type B3
Uncommon involves capitellum trochlea or both
Usually associated with elbow dislocation
Often missed on plain x-rays 66 sensitivity CT recommended
Distal Humerus Fractures
Capitellum Fractures
Classification Type I Hahn-Steinthal
Fragment Large osseous component of capitellum sometimes with trochlear involvement
Type II Kocher-Lorenz Fragment Articular cartilage with minimal subcondylar bone attachment ldquo uncapping of the condylerdquo
Type III markedly comminuted
Distal Humerus Fractures
Capitellum Fractures Treatment Nonoperative Treatment
Primarily for nondisplaced fx Posterior splint immobilization for 3 weeks
Operative Treatment Goal is anatomic reduction ORIF
Indicated for displaced type I fractures Screws placed via lateral approach or posterior with olecranon
osteotomy for trochlea component or medial comminution headless screws may be placed anterior to posterior direction plate added to lateral column for comminution
Fixation should be stable enough to allow early ROM Excision
Contraindicated in the presence of associated elbow fractures Allows for early mobilization and less morbidity but associated
with instability Recommended treatment in old missed fractures with limited
ROM
Distal Humerus Fractures
Capitellum Fractures Complications
Complications Osteonecrosis uncommon
Posttraumatic arthritis increased with failure to restore articular congruity
Cubitus valgus may result with excision of the articular fragment or with associated lateral condylar or radial head fx It is associated with tardy ulnar palsy
Loss of motion (flexion) associated with retained chondral or osseous fragment that may become entrapped in the coronoid or radial fossae
Distal Humerus Fractures Operative
Treatment
Total Elbow Arthroplasty (TEA) Reserved for elderly
patients with poor bone quality low physical demands not amenable to ORIF
Goodexcellent results compared to ORIF in elderly as primary treatment
Distal Humerus Fractures Operative
Treatment
Total Elbow
Arthroplasty (TEA)
Higher rate of
infection nerve
injury implant
failure
Olecranon
Osteotomy
contraindicated
Distal Humerus Fractures
Complications
Ulnar nerve injury Due to initial
trauma or operative treatment
Transposition not proven to beneficial even when nerve is out preoperatively
Decompression recommended when nerve is out preop
Heterotopic Ossification (HO)
After operative fixation
Limits ROM
Prophylactic treatment indications are controversial
Use of indomethacin didnrsquot significantly reduce HO
When prophylaxis used 0-21 clinically significant HO
Distal Humerus Fractures Complications
Heterotopic
Ossification (HO)
1 dose post op
radiation and 2 weeks
indomethacin
treatment 3 rate
clinically significant
HO
Benefits weighted
against risks of union
with prophylactic
treatment
Heterotopic
Ossification (HO)
Risk factors CNS
injury delay in
operative treatment
sx prior to definitive
treatment
Distal Humerus Fractures Complications
Modern dual plate
fixation 89-100
union rates
Failing to adhere to
these principles
increase nonunion
rates
Nonunion treated with
revision ORIF bone
grafting selective
releases
Mean flex-ext arc
ROM 99deg-112deg
Recommended start
ROM at 2 weeks
Functional outcomes
after ORIF 84-100
goodexcellent
Regain 70-75
strength compared
to contra lateral side
DJ 2018 - OleON PPT
Tension Band w K-Wires
65 Cancellous Screw w Tension Band
Lag Screw w Tension Band
Plate Fixation
Current AO product options
Distal Humerus Fractures Fixation
Options of Olecranon Osteotomies
DJ 2018 - OleON PPT
Clinical needs
ndash Improved method to maintain reduction of olecranon osteotomy
ndash Intermedullary solution for fixation of an olecranon osteotomy
Indications The Olecranon Osteotomy Nail is indicated to treat osteotomies of the
olecranon
and simple olecranon fractures
The Olecranon Osteotomy Nail
Overview
DJ 2018 - OleON PPT
Main features and Benefits
Pre-osteotomy fixation ensuring anatomic alignment
Simpler fixation of olecranon osteotomy than current
commonly used techniques after distal humerus
surgery
Simple instrumentation for easy insertion and locking
of nail
Low profile minimizing soft tissue irritation and re-
operation
More stable fixation than current methods
Targeted locking to minimize size of incision
Mechanical testing on file at Synthes
The Olecranon Osteotomy Nail
Overview
Overall
Decision making made on most recent literature
Best available treatment option
Surgeon preference and comfort
Informed decision with patient
Need for prospective multicenter large scale study
Use sound surgical
techinque and use
AO fixation
prinicles
Distal Humerus Fractures
References
Fractures in Adults Rockwood and Wilkins Lippincott William amp Wilkins 2005 6th Edition
Handbook of Fractures Koval and Zuckerman Lippincott William amp Wilkins 2002 2nd Edition
Campbellrsquos Operative Orthopaedics Mosby tenth edition
Chapmans Orthopaedic Surgery 3rd Edition Lippincott Williams amp Wilkins
Distal Humerus Fractures
References Current Concepts Review Distal humerus Fractures in
Adults A Nauth MD M Mckee MD B Ristevski MD JBJS 2011 vol 93-A no 7 4-6-2011
The olecranon osteotomy a six-year experience in the treatment of intraarticular fractures of the distal humerus Coles CP Barei DP Nork SE Taitsman LA Hanel DP Bradford Henley M J Orthop Trauma 2006 Mar20(3)164-71
A true triceps-splitting approach for treatment of distal humerus fractures a preliminary report Ziran BH Smith WR Balk ML Manning CM Agudelo JF J Trauma 2005 Jan58(1)70-5
Distal Humeral Hemiarthroplasty vs Total Elbow Arthroplasty for Acute Distal Humeral Fractures R Rangarajan MD R Papandrea MD A Cil MD Orthopedics JanFeb vol40 no 113-23
Extra Articular fracture Distal Humerus fx
in 67 yo F after someone tried to steal her
purse
SP ORIF Extra Articular fracture with
triceps reflecting
24 yo male GSW
Under went ORIF triceps reflecting
approach
23 yo running from police for no
reasonhellip
SP ORIF with 90-90 plating with
olecranon osteotomy
21 yo SP GSW
SP ORIF with Triceps sparing
approach
2 weeks post op
89 YO SP Mechanical fail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
Distal Humerus Fractures Operative
Treatment based on AO Classification
Debate on location of plate placement Perpendicular or
parallel to each other
Most studies show no significant difference in functional outcomes
Parallel plates had slight higher nonunion rate but stronger with metaphyseal comminution
Distal Humerus Fractures Operative
Treatment based on AO Classification
Use of locked
plating has been
controversial
proven superior in
osteoporotic bone
and comminuted
fractures
No data to go
against locked
plating
Distal Humerus Fractures Operative
Treatment based on AO Classification
Coronal Shear fracture OTAAO type B3
Uncommon involves capitellum trochlea or both
Usually associated with elbow dislocation
Often missed on plain x-rays 66 sensitivity CT recommended
Distal Humerus Fractures
Capitellum Fractures
Classification Type I Hahn-Steinthal
Fragment Large osseous component of capitellum sometimes with trochlear involvement
Type II Kocher-Lorenz Fragment Articular cartilage with minimal subcondylar bone attachment ldquo uncapping of the condylerdquo
Type III markedly comminuted
Distal Humerus Fractures
Capitellum Fractures Treatment Nonoperative Treatment
Primarily for nondisplaced fx Posterior splint immobilization for 3 weeks
Operative Treatment Goal is anatomic reduction ORIF
Indicated for displaced type I fractures Screws placed via lateral approach or posterior with olecranon
osteotomy for trochlea component or medial comminution headless screws may be placed anterior to posterior direction plate added to lateral column for comminution
Fixation should be stable enough to allow early ROM Excision
Contraindicated in the presence of associated elbow fractures Allows for early mobilization and less morbidity but associated
with instability Recommended treatment in old missed fractures with limited
ROM
Distal Humerus Fractures
Capitellum Fractures Complications
Complications Osteonecrosis uncommon
Posttraumatic arthritis increased with failure to restore articular congruity
Cubitus valgus may result with excision of the articular fragment or with associated lateral condylar or radial head fx It is associated with tardy ulnar palsy
Loss of motion (flexion) associated with retained chondral or osseous fragment that may become entrapped in the coronoid or radial fossae
Distal Humerus Fractures Operative
Treatment
Total Elbow Arthroplasty (TEA) Reserved for elderly
patients with poor bone quality low physical demands not amenable to ORIF
Goodexcellent results compared to ORIF in elderly as primary treatment
Distal Humerus Fractures Operative
Treatment
Total Elbow
Arthroplasty (TEA)
Higher rate of
infection nerve
injury implant
failure
Olecranon
Osteotomy
contraindicated
Distal Humerus Fractures
Complications
Ulnar nerve injury Due to initial
trauma or operative treatment
Transposition not proven to beneficial even when nerve is out preoperatively
Decompression recommended when nerve is out preop
Heterotopic Ossification (HO)
After operative fixation
Limits ROM
Prophylactic treatment indications are controversial
Use of indomethacin didnrsquot significantly reduce HO
When prophylaxis used 0-21 clinically significant HO
Distal Humerus Fractures Complications
Heterotopic
Ossification (HO)
1 dose post op
radiation and 2 weeks
indomethacin
treatment 3 rate
clinically significant
HO
Benefits weighted
against risks of union
with prophylactic
treatment
Heterotopic
Ossification (HO)
Risk factors CNS
injury delay in
operative treatment
sx prior to definitive
treatment
Distal Humerus Fractures Complications
Modern dual plate
fixation 89-100
union rates
Failing to adhere to
these principles
increase nonunion
rates
Nonunion treated with
revision ORIF bone
grafting selective
releases
Mean flex-ext arc
ROM 99deg-112deg
Recommended start
ROM at 2 weeks
Functional outcomes
after ORIF 84-100
goodexcellent
Regain 70-75
strength compared
to contra lateral side
DJ 2018 - OleON PPT
Tension Band w K-Wires
65 Cancellous Screw w Tension Band
Lag Screw w Tension Band
Plate Fixation
Current AO product options
Distal Humerus Fractures Fixation
Options of Olecranon Osteotomies
DJ 2018 - OleON PPT
Clinical needs
ndash Improved method to maintain reduction of olecranon osteotomy
ndash Intermedullary solution for fixation of an olecranon osteotomy
Indications The Olecranon Osteotomy Nail is indicated to treat osteotomies of the
olecranon
and simple olecranon fractures
The Olecranon Osteotomy Nail
Overview
DJ 2018 - OleON PPT
Main features and Benefits
Pre-osteotomy fixation ensuring anatomic alignment
Simpler fixation of olecranon osteotomy than current
commonly used techniques after distal humerus
surgery
Simple instrumentation for easy insertion and locking
of nail
Low profile minimizing soft tissue irritation and re-
operation
More stable fixation than current methods
Targeted locking to minimize size of incision
Mechanical testing on file at Synthes
The Olecranon Osteotomy Nail
Overview
Overall
Decision making made on most recent literature
Best available treatment option
Surgeon preference and comfort
Informed decision with patient
Need for prospective multicenter large scale study
Use sound surgical
techinque and use
AO fixation
prinicles
Distal Humerus Fractures
References
Fractures in Adults Rockwood and Wilkins Lippincott William amp Wilkins 2005 6th Edition
Handbook of Fractures Koval and Zuckerman Lippincott William amp Wilkins 2002 2nd Edition
Campbellrsquos Operative Orthopaedics Mosby tenth edition
Chapmans Orthopaedic Surgery 3rd Edition Lippincott Williams amp Wilkins
Distal Humerus Fractures
References Current Concepts Review Distal humerus Fractures in
Adults A Nauth MD M Mckee MD B Ristevski MD JBJS 2011 vol 93-A no 7 4-6-2011
The olecranon osteotomy a six-year experience in the treatment of intraarticular fractures of the distal humerus Coles CP Barei DP Nork SE Taitsman LA Hanel DP Bradford Henley M J Orthop Trauma 2006 Mar20(3)164-71
A true triceps-splitting approach for treatment of distal humerus fractures a preliminary report Ziran BH Smith WR Balk ML Manning CM Agudelo JF J Trauma 2005 Jan58(1)70-5
Distal Humeral Hemiarthroplasty vs Total Elbow Arthroplasty for Acute Distal Humeral Fractures R Rangarajan MD R Papandrea MD A Cil MD Orthopedics JanFeb vol40 no 113-23
Extra Articular fracture Distal Humerus fx
in 67 yo F after someone tried to steal her
purse
SP ORIF Extra Articular fracture with
triceps reflecting
24 yo male GSW
Under went ORIF triceps reflecting
approach
23 yo running from police for no
reasonhellip
SP ORIF with 90-90 plating with
olecranon osteotomy
21 yo SP GSW
SP ORIF with Triceps sparing
approach
2 weeks post op
89 YO SP Mechanical fail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
Distal Humerus Fractures Operative
Treatment based on AO Classification
Use of locked
plating has been
controversial
proven superior in
osteoporotic bone
and comminuted
fractures
No data to go
against locked
plating
Distal Humerus Fractures Operative
Treatment based on AO Classification
Coronal Shear fracture OTAAO type B3
Uncommon involves capitellum trochlea or both
Usually associated with elbow dislocation
Often missed on plain x-rays 66 sensitivity CT recommended
Distal Humerus Fractures
Capitellum Fractures
Classification Type I Hahn-Steinthal
Fragment Large osseous component of capitellum sometimes with trochlear involvement
Type II Kocher-Lorenz Fragment Articular cartilage with minimal subcondylar bone attachment ldquo uncapping of the condylerdquo
Type III markedly comminuted
Distal Humerus Fractures
Capitellum Fractures Treatment Nonoperative Treatment
Primarily for nondisplaced fx Posterior splint immobilization for 3 weeks
Operative Treatment Goal is anatomic reduction ORIF
Indicated for displaced type I fractures Screws placed via lateral approach or posterior with olecranon
osteotomy for trochlea component or medial comminution headless screws may be placed anterior to posterior direction plate added to lateral column for comminution
Fixation should be stable enough to allow early ROM Excision
Contraindicated in the presence of associated elbow fractures Allows for early mobilization and less morbidity but associated
with instability Recommended treatment in old missed fractures with limited
ROM
Distal Humerus Fractures
Capitellum Fractures Complications
Complications Osteonecrosis uncommon
Posttraumatic arthritis increased with failure to restore articular congruity
Cubitus valgus may result with excision of the articular fragment or with associated lateral condylar or radial head fx It is associated with tardy ulnar palsy
Loss of motion (flexion) associated with retained chondral or osseous fragment that may become entrapped in the coronoid or radial fossae
Distal Humerus Fractures Operative
Treatment
Total Elbow Arthroplasty (TEA) Reserved for elderly
patients with poor bone quality low physical demands not amenable to ORIF
Goodexcellent results compared to ORIF in elderly as primary treatment
Distal Humerus Fractures Operative
Treatment
Total Elbow
Arthroplasty (TEA)
Higher rate of
infection nerve
injury implant
failure
Olecranon
Osteotomy
contraindicated
Distal Humerus Fractures
Complications
Ulnar nerve injury Due to initial
trauma or operative treatment
Transposition not proven to beneficial even when nerve is out preoperatively
Decompression recommended when nerve is out preop
Heterotopic Ossification (HO)
After operative fixation
Limits ROM
Prophylactic treatment indications are controversial
Use of indomethacin didnrsquot significantly reduce HO
When prophylaxis used 0-21 clinically significant HO
Distal Humerus Fractures Complications
Heterotopic
Ossification (HO)
1 dose post op
radiation and 2 weeks
indomethacin
treatment 3 rate
clinically significant
HO
Benefits weighted
against risks of union
with prophylactic
treatment
Heterotopic
Ossification (HO)
Risk factors CNS
injury delay in
operative treatment
sx prior to definitive
treatment
Distal Humerus Fractures Complications
Modern dual plate
fixation 89-100
union rates
Failing to adhere to
these principles
increase nonunion
rates
Nonunion treated with
revision ORIF bone
grafting selective
releases
Mean flex-ext arc
ROM 99deg-112deg
Recommended start
ROM at 2 weeks
Functional outcomes
after ORIF 84-100
goodexcellent
Regain 70-75
strength compared
to contra lateral side
DJ 2018 - OleON PPT
Tension Band w K-Wires
65 Cancellous Screw w Tension Band
Lag Screw w Tension Band
Plate Fixation
Current AO product options
Distal Humerus Fractures Fixation
Options of Olecranon Osteotomies
DJ 2018 - OleON PPT
Clinical needs
ndash Improved method to maintain reduction of olecranon osteotomy
ndash Intermedullary solution for fixation of an olecranon osteotomy
Indications The Olecranon Osteotomy Nail is indicated to treat osteotomies of the
olecranon
and simple olecranon fractures
The Olecranon Osteotomy Nail
Overview
DJ 2018 - OleON PPT
Main features and Benefits
Pre-osteotomy fixation ensuring anatomic alignment
Simpler fixation of olecranon osteotomy than current
commonly used techniques after distal humerus
surgery
Simple instrumentation for easy insertion and locking
of nail
Low profile minimizing soft tissue irritation and re-
operation
More stable fixation than current methods
Targeted locking to minimize size of incision
Mechanical testing on file at Synthes
The Olecranon Osteotomy Nail
Overview
Overall
Decision making made on most recent literature
Best available treatment option
Surgeon preference and comfort
Informed decision with patient
Need for prospective multicenter large scale study
Use sound surgical
techinque and use
AO fixation
prinicles
Distal Humerus Fractures
References
Fractures in Adults Rockwood and Wilkins Lippincott William amp Wilkins 2005 6th Edition
Handbook of Fractures Koval and Zuckerman Lippincott William amp Wilkins 2002 2nd Edition
Campbellrsquos Operative Orthopaedics Mosby tenth edition
Chapmans Orthopaedic Surgery 3rd Edition Lippincott Williams amp Wilkins
Distal Humerus Fractures
References Current Concepts Review Distal humerus Fractures in
Adults A Nauth MD M Mckee MD B Ristevski MD JBJS 2011 vol 93-A no 7 4-6-2011
The olecranon osteotomy a six-year experience in the treatment of intraarticular fractures of the distal humerus Coles CP Barei DP Nork SE Taitsman LA Hanel DP Bradford Henley M J Orthop Trauma 2006 Mar20(3)164-71
A true triceps-splitting approach for treatment of distal humerus fractures a preliminary report Ziran BH Smith WR Balk ML Manning CM Agudelo JF J Trauma 2005 Jan58(1)70-5
Distal Humeral Hemiarthroplasty vs Total Elbow Arthroplasty for Acute Distal Humeral Fractures R Rangarajan MD R Papandrea MD A Cil MD Orthopedics JanFeb vol40 no 113-23
Extra Articular fracture Distal Humerus fx
in 67 yo F after someone tried to steal her
purse
SP ORIF Extra Articular fracture with
triceps reflecting
24 yo male GSW
Under went ORIF triceps reflecting
approach
23 yo running from police for no
reasonhellip
SP ORIF with 90-90 plating with
olecranon osteotomy
21 yo SP GSW
SP ORIF with Triceps sparing
approach
2 weeks post op
89 YO SP Mechanical fail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
Distal Humerus Fractures Operative
Treatment based on AO Classification
Coronal Shear fracture OTAAO type B3
Uncommon involves capitellum trochlea or both
Usually associated with elbow dislocation
Often missed on plain x-rays 66 sensitivity CT recommended
Distal Humerus Fractures
Capitellum Fractures
Classification Type I Hahn-Steinthal
Fragment Large osseous component of capitellum sometimes with trochlear involvement
Type II Kocher-Lorenz Fragment Articular cartilage with minimal subcondylar bone attachment ldquo uncapping of the condylerdquo
Type III markedly comminuted
Distal Humerus Fractures
Capitellum Fractures Treatment Nonoperative Treatment
Primarily for nondisplaced fx Posterior splint immobilization for 3 weeks
Operative Treatment Goal is anatomic reduction ORIF
Indicated for displaced type I fractures Screws placed via lateral approach or posterior with olecranon
osteotomy for trochlea component or medial comminution headless screws may be placed anterior to posterior direction plate added to lateral column for comminution
Fixation should be stable enough to allow early ROM Excision
Contraindicated in the presence of associated elbow fractures Allows for early mobilization and less morbidity but associated
with instability Recommended treatment in old missed fractures with limited
ROM
Distal Humerus Fractures
Capitellum Fractures Complications
Complications Osteonecrosis uncommon
Posttraumatic arthritis increased with failure to restore articular congruity
Cubitus valgus may result with excision of the articular fragment or with associated lateral condylar or radial head fx It is associated with tardy ulnar palsy
Loss of motion (flexion) associated with retained chondral or osseous fragment that may become entrapped in the coronoid or radial fossae
Distal Humerus Fractures Operative
Treatment
Total Elbow Arthroplasty (TEA) Reserved for elderly
patients with poor bone quality low physical demands not amenable to ORIF
Goodexcellent results compared to ORIF in elderly as primary treatment
Distal Humerus Fractures Operative
Treatment
Total Elbow
Arthroplasty (TEA)
Higher rate of
infection nerve
injury implant
failure
Olecranon
Osteotomy
contraindicated
Distal Humerus Fractures
Complications
Ulnar nerve injury Due to initial
trauma or operative treatment
Transposition not proven to beneficial even when nerve is out preoperatively
Decompression recommended when nerve is out preop
Heterotopic Ossification (HO)
After operative fixation
Limits ROM
Prophylactic treatment indications are controversial
Use of indomethacin didnrsquot significantly reduce HO
When prophylaxis used 0-21 clinically significant HO
Distal Humerus Fractures Complications
Heterotopic
Ossification (HO)
1 dose post op
radiation and 2 weeks
indomethacin
treatment 3 rate
clinically significant
HO
Benefits weighted
against risks of union
with prophylactic
treatment
Heterotopic
Ossification (HO)
Risk factors CNS
injury delay in
operative treatment
sx prior to definitive
treatment
Distal Humerus Fractures Complications
Modern dual plate
fixation 89-100
union rates
Failing to adhere to
these principles
increase nonunion
rates
Nonunion treated with
revision ORIF bone
grafting selective
releases
Mean flex-ext arc
ROM 99deg-112deg
Recommended start
ROM at 2 weeks
Functional outcomes
after ORIF 84-100
goodexcellent
Regain 70-75
strength compared
to contra lateral side
DJ 2018 - OleON PPT
Tension Band w K-Wires
65 Cancellous Screw w Tension Band
Lag Screw w Tension Band
Plate Fixation
Current AO product options
Distal Humerus Fractures Fixation
Options of Olecranon Osteotomies
DJ 2018 - OleON PPT
Clinical needs
ndash Improved method to maintain reduction of olecranon osteotomy
ndash Intermedullary solution for fixation of an olecranon osteotomy
Indications The Olecranon Osteotomy Nail is indicated to treat osteotomies of the
olecranon
and simple olecranon fractures
The Olecranon Osteotomy Nail
Overview
DJ 2018 - OleON PPT
Main features and Benefits
Pre-osteotomy fixation ensuring anatomic alignment
Simpler fixation of olecranon osteotomy than current
commonly used techniques after distal humerus
surgery
Simple instrumentation for easy insertion and locking
of nail
Low profile minimizing soft tissue irritation and re-
operation
More stable fixation than current methods
Targeted locking to minimize size of incision
Mechanical testing on file at Synthes
The Olecranon Osteotomy Nail
Overview
Overall
Decision making made on most recent literature
Best available treatment option
Surgeon preference and comfort
Informed decision with patient
Need for prospective multicenter large scale study
Use sound surgical
techinque and use
AO fixation
prinicles
Distal Humerus Fractures
References
Fractures in Adults Rockwood and Wilkins Lippincott William amp Wilkins 2005 6th Edition
Handbook of Fractures Koval and Zuckerman Lippincott William amp Wilkins 2002 2nd Edition
Campbellrsquos Operative Orthopaedics Mosby tenth edition
Chapmans Orthopaedic Surgery 3rd Edition Lippincott Williams amp Wilkins
Distal Humerus Fractures
References Current Concepts Review Distal humerus Fractures in
Adults A Nauth MD M Mckee MD B Ristevski MD JBJS 2011 vol 93-A no 7 4-6-2011
The olecranon osteotomy a six-year experience in the treatment of intraarticular fractures of the distal humerus Coles CP Barei DP Nork SE Taitsman LA Hanel DP Bradford Henley M J Orthop Trauma 2006 Mar20(3)164-71
A true triceps-splitting approach for treatment of distal humerus fractures a preliminary report Ziran BH Smith WR Balk ML Manning CM Agudelo JF J Trauma 2005 Jan58(1)70-5
Distal Humeral Hemiarthroplasty vs Total Elbow Arthroplasty for Acute Distal Humeral Fractures R Rangarajan MD R Papandrea MD A Cil MD Orthopedics JanFeb vol40 no 113-23
Extra Articular fracture Distal Humerus fx
in 67 yo F after someone tried to steal her
purse
SP ORIF Extra Articular fracture with
triceps reflecting
24 yo male GSW
Under went ORIF triceps reflecting
approach
23 yo running from police for no
reasonhellip
SP ORIF with 90-90 plating with
olecranon osteotomy
21 yo SP GSW
SP ORIF with Triceps sparing
approach
2 weeks post op
89 YO SP Mechanical fail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
Distal Humerus Fractures
Capitellum Fractures
Classification Type I Hahn-Steinthal
Fragment Large osseous component of capitellum sometimes with trochlear involvement
Type II Kocher-Lorenz Fragment Articular cartilage with minimal subcondylar bone attachment ldquo uncapping of the condylerdquo
Type III markedly comminuted
Distal Humerus Fractures
Capitellum Fractures Treatment Nonoperative Treatment
Primarily for nondisplaced fx Posterior splint immobilization for 3 weeks
Operative Treatment Goal is anatomic reduction ORIF
Indicated for displaced type I fractures Screws placed via lateral approach or posterior with olecranon
osteotomy for trochlea component or medial comminution headless screws may be placed anterior to posterior direction plate added to lateral column for comminution
Fixation should be stable enough to allow early ROM Excision
Contraindicated in the presence of associated elbow fractures Allows for early mobilization and less morbidity but associated
with instability Recommended treatment in old missed fractures with limited
ROM
Distal Humerus Fractures
Capitellum Fractures Complications
Complications Osteonecrosis uncommon
Posttraumatic arthritis increased with failure to restore articular congruity
Cubitus valgus may result with excision of the articular fragment or with associated lateral condylar or radial head fx It is associated with tardy ulnar palsy
Loss of motion (flexion) associated with retained chondral or osseous fragment that may become entrapped in the coronoid or radial fossae
Distal Humerus Fractures Operative
Treatment
Total Elbow Arthroplasty (TEA) Reserved for elderly
patients with poor bone quality low physical demands not amenable to ORIF
Goodexcellent results compared to ORIF in elderly as primary treatment
Distal Humerus Fractures Operative
Treatment
Total Elbow
Arthroplasty (TEA)
Higher rate of
infection nerve
injury implant
failure
Olecranon
Osteotomy
contraindicated
Distal Humerus Fractures
Complications
Ulnar nerve injury Due to initial
trauma or operative treatment
Transposition not proven to beneficial even when nerve is out preoperatively
Decompression recommended when nerve is out preop
Heterotopic Ossification (HO)
After operative fixation
Limits ROM
Prophylactic treatment indications are controversial
Use of indomethacin didnrsquot significantly reduce HO
When prophylaxis used 0-21 clinically significant HO
Distal Humerus Fractures Complications
Heterotopic
Ossification (HO)
1 dose post op
radiation and 2 weeks
indomethacin
treatment 3 rate
clinically significant
HO
Benefits weighted
against risks of union
with prophylactic
treatment
Heterotopic
Ossification (HO)
Risk factors CNS
injury delay in
operative treatment
sx prior to definitive
treatment
Distal Humerus Fractures Complications
Modern dual plate
fixation 89-100
union rates
Failing to adhere to
these principles
increase nonunion
rates
Nonunion treated with
revision ORIF bone
grafting selective
releases
Mean flex-ext arc
ROM 99deg-112deg
Recommended start
ROM at 2 weeks
Functional outcomes
after ORIF 84-100
goodexcellent
Regain 70-75
strength compared
to contra lateral side
DJ 2018 - OleON PPT
Tension Band w K-Wires
65 Cancellous Screw w Tension Band
Lag Screw w Tension Band
Plate Fixation
Current AO product options
Distal Humerus Fractures Fixation
Options of Olecranon Osteotomies
DJ 2018 - OleON PPT
Clinical needs
ndash Improved method to maintain reduction of olecranon osteotomy
ndash Intermedullary solution for fixation of an olecranon osteotomy
Indications The Olecranon Osteotomy Nail is indicated to treat osteotomies of the
olecranon
and simple olecranon fractures
The Olecranon Osteotomy Nail
Overview
DJ 2018 - OleON PPT
Main features and Benefits
Pre-osteotomy fixation ensuring anatomic alignment
Simpler fixation of olecranon osteotomy than current
commonly used techniques after distal humerus
surgery
Simple instrumentation for easy insertion and locking
of nail
Low profile minimizing soft tissue irritation and re-
operation
More stable fixation than current methods
Targeted locking to minimize size of incision
Mechanical testing on file at Synthes
The Olecranon Osteotomy Nail
Overview
Overall
Decision making made on most recent literature
Best available treatment option
Surgeon preference and comfort
Informed decision with patient
Need for prospective multicenter large scale study
Use sound surgical
techinque and use
AO fixation
prinicles
Distal Humerus Fractures
References
Fractures in Adults Rockwood and Wilkins Lippincott William amp Wilkins 2005 6th Edition
Handbook of Fractures Koval and Zuckerman Lippincott William amp Wilkins 2002 2nd Edition
Campbellrsquos Operative Orthopaedics Mosby tenth edition
Chapmans Orthopaedic Surgery 3rd Edition Lippincott Williams amp Wilkins
Distal Humerus Fractures
References Current Concepts Review Distal humerus Fractures in
Adults A Nauth MD M Mckee MD B Ristevski MD JBJS 2011 vol 93-A no 7 4-6-2011
The olecranon osteotomy a six-year experience in the treatment of intraarticular fractures of the distal humerus Coles CP Barei DP Nork SE Taitsman LA Hanel DP Bradford Henley M J Orthop Trauma 2006 Mar20(3)164-71
A true triceps-splitting approach for treatment of distal humerus fractures a preliminary report Ziran BH Smith WR Balk ML Manning CM Agudelo JF J Trauma 2005 Jan58(1)70-5
Distal Humeral Hemiarthroplasty vs Total Elbow Arthroplasty for Acute Distal Humeral Fractures R Rangarajan MD R Papandrea MD A Cil MD Orthopedics JanFeb vol40 no 113-23
Extra Articular fracture Distal Humerus fx
in 67 yo F after someone tried to steal her
purse
SP ORIF Extra Articular fracture with
triceps reflecting
24 yo male GSW
Under went ORIF triceps reflecting
approach
23 yo running from police for no
reasonhellip
SP ORIF with 90-90 plating with
olecranon osteotomy
21 yo SP GSW
SP ORIF with Triceps sparing
approach
2 weeks post op
89 YO SP Mechanical fail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
Distal Humerus Fractures
Capitellum Fractures Treatment Nonoperative Treatment
Primarily for nondisplaced fx Posterior splint immobilization for 3 weeks
Operative Treatment Goal is anatomic reduction ORIF
Indicated for displaced type I fractures Screws placed via lateral approach or posterior with olecranon
osteotomy for trochlea component or medial comminution headless screws may be placed anterior to posterior direction plate added to lateral column for comminution
Fixation should be stable enough to allow early ROM Excision
Contraindicated in the presence of associated elbow fractures Allows for early mobilization and less morbidity but associated
with instability Recommended treatment in old missed fractures with limited
ROM
Distal Humerus Fractures
Capitellum Fractures Complications
Complications Osteonecrosis uncommon
Posttraumatic arthritis increased with failure to restore articular congruity
Cubitus valgus may result with excision of the articular fragment or with associated lateral condylar or radial head fx It is associated with tardy ulnar palsy
Loss of motion (flexion) associated with retained chondral or osseous fragment that may become entrapped in the coronoid or radial fossae
Distal Humerus Fractures Operative
Treatment
Total Elbow Arthroplasty (TEA) Reserved for elderly
patients with poor bone quality low physical demands not amenable to ORIF
Goodexcellent results compared to ORIF in elderly as primary treatment
Distal Humerus Fractures Operative
Treatment
Total Elbow
Arthroplasty (TEA)
Higher rate of
infection nerve
injury implant
failure
Olecranon
Osteotomy
contraindicated
Distal Humerus Fractures
Complications
Ulnar nerve injury Due to initial
trauma or operative treatment
Transposition not proven to beneficial even when nerve is out preoperatively
Decompression recommended when nerve is out preop
Heterotopic Ossification (HO)
After operative fixation
Limits ROM
Prophylactic treatment indications are controversial
Use of indomethacin didnrsquot significantly reduce HO
When prophylaxis used 0-21 clinically significant HO
Distal Humerus Fractures Complications
Heterotopic
Ossification (HO)
1 dose post op
radiation and 2 weeks
indomethacin
treatment 3 rate
clinically significant
HO
Benefits weighted
against risks of union
with prophylactic
treatment
Heterotopic
Ossification (HO)
Risk factors CNS
injury delay in
operative treatment
sx prior to definitive
treatment
Distal Humerus Fractures Complications
Modern dual plate
fixation 89-100
union rates
Failing to adhere to
these principles
increase nonunion
rates
Nonunion treated with
revision ORIF bone
grafting selective
releases
Mean flex-ext arc
ROM 99deg-112deg
Recommended start
ROM at 2 weeks
Functional outcomes
after ORIF 84-100
goodexcellent
Regain 70-75
strength compared
to contra lateral side
DJ 2018 - OleON PPT
Tension Band w K-Wires
65 Cancellous Screw w Tension Band
Lag Screw w Tension Band
Plate Fixation
Current AO product options
Distal Humerus Fractures Fixation
Options of Olecranon Osteotomies
DJ 2018 - OleON PPT
Clinical needs
ndash Improved method to maintain reduction of olecranon osteotomy
ndash Intermedullary solution for fixation of an olecranon osteotomy
Indications The Olecranon Osteotomy Nail is indicated to treat osteotomies of the
olecranon
and simple olecranon fractures
The Olecranon Osteotomy Nail
Overview
DJ 2018 - OleON PPT
Main features and Benefits
Pre-osteotomy fixation ensuring anatomic alignment
Simpler fixation of olecranon osteotomy than current
commonly used techniques after distal humerus
surgery
Simple instrumentation for easy insertion and locking
of nail
Low profile minimizing soft tissue irritation and re-
operation
More stable fixation than current methods
Targeted locking to minimize size of incision
Mechanical testing on file at Synthes
The Olecranon Osteotomy Nail
Overview
Overall
Decision making made on most recent literature
Best available treatment option
Surgeon preference and comfort
Informed decision with patient
Need for prospective multicenter large scale study
Use sound surgical
techinque and use
AO fixation
prinicles
Distal Humerus Fractures
References
Fractures in Adults Rockwood and Wilkins Lippincott William amp Wilkins 2005 6th Edition
Handbook of Fractures Koval and Zuckerman Lippincott William amp Wilkins 2002 2nd Edition
Campbellrsquos Operative Orthopaedics Mosby tenth edition
Chapmans Orthopaedic Surgery 3rd Edition Lippincott Williams amp Wilkins
Distal Humerus Fractures
References Current Concepts Review Distal humerus Fractures in
Adults A Nauth MD M Mckee MD B Ristevski MD JBJS 2011 vol 93-A no 7 4-6-2011
The olecranon osteotomy a six-year experience in the treatment of intraarticular fractures of the distal humerus Coles CP Barei DP Nork SE Taitsman LA Hanel DP Bradford Henley M J Orthop Trauma 2006 Mar20(3)164-71
A true triceps-splitting approach for treatment of distal humerus fractures a preliminary report Ziran BH Smith WR Balk ML Manning CM Agudelo JF J Trauma 2005 Jan58(1)70-5
Distal Humeral Hemiarthroplasty vs Total Elbow Arthroplasty for Acute Distal Humeral Fractures R Rangarajan MD R Papandrea MD A Cil MD Orthopedics JanFeb vol40 no 113-23
Extra Articular fracture Distal Humerus fx
in 67 yo F after someone tried to steal her
purse
SP ORIF Extra Articular fracture with
triceps reflecting
24 yo male GSW
Under went ORIF triceps reflecting
approach
23 yo running from police for no
reasonhellip
SP ORIF with 90-90 plating with
olecranon osteotomy
21 yo SP GSW
SP ORIF with Triceps sparing
approach
2 weeks post op
89 YO SP Mechanical fail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
Distal Humerus Fractures
Capitellum Fractures Complications
Complications Osteonecrosis uncommon
Posttraumatic arthritis increased with failure to restore articular congruity
Cubitus valgus may result with excision of the articular fragment or with associated lateral condylar or radial head fx It is associated with tardy ulnar palsy
Loss of motion (flexion) associated with retained chondral or osseous fragment that may become entrapped in the coronoid or radial fossae
Distal Humerus Fractures Operative
Treatment
Total Elbow Arthroplasty (TEA) Reserved for elderly
patients with poor bone quality low physical demands not amenable to ORIF
Goodexcellent results compared to ORIF in elderly as primary treatment
Distal Humerus Fractures Operative
Treatment
Total Elbow
Arthroplasty (TEA)
Higher rate of
infection nerve
injury implant
failure
Olecranon
Osteotomy
contraindicated
Distal Humerus Fractures
Complications
Ulnar nerve injury Due to initial
trauma or operative treatment
Transposition not proven to beneficial even when nerve is out preoperatively
Decompression recommended when nerve is out preop
Heterotopic Ossification (HO)
After operative fixation
Limits ROM
Prophylactic treatment indications are controversial
Use of indomethacin didnrsquot significantly reduce HO
When prophylaxis used 0-21 clinically significant HO
Distal Humerus Fractures Complications
Heterotopic
Ossification (HO)
1 dose post op
radiation and 2 weeks
indomethacin
treatment 3 rate
clinically significant
HO
Benefits weighted
against risks of union
with prophylactic
treatment
Heterotopic
Ossification (HO)
Risk factors CNS
injury delay in
operative treatment
sx prior to definitive
treatment
Distal Humerus Fractures Complications
Modern dual plate
fixation 89-100
union rates
Failing to adhere to
these principles
increase nonunion
rates
Nonunion treated with
revision ORIF bone
grafting selective
releases
Mean flex-ext arc
ROM 99deg-112deg
Recommended start
ROM at 2 weeks
Functional outcomes
after ORIF 84-100
goodexcellent
Regain 70-75
strength compared
to contra lateral side
DJ 2018 - OleON PPT
Tension Band w K-Wires
65 Cancellous Screw w Tension Band
Lag Screw w Tension Band
Plate Fixation
Current AO product options
Distal Humerus Fractures Fixation
Options of Olecranon Osteotomies
DJ 2018 - OleON PPT
Clinical needs
ndash Improved method to maintain reduction of olecranon osteotomy
ndash Intermedullary solution for fixation of an olecranon osteotomy
Indications The Olecranon Osteotomy Nail is indicated to treat osteotomies of the
olecranon
and simple olecranon fractures
The Olecranon Osteotomy Nail
Overview
DJ 2018 - OleON PPT
Main features and Benefits
Pre-osteotomy fixation ensuring anatomic alignment
Simpler fixation of olecranon osteotomy than current
commonly used techniques after distal humerus
surgery
Simple instrumentation for easy insertion and locking
of nail
Low profile minimizing soft tissue irritation and re-
operation
More stable fixation than current methods
Targeted locking to minimize size of incision
Mechanical testing on file at Synthes
The Olecranon Osteotomy Nail
Overview
Overall
Decision making made on most recent literature
Best available treatment option
Surgeon preference and comfort
Informed decision with patient
Need for prospective multicenter large scale study
Use sound surgical
techinque and use
AO fixation
prinicles
Distal Humerus Fractures
References
Fractures in Adults Rockwood and Wilkins Lippincott William amp Wilkins 2005 6th Edition
Handbook of Fractures Koval and Zuckerman Lippincott William amp Wilkins 2002 2nd Edition
Campbellrsquos Operative Orthopaedics Mosby tenth edition
Chapmans Orthopaedic Surgery 3rd Edition Lippincott Williams amp Wilkins
Distal Humerus Fractures
References Current Concepts Review Distal humerus Fractures in
Adults A Nauth MD M Mckee MD B Ristevski MD JBJS 2011 vol 93-A no 7 4-6-2011
The olecranon osteotomy a six-year experience in the treatment of intraarticular fractures of the distal humerus Coles CP Barei DP Nork SE Taitsman LA Hanel DP Bradford Henley M J Orthop Trauma 2006 Mar20(3)164-71
A true triceps-splitting approach for treatment of distal humerus fractures a preliminary report Ziran BH Smith WR Balk ML Manning CM Agudelo JF J Trauma 2005 Jan58(1)70-5
Distal Humeral Hemiarthroplasty vs Total Elbow Arthroplasty for Acute Distal Humeral Fractures R Rangarajan MD R Papandrea MD A Cil MD Orthopedics JanFeb vol40 no 113-23
Extra Articular fracture Distal Humerus fx
in 67 yo F after someone tried to steal her
purse
SP ORIF Extra Articular fracture with
triceps reflecting
24 yo male GSW
Under went ORIF triceps reflecting
approach
23 yo running from police for no
reasonhellip
SP ORIF with 90-90 plating with
olecranon osteotomy
21 yo SP GSW
SP ORIF with Triceps sparing
approach
2 weeks post op
89 YO SP Mechanical fail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
Distal Humerus Fractures Operative
Treatment
Total Elbow Arthroplasty (TEA) Reserved for elderly
patients with poor bone quality low physical demands not amenable to ORIF
Goodexcellent results compared to ORIF in elderly as primary treatment
Distal Humerus Fractures Operative
Treatment
Total Elbow
Arthroplasty (TEA)
Higher rate of
infection nerve
injury implant
failure
Olecranon
Osteotomy
contraindicated
Distal Humerus Fractures
Complications
Ulnar nerve injury Due to initial
trauma or operative treatment
Transposition not proven to beneficial even when nerve is out preoperatively
Decompression recommended when nerve is out preop
Heterotopic Ossification (HO)
After operative fixation
Limits ROM
Prophylactic treatment indications are controversial
Use of indomethacin didnrsquot significantly reduce HO
When prophylaxis used 0-21 clinically significant HO
Distal Humerus Fractures Complications
Heterotopic
Ossification (HO)
1 dose post op
radiation and 2 weeks
indomethacin
treatment 3 rate
clinically significant
HO
Benefits weighted
against risks of union
with prophylactic
treatment
Heterotopic
Ossification (HO)
Risk factors CNS
injury delay in
operative treatment
sx prior to definitive
treatment
Distal Humerus Fractures Complications
Modern dual plate
fixation 89-100
union rates
Failing to adhere to
these principles
increase nonunion
rates
Nonunion treated with
revision ORIF bone
grafting selective
releases
Mean flex-ext arc
ROM 99deg-112deg
Recommended start
ROM at 2 weeks
Functional outcomes
after ORIF 84-100
goodexcellent
Regain 70-75
strength compared
to contra lateral side
DJ 2018 - OleON PPT
Tension Band w K-Wires
65 Cancellous Screw w Tension Band
Lag Screw w Tension Band
Plate Fixation
Current AO product options
Distal Humerus Fractures Fixation
Options of Olecranon Osteotomies
DJ 2018 - OleON PPT
Clinical needs
ndash Improved method to maintain reduction of olecranon osteotomy
ndash Intermedullary solution for fixation of an olecranon osteotomy
Indications The Olecranon Osteotomy Nail is indicated to treat osteotomies of the
olecranon
and simple olecranon fractures
The Olecranon Osteotomy Nail
Overview
DJ 2018 - OleON PPT
Main features and Benefits
Pre-osteotomy fixation ensuring anatomic alignment
Simpler fixation of olecranon osteotomy than current
commonly used techniques after distal humerus
surgery
Simple instrumentation for easy insertion and locking
of nail
Low profile minimizing soft tissue irritation and re-
operation
More stable fixation than current methods
Targeted locking to minimize size of incision
Mechanical testing on file at Synthes
The Olecranon Osteotomy Nail
Overview
Overall
Decision making made on most recent literature
Best available treatment option
Surgeon preference and comfort
Informed decision with patient
Need for prospective multicenter large scale study
Use sound surgical
techinque and use
AO fixation
prinicles
Distal Humerus Fractures
References
Fractures in Adults Rockwood and Wilkins Lippincott William amp Wilkins 2005 6th Edition
Handbook of Fractures Koval and Zuckerman Lippincott William amp Wilkins 2002 2nd Edition
Campbellrsquos Operative Orthopaedics Mosby tenth edition
Chapmans Orthopaedic Surgery 3rd Edition Lippincott Williams amp Wilkins
Distal Humerus Fractures
References Current Concepts Review Distal humerus Fractures in
Adults A Nauth MD M Mckee MD B Ristevski MD JBJS 2011 vol 93-A no 7 4-6-2011
The olecranon osteotomy a six-year experience in the treatment of intraarticular fractures of the distal humerus Coles CP Barei DP Nork SE Taitsman LA Hanel DP Bradford Henley M J Orthop Trauma 2006 Mar20(3)164-71
A true triceps-splitting approach for treatment of distal humerus fractures a preliminary report Ziran BH Smith WR Balk ML Manning CM Agudelo JF J Trauma 2005 Jan58(1)70-5
Distal Humeral Hemiarthroplasty vs Total Elbow Arthroplasty for Acute Distal Humeral Fractures R Rangarajan MD R Papandrea MD A Cil MD Orthopedics JanFeb vol40 no 113-23
Extra Articular fracture Distal Humerus fx
in 67 yo F after someone tried to steal her
purse
SP ORIF Extra Articular fracture with
triceps reflecting
24 yo male GSW
Under went ORIF triceps reflecting
approach
23 yo running from police for no
reasonhellip
SP ORIF with 90-90 plating with
olecranon osteotomy
21 yo SP GSW
SP ORIF with Triceps sparing
approach
2 weeks post op
89 YO SP Mechanical fail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
Distal Humerus Fractures Operative
Treatment
Total Elbow
Arthroplasty (TEA)
Higher rate of
infection nerve
injury implant
failure
Olecranon
Osteotomy
contraindicated
Distal Humerus Fractures
Complications
Ulnar nerve injury Due to initial
trauma or operative treatment
Transposition not proven to beneficial even when nerve is out preoperatively
Decompression recommended when nerve is out preop
Heterotopic Ossification (HO)
After operative fixation
Limits ROM
Prophylactic treatment indications are controversial
Use of indomethacin didnrsquot significantly reduce HO
When prophylaxis used 0-21 clinically significant HO
Distal Humerus Fractures Complications
Heterotopic
Ossification (HO)
1 dose post op
radiation and 2 weeks
indomethacin
treatment 3 rate
clinically significant
HO
Benefits weighted
against risks of union
with prophylactic
treatment
Heterotopic
Ossification (HO)
Risk factors CNS
injury delay in
operative treatment
sx prior to definitive
treatment
Distal Humerus Fractures Complications
Modern dual plate
fixation 89-100
union rates
Failing to adhere to
these principles
increase nonunion
rates
Nonunion treated with
revision ORIF bone
grafting selective
releases
Mean flex-ext arc
ROM 99deg-112deg
Recommended start
ROM at 2 weeks
Functional outcomes
after ORIF 84-100
goodexcellent
Regain 70-75
strength compared
to contra lateral side
DJ 2018 - OleON PPT
Tension Band w K-Wires
65 Cancellous Screw w Tension Band
Lag Screw w Tension Band
Plate Fixation
Current AO product options
Distal Humerus Fractures Fixation
Options of Olecranon Osteotomies
DJ 2018 - OleON PPT
Clinical needs
ndash Improved method to maintain reduction of olecranon osteotomy
ndash Intermedullary solution for fixation of an olecranon osteotomy
Indications The Olecranon Osteotomy Nail is indicated to treat osteotomies of the
olecranon
and simple olecranon fractures
The Olecranon Osteotomy Nail
Overview
DJ 2018 - OleON PPT
Main features and Benefits
Pre-osteotomy fixation ensuring anatomic alignment
Simpler fixation of olecranon osteotomy than current
commonly used techniques after distal humerus
surgery
Simple instrumentation for easy insertion and locking
of nail
Low profile minimizing soft tissue irritation and re-
operation
More stable fixation than current methods
Targeted locking to minimize size of incision
Mechanical testing on file at Synthes
The Olecranon Osteotomy Nail
Overview
Overall
Decision making made on most recent literature
Best available treatment option
Surgeon preference and comfort
Informed decision with patient
Need for prospective multicenter large scale study
Use sound surgical
techinque and use
AO fixation
prinicles
Distal Humerus Fractures
References
Fractures in Adults Rockwood and Wilkins Lippincott William amp Wilkins 2005 6th Edition
Handbook of Fractures Koval and Zuckerman Lippincott William amp Wilkins 2002 2nd Edition
Campbellrsquos Operative Orthopaedics Mosby tenth edition
Chapmans Orthopaedic Surgery 3rd Edition Lippincott Williams amp Wilkins
Distal Humerus Fractures
References Current Concepts Review Distal humerus Fractures in
Adults A Nauth MD M Mckee MD B Ristevski MD JBJS 2011 vol 93-A no 7 4-6-2011
The olecranon osteotomy a six-year experience in the treatment of intraarticular fractures of the distal humerus Coles CP Barei DP Nork SE Taitsman LA Hanel DP Bradford Henley M J Orthop Trauma 2006 Mar20(3)164-71
A true triceps-splitting approach for treatment of distal humerus fractures a preliminary report Ziran BH Smith WR Balk ML Manning CM Agudelo JF J Trauma 2005 Jan58(1)70-5
Distal Humeral Hemiarthroplasty vs Total Elbow Arthroplasty for Acute Distal Humeral Fractures R Rangarajan MD R Papandrea MD A Cil MD Orthopedics JanFeb vol40 no 113-23
Extra Articular fracture Distal Humerus fx
in 67 yo F after someone tried to steal her
purse
SP ORIF Extra Articular fracture with
triceps reflecting
24 yo male GSW
Under went ORIF triceps reflecting
approach
23 yo running from police for no
reasonhellip
SP ORIF with 90-90 plating with
olecranon osteotomy
21 yo SP GSW
SP ORIF with Triceps sparing
approach
2 weeks post op
89 YO SP Mechanical fail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
Distal Humerus Fractures
Complications
Ulnar nerve injury Due to initial
trauma or operative treatment
Transposition not proven to beneficial even when nerve is out preoperatively
Decompression recommended when nerve is out preop
Heterotopic Ossification (HO)
After operative fixation
Limits ROM
Prophylactic treatment indications are controversial
Use of indomethacin didnrsquot significantly reduce HO
When prophylaxis used 0-21 clinically significant HO
Distal Humerus Fractures Complications
Heterotopic
Ossification (HO)
1 dose post op
radiation and 2 weeks
indomethacin
treatment 3 rate
clinically significant
HO
Benefits weighted
against risks of union
with prophylactic
treatment
Heterotopic
Ossification (HO)
Risk factors CNS
injury delay in
operative treatment
sx prior to definitive
treatment
Distal Humerus Fractures Complications
Modern dual plate
fixation 89-100
union rates
Failing to adhere to
these principles
increase nonunion
rates
Nonunion treated with
revision ORIF bone
grafting selective
releases
Mean flex-ext arc
ROM 99deg-112deg
Recommended start
ROM at 2 weeks
Functional outcomes
after ORIF 84-100
goodexcellent
Regain 70-75
strength compared
to contra lateral side
DJ 2018 - OleON PPT
Tension Band w K-Wires
65 Cancellous Screw w Tension Band
Lag Screw w Tension Band
Plate Fixation
Current AO product options
Distal Humerus Fractures Fixation
Options of Olecranon Osteotomies
DJ 2018 - OleON PPT
Clinical needs
ndash Improved method to maintain reduction of olecranon osteotomy
ndash Intermedullary solution for fixation of an olecranon osteotomy
Indications The Olecranon Osteotomy Nail is indicated to treat osteotomies of the
olecranon
and simple olecranon fractures
The Olecranon Osteotomy Nail
Overview
DJ 2018 - OleON PPT
Main features and Benefits
Pre-osteotomy fixation ensuring anatomic alignment
Simpler fixation of olecranon osteotomy than current
commonly used techniques after distal humerus
surgery
Simple instrumentation for easy insertion and locking
of nail
Low profile minimizing soft tissue irritation and re-
operation
More stable fixation than current methods
Targeted locking to minimize size of incision
Mechanical testing on file at Synthes
The Olecranon Osteotomy Nail
Overview
Overall
Decision making made on most recent literature
Best available treatment option
Surgeon preference and comfort
Informed decision with patient
Need for prospective multicenter large scale study
Use sound surgical
techinque and use
AO fixation
prinicles
Distal Humerus Fractures
References
Fractures in Adults Rockwood and Wilkins Lippincott William amp Wilkins 2005 6th Edition
Handbook of Fractures Koval and Zuckerman Lippincott William amp Wilkins 2002 2nd Edition
Campbellrsquos Operative Orthopaedics Mosby tenth edition
Chapmans Orthopaedic Surgery 3rd Edition Lippincott Williams amp Wilkins
Distal Humerus Fractures
References Current Concepts Review Distal humerus Fractures in
Adults A Nauth MD M Mckee MD B Ristevski MD JBJS 2011 vol 93-A no 7 4-6-2011
The olecranon osteotomy a six-year experience in the treatment of intraarticular fractures of the distal humerus Coles CP Barei DP Nork SE Taitsman LA Hanel DP Bradford Henley M J Orthop Trauma 2006 Mar20(3)164-71
A true triceps-splitting approach for treatment of distal humerus fractures a preliminary report Ziran BH Smith WR Balk ML Manning CM Agudelo JF J Trauma 2005 Jan58(1)70-5
Distal Humeral Hemiarthroplasty vs Total Elbow Arthroplasty for Acute Distal Humeral Fractures R Rangarajan MD R Papandrea MD A Cil MD Orthopedics JanFeb vol40 no 113-23
Extra Articular fracture Distal Humerus fx
in 67 yo F after someone tried to steal her
purse
SP ORIF Extra Articular fracture with
triceps reflecting
24 yo male GSW
Under went ORIF triceps reflecting
approach
23 yo running from police for no
reasonhellip
SP ORIF with 90-90 plating with
olecranon osteotomy
21 yo SP GSW
SP ORIF with Triceps sparing
approach
2 weeks post op
89 YO SP Mechanical fail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
Distal Humerus Fractures Complications
Heterotopic
Ossification (HO)
1 dose post op
radiation and 2 weeks
indomethacin
treatment 3 rate
clinically significant
HO
Benefits weighted
against risks of union
with prophylactic
treatment
Heterotopic
Ossification (HO)
Risk factors CNS
injury delay in
operative treatment
sx prior to definitive
treatment
Distal Humerus Fractures Complications
Modern dual plate
fixation 89-100
union rates
Failing to adhere to
these principles
increase nonunion
rates
Nonunion treated with
revision ORIF bone
grafting selective
releases
Mean flex-ext arc
ROM 99deg-112deg
Recommended start
ROM at 2 weeks
Functional outcomes
after ORIF 84-100
goodexcellent
Regain 70-75
strength compared
to contra lateral side
DJ 2018 - OleON PPT
Tension Band w K-Wires
65 Cancellous Screw w Tension Band
Lag Screw w Tension Band
Plate Fixation
Current AO product options
Distal Humerus Fractures Fixation
Options of Olecranon Osteotomies
DJ 2018 - OleON PPT
Clinical needs
ndash Improved method to maintain reduction of olecranon osteotomy
ndash Intermedullary solution for fixation of an olecranon osteotomy
Indications The Olecranon Osteotomy Nail is indicated to treat osteotomies of the
olecranon
and simple olecranon fractures
The Olecranon Osteotomy Nail
Overview
DJ 2018 - OleON PPT
Main features and Benefits
Pre-osteotomy fixation ensuring anatomic alignment
Simpler fixation of olecranon osteotomy than current
commonly used techniques after distal humerus
surgery
Simple instrumentation for easy insertion and locking
of nail
Low profile minimizing soft tissue irritation and re-
operation
More stable fixation than current methods
Targeted locking to minimize size of incision
Mechanical testing on file at Synthes
The Olecranon Osteotomy Nail
Overview
Overall
Decision making made on most recent literature
Best available treatment option
Surgeon preference and comfort
Informed decision with patient
Need for prospective multicenter large scale study
Use sound surgical
techinque and use
AO fixation
prinicles
Distal Humerus Fractures
References
Fractures in Adults Rockwood and Wilkins Lippincott William amp Wilkins 2005 6th Edition
Handbook of Fractures Koval and Zuckerman Lippincott William amp Wilkins 2002 2nd Edition
Campbellrsquos Operative Orthopaedics Mosby tenth edition
Chapmans Orthopaedic Surgery 3rd Edition Lippincott Williams amp Wilkins
Distal Humerus Fractures
References Current Concepts Review Distal humerus Fractures in
Adults A Nauth MD M Mckee MD B Ristevski MD JBJS 2011 vol 93-A no 7 4-6-2011
The olecranon osteotomy a six-year experience in the treatment of intraarticular fractures of the distal humerus Coles CP Barei DP Nork SE Taitsman LA Hanel DP Bradford Henley M J Orthop Trauma 2006 Mar20(3)164-71
A true triceps-splitting approach for treatment of distal humerus fractures a preliminary report Ziran BH Smith WR Balk ML Manning CM Agudelo JF J Trauma 2005 Jan58(1)70-5
Distal Humeral Hemiarthroplasty vs Total Elbow Arthroplasty for Acute Distal Humeral Fractures R Rangarajan MD R Papandrea MD A Cil MD Orthopedics JanFeb vol40 no 113-23
Extra Articular fracture Distal Humerus fx
in 67 yo F after someone tried to steal her
purse
SP ORIF Extra Articular fracture with
triceps reflecting
24 yo male GSW
Under went ORIF triceps reflecting
approach
23 yo running from police for no
reasonhellip
SP ORIF with 90-90 plating with
olecranon osteotomy
21 yo SP GSW
SP ORIF with Triceps sparing
approach
2 weeks post op
89 YO SP Mechanical fail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
Distal Humerus Fractures Complications
Modern dual plate
fixation 89-100
union rates
Failing to adhere to
these principles
increase nonunion
rates
Nonunion treated with
revision ORIF bone
grafting selective
releases
Mean flex-ext arc
ROM 99deg-112deg
Recommended start
ROM at 2 weeks
Functional outcomes
after ORIF 84-100
goodexcellent
Regain 70-75
strength compared
to contra lateral side
DJ 2018 - OleON PPT
Tension Band w K-Wires
65 Cancellous Screw w Tension Band
Lag Screw w Tension Band
Plate Fixation
Current AO product options
Distal Humerus Fractures Fixation
Options of Olecranon Osteotomies
DJ 2018 - OleON PPT
Clinical needs
ndash Improved method to maintain reduction of olecranon osteotomy
ndash Intermedullary solution for fixation of an olecranon osteotomy
Indications The Olecranon Osteotomy Nail is indicated to treat osteotomies of the
olecranon
and simple olecranon fractures
The Olecranon Osteotomy Nail
Overview
DJ 2018 - OleON PPT
Main features and Benefits
Pre-osteotomy fixation ensuring anatomic alignment
Simpler fixation of olecranon osteotomy than current
commonly used techniques after distal humerus
surgery
Simple instrumentation for easy insertion and locking
of nail
Low profile minimizing soft tissue irritation and re-
operation
More stable fixation than current methods
Targeted locking to minimize size of incision
Mechanical testing on file at Synthes
The Olecranon Osteotomy Nail
Overview
Overall
Decision making made on most recent literature
Best available treatment option
Surgeon preference and comfort
Informed decision with patient
Need for prospective multicenter large scale study
Use sound surgical
techinque and use
AO fixation
prinicles
Distal Humerus Fractures
References
Fractures in Adults Rockwood and Wilkins Lippincott William amp Wilkins 2005 6th Edition
Handbook of Fractures Koval and Zuckerman Lippincott William amp Wilkins 2002 2nd Edition
Campbellrsquos Operative Orthopaedics Mosby tenth edition
Chapmans Orthopaedic Surgery 3rd Edition Lippincott Williams amp Wilkins
Distal Humerus Fractures
References Current Concepts Review Distal humerus Fractures in
Adults A Nauth MD M Mckee MD B Ristevski MD JBJS 2011 vol 93-A no 7 4-6-2011
The olecranon osteotomy a six-year experience in the treatment of intraarticular fractures of the distal humerus Coles CP Barei DP Nork SE Taitsman LA Hanel DP Bradford Henley M J Orthop Trauma 2006 Mar20(3)164-71
A true triceps-splitting approach for treatment of distal humerus fractures a preliminary report Ziran BH Smith WR Balk ML Manning CM Agudelo JF J Trauma 2005 Jan58(1)70-5
Distal Humeral Hemiarthroplasty vs Total Elbow Arthroplasty for Acute Distal Humeral Fractures R Rangarajan MD R Papandrea MD A Cil MD Orthopedics JanFeb vol40 no 113-23
Extra Articular fracture Distal Humerus fx
in 67 yo F after someone tried to steal her
purse
SP ORIF Extra Articular fracture with
triceps reflecting
24 yo male GSW
Under went ORIF triceps reflecting
approach
23 yo running from police for no
reasonhellip
SP ORIF with 90-90 plating with
olecranon osteotomy
21 yo SP GSW
SP ORIF with Triceps sparing
approach
2 weeks post op
89 YO SP Mechanical fail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Tension Band w K-Wires
65 Cancellous Screw w Tension Band
Lag Screw w Tension Band
Plate Fixation
Current AO product options
Distal Humerus Fractures Fixation
Options of Olecranon Osteotomies
DJ 2018 - OleON PPT
Clinical needs
ndash Improved method to maintain reduction of olecranon osteotomy
ndash Intermedullary solution for fixation of an olecranon osteotomy
Indications The Olecranon Osteotomy Nail is indicated to treat osteotomies of the
olecranon
and simple olecranon fractures
The Olecranon Osteotomy Nail
Overview
DJ 2018 - OleON PPT
Main features and Benefits
Pre-osteotomy fixation ensuring anatomic alignment
Simpler fixation of olecranon osteotomy than current
commonly used techniques after distal humerus
surgery
Simple instrumentation for easy insertion and locking
of nail
Low profile minimizing soft tissue irritation and re-
operation
More stable fixation than current methods
Targeted locking to minimize size of incision
Mechanical testing on file at Synthes
The Olecranon Osteotomy Nail
Overview
Overall
Decision making made on most recent literature
Best available treatment option
Surgeon preference and comfort
Informed decision with patient
Need for prospective multicenter large scale study
Use sound surgical
techinque and use
AO fixation
prinicles
Distal Humerus Fractures
References
Fractures in Adults Rockwood and Wilkins Lippincott William amp Wilkins 2005 6th Edition
Handbook of Fractures Koval and Zuckerman Lippincott William amp Wilkins 2002 2nd Edition
Campbellrsquos Operative Orthopaedics Mosby tenth edition
Chapmans Orthopaedic Surgery 3rd Edition Lippincott Williams amp Wilkins
Distal Humerus Fractures
References Current Concepts Review Distal humerus Fractures in
Adults A Nauth MD M Mckee MD B Ristevski MD JBJS 2011 vol 93-A no 7 4-6-2011
The olecranon osteotomy a six-year experience in the treatment of intraarticular fractures of the distal humerus Coles CP Barei DP Nork SE Taitsman LA Hanel DP Bradford Henley M J Orthop Trauma 2006 Mar20(3)164-71
A true triceps-splitting approach for treatment of distal humerus fractures a preliminary report Ziran BH Smith WR Balk ML Manning CM Agudelo JF J Trauma 2005 Jan58(1)70-5
Distal Humeral Hemiarthroplasty vs Total Elbow Arthroplasty for Acute Distal Humeral Fractures R Rangarajan MD R Papandrea MD A Cil MD Orthopedics JanFeb vol40 no 113-23
Extra Articular fracture Distal Humerus fx
in 67 yo F after someone tried to steal her
purse
SP ORIF Extra Articular fracture with
triceps reflecting
24 yo male GSW
Under went ORIF triceps reflecting
approach
23 yo running from police for no
reasonhellip
SP ORIF with 90-90 plating with
olecranon osteotomy
21 yo SP GSW
SP ORIF with Triceps sparing
approach
2 weeks post op
89 YO SP Mechanical fail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Clinical needs
ndash Improved method to maintain reduction of olecranon osteotomy
ndash Intermedullary solution for fixation of an olecranon osteotomy
Indications The Olecranon Osteotomy Nail is indicated to treat osteotomies of the
olecranon
and simple olecranon fractures
The Olecranon Osteotomy Nail
Overview
DJ 2018 - OleON PPT
Main features and Benefits
Pre-osteotomy fixation ensuring anatomic alignment
Simpler fixation of olecranon osteotomy than current
commonly used techniques after distal humerus
surgery
Simple instrumentation for easy insertion and locking
of nail
Low profile minimizing soft tissue irritation and re-
operation
More stable fixation than current methods
Targeted locking to minimize size of incision
Mechanical testing on file at Synthes
The Olecranon Osteotomy Nail
Overview
Overall
Decision making made on most recent literature
Best available treatment option
Surgeon preference and comfort
Informed decision with patient
Need for prospective multicenter large scale study
Use sound surgical
techinque and use
AO fixation
prinicles
Distal Humerus Fractures
References
Fractures in Adults Rockwood and Wilkins Lippincott William amp Wilkins 2005 6th Edition
Handbook of Fractures Koval and Zuckerman Lippincott William amp Wilkins 2002 2nd Edition
Campbellrsquos Operative Orthopaedics Mosby tenth edition
Chapmans Orthopaedic Surgery 3rd Edition Lippincott Williams amp Wilkins
Distal Humerus Fractures
References Current Concepts Review Distal humerus Fractures in
Adults A Nauth MD M Mckee MD B Ristevski MD JBJS 2011 vol 93-A no 7 4-6-2011
The olecranon osteotomy a six-year experience in the treatment of intraarticular fractures of the distal humerus Coles CP Barei DP Nork SE Taitsman LA Hanel DP Bradford Henley M J Orthop Trauma 2006 Mar20(3)164-71
A true triceps-splitting approach for treatment of distal humerus fractures a preliminary report Ziran BH Smith WR Balk ML Manning CM Agudelo JF J Trauma 2005 Jan58(1)70-5
Distal Humeral Hemiarthroplasty vs Total Elbow Arthroplasty for Acute Distal Humeral Fractures R Rangarajan MD R Papandrea MD A Cil MD Orthopedics JanFeb vol40 no 113-23
Extra Articular fracture Distal Humerus fx
in 67 yo F after someone tried to steal her
purse
SP ORIF Extra Articular fracture with
triceps reflecting
24 yo male GSW
Under went ORIF triceps reflecting
approach
23 yo running from police for no
reasonhellip
SP ORIF with 90-90 plating with
olecranon osteotomy
21 yo SP GSW
SP ORIF with Triceps sparing
approach
2 weeks post op
89 YO SP Mechanical fail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Main features and Benefits
Pre-osteotomy fixation ensuring anatomic alignment
Simpler fixation of olecranon osteotomy than current
commonly used techniques after distal humerus
surgery
Simple instrumentation for easy insertion and locking
of nail
Low profile minimizing soft tissue irritation and re-
operation
More stable fixation than current methods
Targeted locking to minimize size of incision
Mechanical testing on file at Synthes
The Olecranon Osteotomy Nail
Overview
Overall
Decision making made on most recent literature
Best available treatment option
Surgeon preference and comfort
Informed decision with patient
Need for prospective multicenter large scale study
Use sound surgical
techinque and use
AO fixation
prinicles
Distal Humerus Fractures
References
Fractures in Adults Rockwood and Wilkins Lippincott William amp Wilkins 2005 6th Edition
Handbook of Fractures Koval and Zuckerman Lippincott William amp Wilkins 2002 2nd Edition
Campbellrsquos Operative Orthopaedics Mosby tenth edition
Chapmans Orthopaedic Surgery 3rd Edition Lippincott Williams amp Wilkins
Distal Humerus Fractures
References Current Concepts Review Distal humerus Fractures in
Adults A Nauth MD M Mckee MD B Ristevski MD JBJS 2011 vol 93-A no 7 4-6-2011
The olecranon osteotomy a six-year experience in the treatment of intraarticular fractures of the distal humerus Coles CP Barei DP Nork SE Taitsman LA Hanel DP Bradford Henley M J Orthop Trauma 2006 Mar20(3)164-71
A true triceps-splitting approach for treatment of distal humerus fractures a preliminary report Ziran BH Smith WR Balk ML Manning CM Agudelo JF J Trauma 2005 Jan58(1)70-5
Distal Humeral Hemiarthroplasty vs Total Elbow Arthroplasty for Acute Distal Humeral Fractures R Rangarajan MD R Papandrea MD A Cil MD Orthopedics JanFeb vol40 no 113-23
Extra Articular fracture Distal Humerus fx
in 67 yo F after someone tried to steal her
purse
SP ORIF Extra Articular fracture with
triceps reflecting
24 yo male GSW
Under went ORIF triceps reflecting
approach
23 yo running from police for no
reasonhellip
SP ORIF with 90-90 plating with
olecranon osteotomy
21 yo SP GSW
SP ORIF with Triceps sparing
approach
2 weeks post op
89 YO SP Mechanical fail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
Overall
Decision making made on most recent literature
Best available treatment option
Surgeon preference and comfort
Informed decision with patient
Need for prospective multicenter large scale study
Use sound surgical
techinque and use
AO fixation
prinicles
Distal Humerus Fractures
References
Fractures in Adults Rockwood and Wilkins Lippincott William amp Wilkins 2005 6th Edition
Handbook of Fractures Koval and Zuckerman Lippincott William amp Wilkins 2002 2nd Edition
Campbellrsquos Operative Orthopaedics Mosby tenth edition
Chapmans Orthopaedic Surgery 3rd Edition Lippincott Williams amp Wilkins
Distal Humerus Fractures
References Current Concepts Review Distal humerus Fractures in
Adults A Nauth MD M Mckee MD B Ristevski MD JBJS 2011 vol 93-A no 7 4-6-2011
The olecranon osteotomy a six-year experience in the treatment of intraarticular fractures of the distal humerus Coles CP Barei DP Nork SE Taitsman LA Hanel DP Bradford Henley M J Orthop Trauma 2006 Mar20(3)164-71
A true triceps-splitting approach for treatment of distal humerus fractures a preliminary report Ziran BH Smith WR Balk ML Manning CM Agudelo JF J Trauma 2005 Jan58(1)70-5
Distal Humeral Hemiarthroplasty vs Total Elbow Arthroplasty for Acute Distal Humeral Fractures R Rangarajan MD R Papandrea MD A Cil MD Orthopedics JanFeb vol40 no 113-23
Extra Articular fracture Distal Humerus fx
in 67 yo F after someone tried to steal her
purse
SP ORIF Extra Articular fracture with
triceps reflecting
24 yo male GSW
Under went ORIF triceps reflecting
approach
23 yo running from police for no
reasonhellip
SP ORIF with 90-90 plating with
olecranon osteotomy
21 yo SP GSW
SP ORIF with Triceps sparing
approach
2 weeks post op
89 YO SP Mechanical fail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
Distal Humerus Fractures
References
Fractures in Adults Rockwood and Wilkins Lippincott William amp Wilkins 2005 6th Edition
Handbook of Fractures Koval and Zuckerman Lippincott William amp Wilkins 2002 2nd Edition
Campbellrsquos Operative Orthopaedics Mosby tenth edition
Chapmans Orthopaedic Surgery 3rd Edition Lippincott Williams amp Wilkins
Distal Humerus Fractures
References Current Concepts Review Distal humerus Fractures in
Adults A Nauth MD M Mckee MD B Ristevski MD JBJS 2011 vol 93-A no 7 4-6-2011
The olecranon osteotomy a six-year experience in the treatment of intraarticular fractures of the distal humerus Coles CP Barei DP Nork SE Taitsman LA Hanel DP Bradford Henley M J Orthop Trauma 2006 Mar20(3)164-71
A true triceps-splitting approach for treatment of distal humerus fractures a preliminary report Ziran BH Smith WR Balk ML Manning CM Agudelo JF J Trauma 2005 Jan58(1)70-5
Distal Humeral Hemiarthroplasty vs Total Elbow Arthroplasty for Acute Distal Humeral Fractures R Rangarajan MD R Papandrea MD A Cil MD Orthopedics JanFeb vol40 no 113-23
Extra Articular fracture Distal Humerus fx
in 67 yo F after someone tried to steal her
purse
SP ORIF Extra Articular fracture with
triceps reflecting
24 yo male GSW
Under went ORIF triceps reflecting
approach
23 yo running from police for no
reasonhellip
SP ORIF with 90-90 plating with
olecranon osteotomy
21 yo SP GSW
SP ORIF with Triceps sparing
approach
2 weeks post op
89 YO SP Mechanical fail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
Distal Humerus Fractures
References Current Concepts Review Distal humerus Fractures in
Adults A Nauth MD M Mckee MD B Ristevski MD JBJS 2011 vol 93-A no 7 4-6-2011
The olecranon osteotomy a six-year experience in the treatment of intraarticular fractures of the distal humerus Coles CP Barei DP Nork SE Taitsman LA Hanel DP Bradford Henley M J Orthop Trauma 2006 Mar20(3)164-71
A true triceps-splitting approach for treatment of distal humerus fractures a preliminary report Ziran BH Smith WR Balk ML Manning CM Agudelo JF J Trauma 2005 Jan58(1)70-5
Distal Humeral Hemiarthroplasty vs Total Elbow Arthroplasty for Acute Distal Humeral Fractures R Rangarajan MD R Papandrea MD A Cil MD Orthopedics JanFeb vol40 no 113-23
Extra Articular fracture Distal Humerus fx
in 67 yo F after someone tried to steal her
purse
SP ORIF Extra Articular fracture with
triceps reflecting
24 yo male GSW
Under went ORIF triceps reflecting
approach
23 yo running from police for no
reasonhellip
SP ORIF with 90-90 plating with
olecranon osteotomy
21 yo SP GSW
SP ORIF with Triceps sparing
approach
2 weeks post op
89 YO SP Mechanical fail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
Extra Articular fracture Distal Humerus fx
in 67 yo F after someone tried to steal her
purse
SP ORIF Extra Articular fracture with
triceps reflecting
24 yo male GSW
Under went ORIF triceps reflecting
approach
23 yo running from police for no
reasonhellip
SP ORIF with 90-90 plating with
olecranon osteotomy
21 yo SP GSW
SP ORIF with Triceps sparing
approach
2 weeks post op
89 YO SP Mechanical fail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
SP ORIF Extra Articular fracture with
triceps reflecting
24 yo male GSW
Under went ORIF triceps reflecting
approach
23 yo running from police for no
reasonhellip
SP ORIF with 90-90 plating with
olecranon osteotomy
21 yo SP GSW
SP ORIF with Triceps sparing
approach
2 weeks post op
89 YO SP Mechanical fail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
24 yo male GSW
Under went ORIF triceps reflecting
approach
23 yo running from police for no
reasonhellip
SP ORIF with 90-90 plating with
olecranon osteotomy
21 yo SP GSW
SP ORIF with Triceps sparing
approach
2 weeks post op
89 YO SP Mechanical fail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
Under went ORIF triceps reflecting
approach
23 yo running from police for no
reasonhellip
SP ORIF with 90-90 plating with
olecranon osteotomy
21 yo SP GSW
SP ORIF with Triceps sparing
approach
2 weeks post op
89 YO SP Mechanical fail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
23 yo running from police for no
reasonhellip
SP ORIF with 90-90 plating with
olecranon osteotomy
21 yo SP GSW
SP ORIF with Triceps sparing
approach
2 weeks post op
89 YO SP Mechanical fail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
SP ORIF with 90-90 plating with
olecranon osteotomy
21 yo SP GSW
SP ORIF with Triceps sparing
approach
2 weeks post op
89 YO SP Mechanical fail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
21 yo SP GSW
SP ORIF with Triceps sparing
approach
2 weeks post op
89 YO SP Mechanical fail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
SP ORIF with Triceps sparing
approach
2 weeks post op
89 YO SP Mechanical fail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
2 weeks post op
89 YO SP Mechanical fail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
89 YO SP Mechanical fail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
SP ORIF triceps reflecting
approach
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
26 yo sp GSW
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
SP ORIF
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
47 yo MCC Polytrauma patient
multiple visceral CH injuries
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
SP ORIF with Triceps sparing
approach
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
77 yo obese F SP mechanical fail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
Same patient same arm
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
SP ORIF with 90-90 plating and
olecranon osteotomy
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
SP ORIF Distal raduis
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Review 81508
Comminuted distal humerus fx
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail
DJ 2018 - OleON PPT
Case Review 81508
SP ORIF 90-90 plating with olecranon osteotomy and
olecranon IMN
The Olecranon Osteotomy Nail