T-Intercondylar Distal Humerus Fracture
Carley Vuillermin, MBBS, MPH, FRACS
Indications
Displaced intra-articular T-type intercondylar distal humerus fracture (Figure 8-1)
Besides plain radiographs, CT scan is often necessary for surgical planning (Figure 8-2)
Sterile Instruments/Equipment
Anatomic specific distal humeral locking plates
3.5 mm pelvic recon plate/small fragment set
4.0 mm cannulated screws
6.5/7.3 mm cannulated screws (olecranon osteotomy)
See AlsoDistal Humerus Fractures - TraumaFractures of the Distal HumerusDistal Humerus Fractures of the Elbow - OrthoInfo - AAOSDistal Humeral fracturesWeber bone clamp
Figure 8-1 ▪ AP radiograph of displaced T-condylar humerus fracture in a skeletally immature patient requiring ORIF.
Figure 8-2 ▪ CT image of disrupted joint, medial, and lateral columns with comminution.
K-wires
Oscillating saw for olecranon osteotomy
Osteotomes
Fluoroscopy
Patient Positioning: Supine, Lateral Decubitus, or Prone
Lateral decubitus position (most common) (Figure 8-3)
Arm holder
Axillary role
Mayo stand padded
C-arm from the head
 Figure 8-3 ▪ Patient positioned in lateral decubitus for ORIF. |
Surgical Approaches
Posterior approaches
Paratricipital
Olecranon osteotomy
Triceps reflecting (Bryan-Morrey)
Triceps V-Y/split
Curve the incision around the tip of the olecranon
Full thickness fasciocutaneous flaps elevated with coagulation of penetrating vessels,
usually with a knife or careful bovie particularly near the medial and lateral edges due to proximity to ulnar and radial nerves, respectively
Scissor dissection down to the level of the intermuscular septum on both sides, taking care on the medial side to identify the ulnar nerve with vessel loop placement for
identification, decompression, and protection of ulnar nerve throughout the case,
lateral triceps edge flap carries radial nerve with it if dissection has to go more proximal.
Triceps V-Y/split exposure: Only for AO C1 and C2 fractures
Long, oblique incisions from medial (protecting ulna nerve distally) and lateral (being aware of radial nerve more proximally) to the central point on triceps proximally to create a tongue of triceps fascia (a direct posterior split is also possible; however, less exposure is achieved)
Elevate central triceps tendon from proximal to distal to olecranon, exposing fossa and fractures
Elbow flexion allows visualization of the posterior portion of the articular surface and reduction of fracture fragments
Triceps elevating (Bryan-Morrey) exposure: AO C1, C2, and C3 fractures
Partial elevation of triceps off the olecranon to roll the triceps either medial or lateral for complete exposure of fracture fragments. Careful elevation is required; the very distal insertion of the triceps is left attached to the ulna.
In children with a nonossified or open apophysis, additional care in elevation of the triceps insertion and periosteum off the apophysis is necessary so as to not button-hole the triceps fascia and create risk of triceps rupture or deviate into the cartilaginous anlage. This should be done precisely with a sharp blade.
Olecranon osteotomy exposure: AO C1, C2, and C3 fractures. Best for fractures with anterior comminution, most extensile
Confirm desired apex distal chevron osteotomy site on fluoroscopy, this should be at the location of the bare area, midpoint of the olecranon (Figure 8-4).
Figure 8-4 ▪ Anatomic location of planned olecranon osteotomy.
Predrilling the intramedullary compression screw before osteotomy (for later osteotomy fixation)
Place a 2.8 mm guide wire parallel to the subcuticular border of the ulna to run intramedullary, perpendicular to the planned osteotomy site
Predrill the proximal ulna with a 5.0 mm cannulated drill
Place and remove partially threaded cancellous screw that is wide enough to get distal cortical purchase within the ulna canal
Position two retractors over the central part of the olecranon groove.
Reconfirm the site of osteotomy with fluoroscopy (Figure 8-4) and then use an oscillating saw to score the cut approximately 75% and complete with an osteotome (this creates an ‘uneven’ edge for anatomic interdigitation during final fixation)
Retract the olecranon tip and triceps proximally to reveal the distal articular humeral surface
Reduction and Fixation Techniques (Figure 8-5)
Carefully identify fracture lines and fragments.
Preoperative CT and/or traction fluoroscopy taken once asleep can be very helpful.
Anatomic realignment is very important; if needed, use fluoroscopy for proper orientation of complex fractures (Figure 8-6).
Copious irrigation and removal of any small-comminuted pieces of the distal intra-articular segment.
If fragments are too small for screw fixation, then suture or bioabsorbable pins may be used to not leave a large articular gap.
First priority is anatomic stable reduction of the articular fragments (Figure 8-7)
Then reduce the stable joint fracture fragments to the metaphysis and diaphysis fragments for both columns
Articular Fracture Fragment Reduction
Intra-articular segment reduced with a Weber bone clamp and then a K-wire placed across from the medial to lateral or lateral to medial just distal to the epicondyles within the capitellum and trochlea.
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Tags: Boston Children's Illustrated Tips and Tricks in Pediatric Orthopaedic Fracture Surgery
Feb 5, 2020 | Posted by drzezo in ORTHOPEDIC | Comments Off on T-Intercondylar Distal Humerus Fracture
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