Life is movement, Movement is life. This sentence has always been cited as the steering principle of fracture care.¹ This principle is more than vital in the management of intra-articular fractures: fractures that extend or involve the articular cartilage. It is an irony that junior most orthopedic surgeons operate most of the intra-articular fractures like patellar fractures, malleolar fractures, neck femur fractures, olecranon fractures, etc. (Fig. 1.1).

2Several other authors including Neer et al³ and Stewart et al⁴ also advocated the same. The main reason for this favor for conservative management was unavailability of proper internal fixation devices as well as lack of proper understanding of orthopedic surgical principles.

Müeller et al¹ enunciated the AO principles of intra-articular fracture care that anatomical reduction as well as absolute stability is vital to the optimum healing of articular fractures. These factors also enable the patient for early motion, leading to best outcome for intra-articular fractures. Mitchell and Shepard⁹ reported that articular cartilage regenerate after intraarticular fractures provided anatomical reduction and absolute stability. Salter et al¹⁰ showed that continuous passive motion stimulates articular cartilage healing as well as regeneration. Schatzker et al¹¹ pointed out following principles of intra-articular fracture treatment:

Articular cartilage is an aneural structure with no blood or lymphatic supply and is dependent upon diffusion from surrounding tissues for nutrition. The cartilage matrix has got hypoxic environment and depends on anaerobic glycolysis and mainly consists of type-2 collagen and proteoglycans important for the joint. This structure makes articular cartilage very sensitive to injury and confers to it poor reparative potential.

4Severity of articular cartilage injury has also been linked to the outcome of intra-articular fractures. Marsh et al¹³ reported that development of post-traumatic osteoarthritis correlate with the severity of articular damage. Several other authors have also reported the same findings.^14,15

A detailed radiographic work-up is essential to understand the fracture anatomy of intra-articular fractures. Anteroposterior and lateral X-rays alone are usually not sufficient. Computed tomography is very useful for delineating the fracture configuration and has proved invaluable in current planning and management of intra-articular fractures (Fig. 1.4). This is more important in certain complex fractures like acetabular fractures, distal humerus fractures, distal tibia fractures, etc. CT gives detailed description of articular gap and step offs.^22,23 According to a study by Tornetta,²⁴ surgical plan changed in 64% cases after CT and additional information was available in 82% cases.

Intra-articular fractures rarely require urgent ORIF except in open fractures, fractures with neurovascular complications, associated compartment syndrome and irreducible fracture dislocations. Proper management of intra-articular fractures requires appreciation of fracture anatomy as well as soft tissue injury. Usually complex intra-articular fractures are associated with significant trauma to surrounding soft tissue. Surgical approach through such traumatized soft tissue envelop, if done early, will cause additional trauma to soft tissue envelope, leading to problems related to wound healing and infection (Fig. 1.5). So it is prudent to wait for soft tissue healing before embarking upon the surgery. This can vary from days to weeks.¹¹ In between the time, one can use bridging external fixators also known as traveling fixators (Fig. 1.6) with definitive fixation later on. Several indirect reduction techniques and biological fixation concepts have also come to reduce trauma to the soft tissue envelope.

An atraumatic surgical approach should be used. Both minimally invasive and open approaches are available, however all articular fragments must be reduced anatomically and preferably under vision. Ligamentotaxis will only work for fragments with ligament attachment (i.e. some split fractures of the tibial plateau).

This articular reduction is then secured with K-wires or screws and then this articular block is fixed to the metaphysis with the help of definitive implant. Nowadays, periarticular anatomical locking plates have become indispensable in the management of these fractures. All measures are taken to minimize trauma to the surrounding soft tissue.

Several studies^29-31 have reported beneficial effects of early motion in intra-articular fractures. Active assisted exercises are preferable, muscles and joints both are rehabilitated. Continuous passive motion (CPM) does not prevent muscle atrophy, however; it is still a useful tool in the management of intra-articular fractures. Sometimes, stability of fixation can be of concern. Some sort of additional stability can be provided with 7ROM-splints. Plaster immobilization should not be used after ORIF of intra-articular fractures as it leads to more stiffness. Patients are kept non-weight bearing until articular fracture is healed.

T1-rho MRI mapping, which measure relaxation times in cartilage can assess specific components of articular cartilage biochemistry and ultra-structure. It has shown to be more sensitive to cartilage degradation than conventional MRI techniques.^32-34

Scapular fractures comprise of approximately 1% of all fractures. Of these, one-third affect the glenoid process, including the fractures of glenoid cavity and neck. More than 90% of glenoid fractures are minimally displaced and can be managed nonoperatively, the other 10% need surgery. The displaced fractures may affect stability of the shoulder if they involve glenoid rim or result in substantial tilt of the glenoid. These fractures can occur in isolation, in association with other scapular fractures, and as a part of glenohumeral dislocations. They often occur due to high-energy trauma, or fall on an out-stretched arm.

Glenoid inclination is variable. On an average, it is inclined 4.25 degrees superiorly and is in retroversion of 1.23 degrees. Any significant change in inclination may result in an unstable shoulder. The glenoid width averages 28.8 ± 1.6 mm in males and 23.6 ± 1.5 mm in females. Its height averages 37.5 ± 2.2 mm in males and 32.6 ± 1.8 mm in females.

Common presentation of a glenoid fracture is in association with an acute anterior dislocation of the shoulder, which has the tendency to re-dislocate after reduction. On X-rays, one can see a fracture of the anterior glenoid rim. Posterior glenoid fractures often result in persistent posterior dislocation. Glenoid fossa fractures have few symptoms. Often these injuries are associated with a multiply injured patient, and are associated with serious chest injury. For this reason such injuries are commonly missed. One must look for brachial plexus and vascular injuries, sometimes associated with ‘high-velocity’ trauma.10

Trauma series including a true AP of the shoulder and axillary (mostly possible) form the basic views. Computed tomography (CT) scan, particularly a 3-D CT scan with ‘end-on glenoid’ with head removed, gives the best idea about the type of fracture. Magnetic resonance imaging (MRI) is sometimes done to assess for the associated rotator cuff injuries.

Ideberg and Goss classified¹ these fractures into six types (Fig. 2.1):

Non-surgical: Minimally displacement (less than 5 mm step and less than 5 mm separation) is acceptable as it does not cause long-term issues. Usually a sling for 2 to 3 weeks is adequate. Most fractures heal in 6 weeks.

Surgical: Surgical indications of glenoid fossa fractures broadly depend upon the following:

11Depending upon the type of fracture, the treatment is as follows:

Thorough knowledge of the surgical anatomy is necessary to adequately stabilize a glenoid fracture. It is important is to decide from which side can the fracture be best approached—anterior, posterior, superior or combined. Anterior rim fracture can be approached from front (deltopectoral approach). Posterior rim fractures and all the other fractures are best approached from behind. In some, an additional exposure from superiorly is required to control the superior fragment. Basic orthopedic and shoulder instruments are required. K-wires, 4 mm cannulated screws, and small fragment recon plates form the mainstay of implants required to fix these fractures.

Deltopectoral approach: This approach is used essentially for anterior glenoid rim fractures. The approach is similar to that used for any anterior surgery on the shoulder, and consists of the following steps (Fig. 2.2).

The underlying anterior capsule is likewise cut from the lessor tuberosity, and retracted medially. The anterior part of the glenoid rim can now be seen and tilt (Fig. 2.2F). A special humeral head retractor (Facuda) comes handy in keeping the head out of the way (Fig. 2.2G). Often one needs to carefully dissect the capsule from lower pole of the glenoid to adequately expose the fracture extending to the lower pole. Great care needs to be taken while doing this as the axillary nerve is close. The fracture is reduced under direct vision. It is temporarily fixed with one or two K-wires. It is best to use 4 mm cannulated screws to fix the fracture. One needs to be careful while drilling and fixing the anterior rim as the axillary nerve is close. Attention is required to drill in mediolateral 13direction to avoid putting the screw intra-articular. An osteotomy of the coracoid may be required for better exposure.

Posterior approach (Figs 2.3A to F): With the patient in lateral decubitus position, bony landmarks are drawn (Fig. 2.3A). A curved skin incision is made starting at lateral prominence of acromion, going medially along scapular spine and distally to the inferior angle of scapula (Fig. 2.3B). The deltoid is detached sharply from the scapular spine alongwith some periostium. Interval between the posterior deltoid and underlying infraspinatus muscle is created by careful blunt dissection with finger. The detached deltoid is retracted laterally. Under the deltoid one would find the bellies of infraspinatus and teres minor (Fig. 2.3C). A plane can be identifies more easily between the two at the lateral end where they attach to the posterior part of the greater tuberosity. Further dissection is between the infraspinatus and teres minor (Fig. 2.3D), as these muscles are suplied by two different nerves (suprascapular and axillary nerves respectively). Under the muscles, one will find the posterior capsule covering the head, which can appropriately expose the glenoid (Fig. 2.3E). The exposure can be further improved by detaching the origin of triceps from infragenoid tubercle, and by placing a head retractor to expose the glenoid (Fig. 2.3F).

Superior approach: This may be required as an additional approach to control the superior glenoid fragment. It is a direct approach to the superior part of the glenoid, which can be reached by splitting the fibers of trapezius and supraspinatus.

The shoulder area does not respond too well to the operative treatment.

Glenoid fossa fractures are rare. The indication for conservative or surgical treatment is controversial, especially because of limited reports in the literature. Many authors prefer conservative treatment for most type of glenoid fractures.³ Kligman and Roffman reported on a small series of four patients with displaced, intra-articular glenoid fossa, who were treated either surgically or conservatively. After an average 7-year follow-up, clinical and radiographic results were satisfactory in all patients. Kraus et al³ reported good results of type 1b fractures treated conservatively in elderly patients.

This 30-year-old man fell from a bike and sustained injury to his right (dominant) shoulder. It was diagnosed as shoulder dislocation. The attending surgeon made an attempt at closed reduction. He noticed that, though it could be easily reduced, but it was dislocating with equal ease. The X-ray showed fracture of the anterior rim of the glenoid (Fig. 2.4A). CT scan confirmed the presence of a significant fracture of the anterior rim of the glenoid. A further study with 3D CT showed the exact size of the glenoid fragment, constituting nearly 40% of the glenoid (Fig. 2.4B).

Proximal humeral fractures account for around 4 to 5% of all fractures. It is the second most common fracture type of upper extremity and 3rd most common fracture in patients > 65 years. Most of proximal humeral fractures (80–85%) are minimally displaced. These fractures have a bimodal distribution. In the younger age group, proximal humeral fractures usually occur because of high energy injury, while in elderly, low energy injuries are usually the culprit due to underlying osteoporosis.¹

The decision to operate and the selection of the appropriate surgical modality for proximal humerus fractures are largely based on the fracture pattern. Understanding the particular fracture pattern in each case is complicated. Because of the increase in treatment methods as well as understanding of proximal humeral fractures, a variety of classification systems have been devised. The Neer's 4-part classification² (Fig. 3.1) is still the most widely used classification and is based on pathoanatomy of proximal humerus fractures. AO/ASIF³ classification system (Fig. 3.2) considered vascularity also in addition to patho-anatomy. In 2004, Edelson et al⁴ published a CT based classification, which has shown potential to improve as well as modify the surgical procedures. This classification divides proximal humerus fractures into 5 major patterns:

The standard trauma series (Fig. 3.3) for proximal humerus fracture includes true AP, axillary lateral and scapular Y view. The trauma series evaluates the glenohumeral joint and proximal humerus in three perpendicular planes. The axillary radiograph best shows displacement of the lesser and greater tuberosities and splits and dislocations of the humeral head. If the patient is unable to tolerate the axillary view because of pain, a Velpeau axillary view can be substituted. The axillary view is the most frequently omitted image and is a common reason for missed dislocations and fractures.

Computed tomography (CT) has enhanced tremendously our ability to image and understand complex proximal humerus fractures. CT represents an invaluable tool in the preoperative planning and execution of internal fixation for these complex fractures. Most authors recommend the systematic use of CT scans for preoperative planning, especially for fractures including the greater or lesser tuberosities, humeral head impaction, head splitting, or any other fracture with intra-articular fragments.

Magnetic resonance imaging (MRI) can be a useful diagnostic tool in assessing osseous abnormalities about the proximal humerus potentially leading to improved patient evaluation and treatment. MRI may help identify occult fractures and detect associated rotator cuff tears. In general, MRI is rarely used in the standard preoperative imaging protocol of proximal humerus fractures.

Bone mineral density can be roughly determined by radiographic evaluation and can have a considerable effect on treatment options. Tingart and colleagues⁵ identified a reliable and reproducible predictor of bone mineral density of the proximal humerus. They compared the cortical thickness of the proximal humeral diaphysis with the bone mineral density of the proximal humerus. They noted that a cortical thickness (defined as the sum of the cortical thickness of the medial and lateral cortex of the proximal humerus) less than 4 mm was highly predictive of low bone mineral density. Additionally the radiographic images must be evaluated for the presence of an intact medial buttress because this has been theorized to be important in strength of fixation, especially regarding current locking plate technology.

Another consideration in the radiographic classification of proximal humeral fractures is the vascularity of the humeral head.

21Avascular necrosis is known as sequela of proximal humeral fractures and has been reported at rates of 21 to 75%. The vascularity of the humeral head segment in conjunction with the state of the articular surface and other mitigating patient factors help to determine optimum treatment. Hertel and colleagues⁷ devised a series of criteria that could be predictive of humeral head ischemia after fracture. Fractures that were predictive of ischemia were those of the anatomic neck, four-part displaced and all three-part fractures configurations except one. The exception three-part fracture that maintained perfusion involved a fracture at the anatomic neck and a fracture below the tuberosities at the surgical neck; however, the tuberosities did not have a fracture between them. Additional elements, such as length of the posteromedial metaphyseal extension (<8 mm associated with vascular compromise) and the integrity of the medial hinge, were also key in predicting vascular disruption.

In this operative era, there is still a role of conservative management. The indications for closed treatment are:

Indications for ORIF can be summarized as follows:

A variety of surgical approaches have been described for proximal humeral fractures. Choice of surgical approach depends upon fracture pattern (Table 3.1).

A variety of ammunition is present in an orthopedic surgeon's armamentarium to deal with proximal humeral fractures. They can be discussed in brief as follows:

This is best suited for limited 2 or 3 part fractures when other techniques are not favorable. This is usually done in beach-chair position under C arm control. After closed reduction, bidirectional pins are used, which are preferably terminally threaded. Associated problems include pin migration, axillary nerve injury, pin loosening and infection. Another major disadvantage is that no early motion can be instituted leading to shoulder stiffness.

This is best suited for isolated greater tuberosity, lesser tuberosity, or both, or both tuberosities associated with undisplaced surgical neck fracture. Associated problems include cuff constriction, limited head fixation to shaft and wire migration.

Two types of intramedullary nails are available: Flexible (Fig. 3.9) and locked rigid nails (Fig. 3.10). They are best suited for two part surgical neck fractures. Associated problems are limited head fixation, migration into subacromial space, cuff violation, etc. Locked nails provide enhanced proximal fixation with twisted blades or multiple screws.

Buttress plate technique (Fig. 3.11) is usually applied lateral to the bicipital groove to minimize vascular damage. This is rarely used now a days due to impingement and poor head fixation. This is best suited for low 2-part surgical neck fracture alone or associated with greater tuberosity fracture. These plates have high failure rate due to impingement and poor screw purchase.

However, Meier et al¹⁶ reviewed 36 cases with blade plate fixation and found that 8 patients out of 36 had blade plate perforation and recommended alternate fixation if possible.

General anesthesia is used. The patient is positioned on the operating room table in a semi-sitting beach-chair position; the head is rotated to the opposite side.

25To prevent the patient from sliding down the operating room table, a pillow is placed behind the knees and a seat belt across the patient's thighs. The shoulder is positioned off the edge of the table so that the arm can be extended and imaged properly when needed intraoperatively.

A standard deltopectoral approach is used. The incision is around 10 to 15 cm in length starting from the coracoid process to deltoid insertion (Fig. 3.14). Interval between pectoralis major and deltoid is easily identified by the presence of cephalic vein (Fig. 3.15), which is reflected laterally. This is an extensile approach and can be extended distally as an anterolateral approach if there is a diaphyseal extension. The insertion of the pectoralis major is partially released for exposure. Abducting the humerus during the procedure aids in relaxing the deltoid. If excessive deltoid tension is present, a transverse division of the anterior 1 cm of the deltoid insertion distally improves exposure and, more importantly, avoids damaging the deltoid.

The long head of the biceps tendon serves as the key landmark in separating the greater and lesser tuberosity segments. In three and four part fractures, the split in the tuberosities is located just posterior to the bicipital groove. The space formed by this fracture line is developed to gain access to the humeral head and glenohumeral joint (Fig. 3.16).

Nonabsorbable intraosseous or intratendinous (in case of osteoporotic bone) sutures are passed through both tuberosities (Fig. 3.17). It is important to open the rotator interval to inspect the articular surface for any loose fragments or defects. If humeral head is dislocated, it is reduced first before performing any reduction maneuver.

Humeral head is reduced over the shaft in all the three planes (coronal, sagittal and horizontal) either manually or with the help of K-wires, periosteal elevator or osteotomes. Lateralizing the shaft also helps shaft reduction, as it is usually displaced anteromedially due to the pull of pectoralis major. This can be achieved either by reduction forceps or by indirect pressure in the axilla through customized bolster. Aligning of fracture spikes as well as bicipital groove also help in ensuring optimum alignment. Tuberosities are also reduced with the help of holding sutures.

Once reduction is achieved, it is held with the help of K-wires (Figs 3.19 and 3.20). Bone graft or bone substitutes may be used if there is extensive metaphyseal defect (Fig. 3.21).27

Gardner et al¹⁹ emphasized the importance of medial buttress in proximal humerus fractures and recommended restoration of the medial buttress with reduction. If it is not possible, then it should be substituted with oblique locking (kickstand) screw or a fibular strut graft.

We routinely use the PHILOS^® (Synthes) locking plate for proximal humerus fractures. Plate length is chosen optimally to insert 3 to 4 screws distal to fracture and 4-6 screws in the humeral head depending upon the bone quality. The correct plate position is about 8 mm distal to the top of the greater tuberosity, aligned properly along the axis of the humeral shaft and slightly posterior to the bicipital grove (2–4 mm) (Fig. 3.22).

Placing the plate too low can prevent the optimal distribution of screws in the humerus head. The plate may also be used as a reduction tool.

The function of plate is to connect the humeral head to the shaft. Tuberosity fragments must be fixed separately. Tuberosities are secured with tension band sutures through the small holes in the plate (Fig. 3.27). Check the sutures to ensure that they do not rupture during motion.31

After a thorough wash, wound is closed in layers (Fig. 3.28). A drain may or may not be used depending upon surgeon's preference.

Usually a shoulder immobilizer is used for 2 to 4 weeks depending upon the stability of fixation. Pendulum exercises and elbow ROM exercises are started immediately as soon as the pain subsides. Sequentially active assisted and active exercises are initiated. However, full load is exerted only after fracture has consolidated, usually at 6 months.

These locking plates have their own set of complications. Plate breakage and locking screw backout are two major problems (Figs 3.29A to D). Also humeral diaphyseal split fractures have been reported with use of short proximal humerus locking plates. Simple fractures at the surgical neck may run with an increased risk of a fatigue failure of the plate. In a recent systemic review,²⁰ fixation of proximal humerus fractures with proximal humerus locking plates was found to be associated with a high rate of complications and reoperation and the authors suggested that the surgical technique should be used carefully and only in well-selected patients.

Saudan et al²¹ presented first results of locking plates in proximal humerus fractures and recommended ORIF of 2, 3-part fractures regardless of age, ORIF of 4-part fractures in younger patients and hemiarthroplasty for elderly 4-part fractures. Fankhauser et al²² reported that results of locking plate are inversely proportional to the severity of injury. Koukakis et al²³ reported better results in younger patients as compared to elderly patients. Now longer plates are also available to deal with diaphyseal extension of proximal humerus fractures. Results have been very encouraging as most authors report a very high union rate combined with satisfactory functional results.^24-2933

A lot has changed in our understanding and management of proximal humerus fractures. Surgical treatment of proximal humeral fractures continues to be a challenge especially in osteoporotic patients. Locking plates have been used with satisfactory results but the previous reported complications have not been substantially reduced. Most of the existing studies involve a small number of patients followed up for a rather short period of time. Since proximal humeral fractures constitute a heterogeneous group of complex fractures in an even more heterogeneous population, no single fixation method is a panacea. Choice of implant and method of fixation should be selected according to individual patient and fracture pattern characteristics based on clearly defined indications and contraindications.

A 45-year-old male sustained bilateral proximal humerus fractures during a road traffic accident. He sustained a 4-part fracture on right side and a three-part fracture on left side (Fig. 3.30). Both sides were managed with proximal humerus locking plate fixation. He made an excellent recovery with almost full range of motion at the end of 6 months. His postoperative X-rays at 3 years follow-up are shown in Figure 3.31.34

The optimal and ideal management of complex proximal humeral fractures remains controversial. Although innovations in surgical techniques as well as newer implants like locking plates have enabled orthopedic surgeons to fix more and more complex proximal humerus fractures, hemiarthroplasty still remains an often needed and valid surgical option.

Not all proximal humerus fractures can be reconstructed. Only such selected cases need hemiarthroplasty. Indications vary depending upon age. In elderly, many 4 parts, some severe 3 part fractures and most 3,4 part fracture dislocations are treated by hemiarthroplasty, while in young, they are usually attempted to treat by reconstruction. However, nonreconstructible articular surface (severe head split) or extruded anatomic neck are treated by hemiarthroplasty in young as well as elderly patients.

The surgical technique for hemiarthroplasty in proximal humeral fractures can be discussed as follows:38

General anesthesia is used. The patient is positioned on the operating room table in a semi-sitting beach-chair position; the head is rotated to the opposite side. Usually the patient sits up at an angle of approximately 45 to 50 degrees. To prevent the patient from sliding down the operating room table, a pillow is placed behind the knees and a seat belt across the patient's thighs. A towel is placed under the medial border of the scapula. The shoulder is positioned off the edge of the table so that the arm can be extended and imaged properly when needed intraoperatively.

An extensile deltopectoral approach is used. The incision is around 15 to 20 cm in length starting from the coracoid process to deltoid insertion (Fig. 4.3).39

Interval between pectoralis major and deltoid is easily identified by the presence of cephalic vein (Fig. 4.4), which is reflected laterally. This is an extensile approach and can be extended distally as an anterolateral approach if there is a diaphyseal extension. The insertion of the pectoralis major is partially released for exposure. Abducting the humerus during the procedure aids in relaxing the deltoid. If excessive deltoid tension is present, a transverse division of the anterior 1 cm of the deltoid insertion distally improves exposure and, more importantly, avoids damaging the deltoid. Superiorly dissection should not go medial to coracoid process.40

The long head of biceps should be identified and isolated. The long head of the biceps tendon serves as the key landmark in separating the greater and lesser tuberosity segments. In three and four part fractures, the split in the tuberosities is located just posterior to the bicipital groove. The space formed by this fracture line is developed to gain access to the humeral head and glenohumeral joint.

Both lesser as well as greater tuberosities are mobilized medially, laterally, superiorly and inferiorly and tagged with heavy sutures. We prefer no. 5 Ethibond suture for this. The sutures should be passed through the tendons of rotator cuff, just proximal to their insertion. This helps in avoiding any cut-through of suture from the bone.

The proximal aspect of shaft is cleared from all sides. It is important to handle the shaft carefully, especially if it is osteoporotic. Sometimes there is undisplaced fracture of the shaft, which can usually be managed by extending and external rotating the arm helps in exposing the humeral shaft.

Regarding placement of prosthesis, it is important to choose proper orientation, size and position of the implant (Fig. 4.9). These all involve proper adjustment of height, retroversion and size of prosthesis head.⁸

Height of prosthesis can be determined by following methods:⁹

This is an important step, which should be done meticulously. The tuberosities are sutured to each other and to the proximal shaft with sutures passing through the lateral holes of prosthetic fin (Fig. 4.12). We routinely perform bone grafting around this repair, which is usually harvested from removed humeral head (Fig. 4.13). The arm should be gently moved to check the stability of repair.

Hemostasis is achieved. Rotator interval is closed. Wound is closed in layers over a suction drain (Fig. 4.14). A supporting arm pouch is given.

Passive mobilization and the pendulum exercises are begun early, usually first or second postoperative day. After healing of tuberosities, active assisted exercises can be started. Pulley and active exercises are not allowed in the first 6 weeks. At 6 weeks, if there is radiographic evidence of tuberosity healing, resistive exercises are started.⁸

Following complications may be seen:

Neer⁵ reported excellent results following arthroplasty for acute proximal humerus fractures. Bastian et al⁶ presented a series of 49 cases of hemiarthroplasty and suggested that hemiarthroplasty is a viable alternative in patients with osteopenic bone and/or comminuted fractures.

A 64-year-old farmer had a fall from tree and sustained a four-part fracture of left proximal humerus. His bones are very osteoporotic and a cemented hemiarthroplasty was performed (Fig. 4.15). At one-year follow-up, patient had no pain and a useful range of motion at left shoulder (Fig. 4.16).

Proximal humeral fracture is the third most common fracture in the elderly. The incidence is increasing as well as the mean age of the patient being treated for a proximal humeral fracture.^1,2 The majority of these fractures are minimally displaced and can be treated conservatively (70-80%). In our institution we perform surgery in about 25% of the cases. The most commonly used classification system is the 4-part fracture classification by Neer.^3,4 The four main fragments are the head, greater tuberosity, lesser tuberosity, and the shaft. The most complex fractures are the 3- and 4-part fractures. Hemiarthroplasty has been advocated for treating complex proximal humerus fractures in the elderly, but outcome has been very variable and unpredictable.^5-10 In a recent prospective randomized study there were no significant differences between hemiarthroplasty and nonoperative treatment regarding Constant score, range of motion and pain.¹¹ However, quality of life was better in patients treated with hemiarthroplasty, and there was a trend towards less pain with hemiarthroplasty. The alternative to hemiarthroplasty has been locked plating since these plates can be used to reduce and maintain reduction even in osteoporotic bone. The reported overall outcome for locked plating in 3- and 4-part fractures has been superior to hemiarthroplasty,^12-15 but the incidence of complications and revision surgery have been high. In 2009 Brunner et al reported on a series of 157 patients with 3- and 4-part fractures treated with locked plating.¹⁶ There was a complication rate of 45% and revision surgery was needed in 25% of the patients. Patients older than 75 years had 3.3 times higher risk for complications. Several reports have seen similar high-risk for complications after locked plating in the elderly, such as screw cutout and secondary displacement.^17-19

Preoperative evaluation of the function of the plexus brachialis, including the axillary nerve, is important. Clinical examination is sufficient and an electrophysiological test is usually not indicated. In complex proximal humeral fractures plain radiographs and CT scan are commonly performed. This gives the treating surgeon a possibility to evaluate the fracture system, the glenoid and the status of the rotator cuff muscles. On several occasions I have found that the proximal humeral fracture has been associated with a rim fracture of the glenoid, which reduced the surface area of the glenoid and therefore, needed to be treated. Ideally the surgery should be performed within 7 days from the trauma to facilitate mobilization and reattachment of the tuberosities.

My indication for using the reverse arthroplasty in proximal humerus fracture is complex 3-part and 4-part fractures in patients older than 75 years. If significant cuff deficiency is seen during surgery or detected on preoperative CT scan in patients between 65 and 75 years of age a reverse arthroplasty is considered, but decision process depends on the general health and activity level of the patient. In our algorithm for proximal humeral fractures open reduction and internal fixation with a locked plate is attempted in patients younger than 75 years and if that is not possible a hemiarthroplasty is used.

There are many different designs available today, but they are all based on the original ideas of Grammont's Delta reverse design.³⁴ There is a large glenoid hemisphere and a small humeral cup with a nonanatomical inclination angle of 155 degrees. The center of rotation is medialized, which improves the lever arm for the deltoid muscle and recruits more deltoid muscle fibers for abduction. Since the humerus is lowered it restores the length of the deltoid muscle, and actually increases the tension of the deltoid muscle. This design has proven to restore biomechanical balance in cuff deficient shoulders.³⁴ The glenoid component has noncemented fixation with a central peg and 4 screws. The screws can create compression and angle stability. This type of fixation has been very reliable and the author has not seen any glenoid loosening in almost 600 cases of Delta Xtend since 2006.

I prefer to do the surgery under combined general anesthesia and ultrasound guided interscalene block with the patient in the beach chair position (Fig. 5.2). The arm on the injured side should be lateral of the edge of the table in order to be able to extend the arm in the posterior direction to facilitate reaming of the humerus. This is particularly important if the surgery is performed through the deltopectoral approach. The sterile field should include the shoulder and the upper arm down to approximately 10 centimeters above the elbow. An antimicrobial incision drape (Ioban™, 3M, St Paul, MN, USA) is routinely used to reduce the risk for infection. It is especially important to cover the skin in the axilla. Half an hour before the surgery 2 gram of cloxacillin 50(Ekvacillin®, Astra Zeneca, Södertälje, Sweden) is given intravenously as prophylaxis, followed by two more injections, 8 and 16 hours, after surgery.

The author also routinely gives tranexamic acid (Cyklokapron®, MEDA, Solna, Sweden) 10 mg/kg bodyweight 30 minutes before surgery to reduce bleeding.

The skin incision is in the anterior-posterior direction centered over the lateral part of the acromion, approximately 5 millimeter from the lateral margin. It starts posteriorly over the most posterior part of the acromion and ends 4 to 5 cm anterior of the tip of the acromion (Fig. 5.3). The total length of the incision is normally 8 to 10 cm, but can be extended if necessary. Subcutaneous dissection in the medial and lateral direction makes it possible to fold the medial and lateral skinfolds away from the operative field and they are held in this position with stay sutures. The deltoid release/splitting starts at the level of the AC-joint approximately 5 mm posterior of the tip of the acromion and is extended in the lateral direction about 4 cm lateral of the acromion (further extension laterally can be performed, but the axillary nerve is running on the undersurface of the deltoid muscle in this region and has to be protected). The deltoid can be released from the tip of the acromion with electrocautery or taken down with a small piece of bone from the acromion. The author prefers to take 5 to 6 mm of the tip of the acromion together with the deltoid insertion anteriorly in order to protect the tendon during surgery and to facilitate the repair at the end of the procedure. The coracoacromial ligament is released to create more room.

A tenotomy of the long head of the biceps is performed. Stay sutures (no 2 Orthocord (DePuy Mitek, Raynham, MN, USA) or similar) are placed close to the cuff insertion of the lesser and greater tuberosity. The stay suture in the greater tuberosity should be placed in the infraspinatus tendon insertion. The supraspinatus tendon is excised by releasing it from the insertion on the greater tuberosity using electrocautery and cutting it at the muscle-tendon junction (Fig. 5.5). The lesser tuberosity with the insertion of the subscapularis and the greater tuberosity with the insertion of the infraspinatus and teres minor are mobilized. If the greater tuberosity is fragmented into several pieces it may be necessary to place two or more stay sutures to control the major fragments.

Two drill holes are made in the shaft anteriorly (one in the area of the bicipital groove and one more anteriorly) and two drill holes are made in the shaft laterally. These 4 drill holes are placed 5 to 7 mm away from the fracture line.

A 360 degree release around the glenoid is performed and the cartilage and labrum is removed. The inferior bony pillar of scapula is identified as well as the base of the coracoid process. The inferior pillar is located slightly posterior (7 o'clock position in a right shoulder). The specific forked glenoid retractor is placed inferiorly below the glenoid with one prong on each side of the inferior bony pillar and pushed downward to displace the shaft (Fig. 5.6). The lower part of the glenoid is forming a circle (Fig. 5.7) and with the specific glenoid guide instrument a guidepin is drilled into the center of this inferior circle (Fig. 5.8).

The inferior edge of the metaglene component should follow the inferior border of the glenoid. The guidepin should be placed perpendicular to the surface of the glenoid. It is particularly important to avoid a superior tilt of the guidepin (Fig. 5.9). Once the guidepin is in a good position the reaming is done. The small circular reamer creates a surface for the metaglene. The hard subchondral bone plate should be maintained i.e. only minimal reaming is necessary. This is followed by using the hand held reamer to create room for the glenosphere superiorly. The central hole is then drilled followed by removal of the guidepin. Many times the guidepin will be removed together with the drill. The metaglene component is impacted and rotated so that the inferior hole is in line with the inferior pillar.

Using the guide system the hole for the inferior screw is drilled (Fig. 5.10). I use the drill-push technique, i.e. I drill just a little distance into scapula and then carefully push the drill inward in order to feel that there is a bony stop at the bottom. Then drilling is done a little further followed by pushing the drill inward to feel that there is still a bottom in the hole. These steps are repeated until a hole for a 42 mm screw has been created. A 36 mm screw is acceptable, but I prefer a 42 mm in the inferior hole. With this technique it is possible to be sure that there is bone at the bottom of the drill hole i.e. the screw is inside the scapula pillar. If the drill exits the bone before a 36 mm hole is created there are several adjustments that can be performed. The first step is to palpate the inferior pillar again and to look at the plain radiographs. If the patient has a prominent long scapular neck a more horizontal drilling usually results in a deeper drill hole inside scapula. It is also possible to rotate the metaglene to place the inferior hole slightly more posterior or anterior and then aim the drill towards the inferior pillar. The guidepin for the screw is placed into the drill hole and by pushing this pin into the hole the surgeon can feel that there is a stop at the bottom i.e. the drill hole is all inside the bone. The self-tapping locking screw is placed over the guidewire (Fig. 5.11). The screw should not be tightened completely since this can create a tilting of the metaglene component if the bone is osteoporotic (Fig. 5.12). The superior drill hole is done with the same technique aiming at the base of the coracoid process. This screw is bicortical, thus the drill hole should exit through the distal cortex. To avoid placing a screw that is too long I prefer to drill this hole until I hit the second more distal cortex. I measure the distance at this stage. The second cortex is then drilled and a locking screw 5 mm longer than the previous measurement is used. This technique avoids the risk of placing a too long screw in this position, which could injure the suprascapular nerve. A guidewire is placed in the superior hole and a locking screw (usually 30 or 36 mm) introduced. Once the superior screw is almost fully seated the inferior screw is completely tightened followed by tightening of the small locking screw. This creates compression followed by locking the screw to the metaglene component. The same steps are done with the superior screw. The anterior and posterior screws are introduced and these are usually 18 mm nonlocking screws. If one or more of these drill holes are 24 mm or more I prefer to use locking screws in these holes, thus as many locking screws as possible is recommended (Fig. 5.13).

A 42 mm trial glenosphere is placed on the metaglene and a monobloc, epiphysis size 1 humeral component (stem size according to the last reamer used, usually size 10) is placed into the shaft. I prefer to use the smaller size epiphyseal component to maximize the space available for the tuberosities. A trial polyethylene insert 42 +3 is placed on top of the humeral component. I place the humeral component is neutral version in relation to the forearm i.e. no ante- or retroversion. The Delta Xtend monobloc stem is designed so that in a standard 3-4 part fracture without comminution below the surgical neck the 55humeral component can be pushed down as far as possible.

The proximal epiphyseal part of the humeral component will come against the proximal end of the shaft and automatically determine the correct height of the implant. The soft tissue balance can later be adjusted using a 9 mm spacer and different heights of the polyethylene inserts. A trial reduction is performed to see that the humeral component is positioned correctly without any lateral gap between the glenosphere and the insert. At this time I do not test stability in too much detail.

The screwdriver removed and the impactor is used to impact the glenosphere onto the metaglene, followed by further tightening of the central screw. These steps are repeated until the glenosphere is fully seated onto the metaglene.

The operated arm is placed in a sling. Elbow and hand exercises are started the day after surgery. Two weeks after surgery passive range of motion with elevation to 70 degrees, external rotation to neutral, and internal rotation to the buttock is initiated. Three to four weeks after surgery assisted active excercises are started and after 5 to 6 weeks free active rehabilitation is allowed. Postoperative radiographs are taken under fluoroscopic control 2 days after surgery to get a perfect A-P projection. Routine follow- up with new radiographs are done 3 months after surgery.

There are a few reports on the outcome after using the reverse arthroplasty in proximal humerus fractures in the elderly.^35-44 Outcome and complication rates vary considerably as well as surgical technique. Bufquin et al repaired the tuberosities while Cazeneuve et al excised the tuberosities in most cases. Removing the tuberosities means removing the posterior rotator cuff muscles which are the main providers for functional external rotation. There are several reports showing inferior outcome after reverse arthroplasty in patients with cuff tear arthropathy if the infraspinatus and teres minor were missing.^26,28 To improve functional external rotation by adding lattissimus dorsi/teres major transfers have been recommended in such cases. In order to restore functional external rotation in fractures cases the author believes it is important to repair the posterior cuff. This is supported by a recent paper where Galinet et al found that external rotation and Constant score were significant better if the tuberosities healed in an anatomic position.⁴⁵

The most important reported complications have been dislocation, infection, and tuberosity nonunions.⁴⁶ However, no infections, dislocation or loosening have been seen and no revision surgery performed in the author's series of over 100 Delta Xtend reverse arthroplasty in patients with acute proximal humeral fractures since 2006.

A 75 years old healthy male sustained a comminuted proximal humeral fracture on the right side (Figs 5.18A to D). Plain radiographs and a CT scan were performed and it was decided that a reverse arthroplasty would be the best treatment. Postoperative radiographs show good position of implant with an inferior overhang of the glenosphere and tuberosities reattached with a bony overlap to the shaft. Functional outcome excellent at 6 months.60

Complex proximal humeral fractures in the elderly are a challenge to treat. Traditional methods of managing these fractures with hemiarthroplasty or locked plating have been associated with unpredictable outcome and a high incidence of complications and revision surgery. Hemiarthroplasty has shown to give similar outcome as nonoperative treatment. One of the main reasons for failure of hemiarthroplasties has been secondary displacement and resorption of the tuberosity resulting in a nonfunctioning rotator cuff. Since the reverse arthroplasty does not rely on the function of the rotator cuff to the same extent as an anatomical arthroplasty it offers an attractive alternative in complex fractures of the proximal humerus in older patients. Published results have shown encouraging results and the author have routinely used the Delta reverse arthroplasty for treating complex 3-4 part proximal humerus fractures in patients older than 75 years since 1998. The outcome is superior to our previous results with hemiarthroplasty and locked plating and more predictable.^10,16

Fractures of the distal humerus present challenges to the orthopedic surgeons. The aim of treatment is anatomical restoration of the joint surface to prevent arthritic change, as well as rigid internal fixation to allow early range of motion exercises. The difficulties lie in the complex anatomy of the distal humerus, as well as the problems of fracture comminution and possible intra-articular involvement. The small distal articular fragments offer little room for screw purchase. Nevertheless it is crucial that a stable fixation allowing early joint motion is achieved at the end of the surgery. In treating elderly distal humeral fractures, the quality of fixation is further compromised by pre-existing osteoporosis.

The most common classification used for distal humerus fractures is AO/ASIF or Müller's classification, which can be described as follows:

Type 13 A–Extra articular fracture

Type 13 B–Partial articular fracture

B1–Sagittal lateral condyle

Type 13 C–Complete articular fractures

Displaced intra-articular distal humerus fractures in adults.64

The operation is performed under general anesthesia with or without regional block. Antibiotics prophylaxis with first generation cephalosporin is recommended.

The patient can be put in a prone position or a lateral decubitus position with the arm supported (Fig. 6.1). Care is taken to pad and protect all bony prominences. A pneumatic tourniquet is used before preparation and draping for a blood-less field. For more extensive fractures or larger arm, a sterile tourniquet should be used to minimize the compromise on the size of the prepared field.

A midline posterior incision is made curving around the tip of the olecranon to avoid making a scar directly on it (Fig. 6.2).

An anconeus flap transolecranon approach, which preserves anconeus innervation and blood supply, can also be used. Olecranon osteotomy can be done as a Chevron shape or as a straight transverse fashion about two centimeters from the tip of the olecranon with a thin oscillating saw (Figs 6.3A to C). This centers the osteotomy in the mid portion of the greater sigmoid notch, which contains minimal articular cartilage. The final cut into the joint surface is made with a sharp, narrow osteotome to avoid taking a cut onto the joint surface. In addition, this kind of controlled fracture of the olecranon which contains an interdigitation, is a key to an accurate reduction at the end of the procedure. Thick osteotomes should not be used because anatomic reduction will not be achieved and the fragments will be overcompressed. The olecranon fragment is then retracted proximally and the distal humerus is exposed (Fig. 6.4)

Once the fracture configuration is confirmed, the aim is to reduce the articular fracture in anatomical position and then to reduce the articular block to the shaft in corrected alignment. The joint surface is restored first. The fragment can be manipulated with a reduction forceps or joystick K-wires. 3.5 mm cortical screw or 4.0 mm cancellous lag screw are used to provide a firm hold of the articular fragment (Fig. 6.5).

In some other conditions, the intra-articular fracture may extend in coronal or sagittal planes. In these cases, a headless screw like Herbert screw or threaded K-wires which are buried under the articular surface can be used. Once the distal articular fragments are assembled, they are repositioned and reduced onto the end of the humeral shaft. The reduction is temporarily held with 1.6 mm K-wires (Fig. 6.6). The final alignment of reduction is checked under direct vision or with the help of the image intensifier before definitive fixation is performed.

3.5 mm locking compression reconstruction plates are used to fix the fracture. Locking plates construct at 90 degree orientation to each other increase the overall stiffness to torsional and bending forces. The plates are applied to the medial ridge of the medial column and along the posterior aspect of the lateral column. During the contouring of the locking compression plate, temporary blockage of the holes with spacers is recommended to avoid deformation of the threaded plate holes. Although exact anatomical contouring to the underlying cortex is not necessary, care should be taken 67not to exceed a distance of 2 to 3 mm within the meta- and epiphyseal region in order to prevent soft tissue impingement. For the dorsally applied radial plate, the plate should be placed as possible to maximize screw placements but not to the extent to interfere with the extension of the elbow. The distal margin of radial plate should be adjacent to the posterior articular cartilage of the capitellum. The medial plate is contoured around the medial epicondyle in such a configuration that a long locking head screw can be inserted in the distal locking hole to transfix the articular fragment. Any screw perforation into the olecranon fossa or the coronoid fossa should be avoided. If locking head screws and conventional screws are used together on the same locking plate, it is always necessary to use the conventional screw first. Otherwise, the LCP principle of an internal fixator is disregarded, resulting in additional stress on the locking head screws.

The triceps aponeurosis is repaired on both sides. The ulnar nerve is checked again and assessed for the necessity for anterior transposition. A suction drain is inserted and the skin is closed in layers. Postoperatively, the elbow is kept elevated in a sterile dressing and immediate active motion can be allowed for the patients. If the soft tissue is compromised or the fixation is inadequate, a short-term immobilization can be used.

Active and active assisted elbow range of motion is started on the first postoperative day. Continuous passive motion devices are usually not necessary. Early motion ensures a good return of function range of movements. Muscle strengthening can be started when the fracture starts to heal, usually at 4 to 6 weeks time.

Chan et al (2009) reported 24 patients with distal humeral fractures treated with open reduction and internal fixation with 3.5 mm locking compression plates. Most of the patients in this series had osteoporotic bone. All patients were shown to achieve excellent or good results and this is similar to the series of Huang et al (2005). They also showed better results with type A, extra-articular fractures, and this is not difficult to comprehend that type C, complete articular, fractures will have worse prognosis.

Complications include nonunion at the fracture and/or osteotomy site, and implant loosening and pull-out. Residual elbow stiffness can occur and hence early mobilization is mandatory to ensure a good functional range.

Stable fixation and a precise restoration of normal anatomy is the goal of treatment in distal humeral fractures and the use of locking compression plate can facilitate fulfillment of these requirements. Early mobilization can be started early postoperatively and complications are uncommon.

A 46-year-old man slipped and fell while walking downstairs. He sustained a grade I open C2 fracture of his left distal humerus (Figs 6.7A and B). Double plate fixation was done with 2 locking plates at 90 degrees orientation to each other (Figs 6.8A and B). Active and passive assisted elbow range of motion were started on the first postoperative day and a good return of function was seen at 3 months (Figs 6.9A and B).

Fractures of the distal humerus account for 2 to 6% of all fractures¹ which tend to occur in a bimodal age distribution, with fractures in younger patients occurring as a result of high energy mechanisms and fragility fractures occurring in the elderly as a result of low energy falls. The subsequent fracture pattern may be extra-articular (AO type A), partial articular (AO type B), or complete articular (AO type C).

All displaced nonpathological fractures of the distal humerus involving both the columns, i.e AO/OTA type A (or supracondylar fractures), fractures with intra-articular involvement with bicolumnar involvement, i.e. AO/OTA type C (or intercondylar fractures) in skeletally mature patients (fused physis aound the elbow) are indications for open reduction and internal fixation (ORIF).

The initial management and resuscitation is on the lines of ATLS (Advanced Trauma Life Support) protocol. The affected elbow is provisionally splinted and only after hemodynamic stabilization, radiographic evaluation should be done.

Radiographs of the affected elbow, anteroposterior and lateral views, if possible under gentle traction, should be done and the fracture classified according to the AO/OTA classification system. However, if doubt persists regarding intra-articular extension of the fracture or regarding classification of the fracture a CT scan of the affected elbow must be done.

As with any complex fracture procedure, ORIF of distal humerus fractures is best undertaken during daylight hours, after adequate planning, and with a rested, experienced surgical team and staff. Poor skin condition like blisters in the vicinity of the surgical incision or approach should be treated first by rupturing them under sterile conditions and then allowing them to heal till they turn into a scab, before proceeding for surgery. Intravenous third generation cephalosporin and aminoglycoside (metronidazole is added in open fractures) are usually given as preoperative prophylactic antibiotic 15 minutes before inflation of tourniquet.

The concept of parallel plating was conceived because various authors had reported a rate of 20 to 25% unsatisfactory results following orthogonal plating of distal humeral fractures.^2,15-20 Realizing the technical limitations of orthogonal plating, it was noted that whenever nonunion or failure of fixation occurred, it did at the supracondylar level due to suboptimal anchorage of the articular fragments to the shaft caused by the limited number and length of screws that can be placed in the distal fragments, resulting in inadequate stability of fixation of the distal fragment to the shaft at this level.^3,4 This was so because of various reasons: (a) when used in cases of low intercondylar fractures, adequate bone-stock for holding the screws in 90 to 90 plate configuration may not be available; (b) Since the articular fragments are first fixed independently with a cannulated cancellous screw, no further intercondylar compression can be expected when the plates are applied; (c) Further, the posterolateral plate does not allow the insertion of longer screws, so the amount of bone-stock available for purchase of the distal screws is not adequate, and hence the stability is less.^1,3,4 Hence, when orthogonal method of plating fails, it is due to the nonunion at the supracondylar level, or stiffness resulting from prolonged immobilization that has been used in an attempt to avoid failure of fixation that had been inadequate.^4,19,20

The patient is operated under tourniquet, if feasible, in the lateral decubitus position with the arm hanging free over a bolster, allowing free unhindered elbow flexion beyond 90 degree (Fig. 7.2)

An extensile posterior midline skin incision, around 15 cm long, is given curving medially or laterally to avoid the tip of the olecranon. The incision starts and finishes in the midline (Fig. 7.3A).

Part 1: Lateral approach: The deep exposure involves combined approaches from the lateral and medial sides of the elbow. We always start with the lateral portion of the approach first, which is a modified Kocher's approach. We palpate the olecranon tip, lateral humeral epicondyle and the subcutaneous border of the ulna, which are the boundaries within which the triangular shaped anconeus muscle lies. A fibrous intermuscular fascia “white line”—is usually amenable to visualization and just barely palpable in each case, which separates the extensor carpi ulnaris (ECU) from the anconeus.⁶ Distally the tip of the anconeus is usually 10 cm from the tip of the olecranon. Once the anconeus is visualized, we then incise the deep fascia directly over the “white line” and then we start separating the anconeus from the ECU. We then proceed from distal to proximal in this interval towards the lateral humeral epicondyle separating the anconeus from the ECU and also subperiosteally from the subcutaneous border of the ulna (Fig. 7.3C).

Part II: Medial approach: The medial exposure consists of the triceps-reflecting approach to the posterior aspect of the elbow, as described by Bryan and Morrey. We start at the point corresponding to the distal most extent of the anconeus muscle attachment that is usually 10 cm distal to the olecranon. We then incisie the periosteum on the subcutaneous border of the ulna, continuing proximally along the edge of the flexor carpi ulnaris origin (Fig. 7.3D).

77Although the triceps inserts on most of the olecranon and continues distally as a periosteal sleeve on the proximal ulna, the critical portion is an area approximately 1 cm in diameter on the olecranon. This area is located in line with the intramedullary long axis of the ulna (i.e. where K-wires are inserted for tension band fixation of an olecranon fracture). It is important to reattach the triceps precisely at that point at the completion of the procedure, so that the proper length-tension relationship is restored and the mechanical advantage of the olecranon is not lost. We then place a marking suture in the Sharpey fibers at the time of their release (Fig. 7.3E).

Once the fracture is exposed, the first step is reassembly of the articular surface. The articular fragments are provisionally fixed with smooth Kirschner wires (K-wire). In cases with extensive intra-articular comminution, fine threaded wires (1–1.5 mm) are used and then cut off and left in as definitive adjunctive fixation. Fracture re-assembly is completed with provisional fixation of intercondylar with the supracondylar component of the fracture with K-wires (1.5–2 mm) along the respective columns (Fig. 7.4A).

The next step is to contour the reconstruction plates, using AO bender and L-benders to fit the reassembled humerus medially and laterally. The medial plate should be extended to the articular margin in cases of very distal or comminuted fractures and is contoured to the shape of the medial epicondyle. The lateral plate is placed laterally, rather than posteriorly, on the lateral column. While we refer to the plates as being parallel, each plate is actually rotated posteriorly slightly out of the sagittal plane such that the angle between them is often in the range of 150 to 160 degree. This orientation permits the insertion of at least four long screws in the intercondylar region, i.e. the distal fragments from one side to the other.

79As far as possible it should be attempted that the plates end at different levels proximally to avoid the creation of a stress-riser. The plates are then provisionally applied according to the following steps. First, two smooth 2 mm K-wires are introduced at the medial and lateral epicondyles through holes in the plates while they are held snugly against the bone (Fig. 7.4B).

Once the plates are provisionally applied, medial and lateral screws are introduced distally to provide stable fixation of the intra-articular fragments and rigid anchorage to the plates. The two distal screws (fully threaded 4 mm cancellous screws, sizes 45–60 mm) one medial and one lateral, are inserted after drilling with a drill-bit. As stated above, the screws placed are aimed to be as long as possible, should pass through as many fragments as possible, and should engage in the opposite column (Figs 7.4D and E).

The plates are then fixed proximally under maximum compression at the supracondylar level. First, the proximal diaphyseal screw on one side is backed out and a large bone clamp is then applied distally on that side and proximally on the opposite cortex to eccentrically load the supracondylar region. A second proximal screw is then inserted through the plate in compression mode, and then the screw in the slotted hole is retightened. Second, the same steps are followed on the opposite side (Fig. 7.4F). Diaphyseal screws are then introduced, providing additional compression as a result of the under-contoured plates being pulled down to the underlying bone.

The smooth K-wires holding the plates to the bones inserted in step one are now removed, the remainder of the screws are inserted and the final fracture fixation is completed (Fig. 7.4G).

Two crisscross drill holes are made through the ulna, proximal to distal, beginning at the normal critical attachment site of Sharpey's fibers on the olecranon as identified by the mark of the cautery earlier. These holes exit distally on either side of the ulna. One transverse hole is also drilled.

Immediately after closure, the elbow is placed in a bulky dressing with a posterior plaster slab to maintain the elbow in maximum possible extension (with a belief to keep the olecranon fossa free of hematoma which may later reorganize and lead to an extensor lag postoperatively during rehabilitation) and the upper extremity is kept elevated. The first postoperative dressing is changed after 2 days and an elastic non-constrictive dressing is applied over an absorbent dressing placed on the wound. A physical therapy program including only active elbow flexion and no active elbow extension is initiated on day 3. However, passive extension and flexion are both allowed. Further periodic in patient wound inspections are done on a case to case basis and patients are discharged when early wound healing is found satisfactory. All patients are permitted active use of the hand and are instructed not to lift (or push or pull) anything heavier than a glass of water or a telephone receiver for the first 6 weeks. External protection, such as a removable above elbow POP splint or brace, is used by all patients in an intermittently removable fashion for at least 6 weeks. Continuous active and passive range of motion (ROM) exercises are encouraged with an emphasis on minimum period of 3 hours of daily exercise. Patients are followed at monthly intervals till fracture union and three monthly thereafter. Postoperative radiographs are evaluated for fracture union, changes in hardware position, subchondral collapse and the development of heterotopic ossification.

Postoperative hematoma: Being an extensile approach, where the proximal 10 to 12 cm of the ulna with the olecranon process is denuded off the soft tissues, formation of postoperative hematoma is likely as this region is highly vascular.¹⁴ Hence, after the tourniquet is removed and before final closure, meticulous hemostasis is essential to decrease its incidence.

Delayed wound healing and/or superficial skin necrosis around the tip of the olecranon: Even though thick fasciocutaneous flaps are elevated on either sides, one may still encounter superficial skin necrosis around the tip of the olecranon. One of the reasons for this is that while reattaching the triceps, four to five knots of the ethibond suture are directly placed over the olecranon tip. If not buried into the substance of the triceps muscle, these knots may continue to irritate this area during early elbow rehabilitation which may then present as superficial skin necrosis or delayed wound healing around the tip of the olecranon. This has been reported by O'Driscoll and also by the current author (PM) in previously reported series.^11,14 Secondly, most of these fractures are high energy and the skin area around the tip of the olecranon is the one that bears the brunt of the impact when one falls over the point of the elbow. Hence its blood supply due to the impact of the injury is already precarious. Skin incision and surgical dissection around 82the tip of the olecranon could be another reason for this complication. Hence, extensive dissection around the tip of the olecranon should be avoided in all the posterior approaches to the elbow.

Triceps detachment: TRAP approach requires familiarity with the anatomy and it may not be obvious to those who have not seen the approach being performed.^11,12,14 Most importantly, the technical details of tendon reattachment need to be understood well and should be observed which being performed. We strongly feel that attention to the details of the technique of triceps reattachment is absolutely essential so that unhindered postoperative elbow rehabilitation can be followed. Insecure attachment of the triceps and give way of the sutures during aggressive elbow mobilization could lead to of tendon detachment.

Triceps weakness: TRAP approach may be associated with triceps weakness which has been frequently noted even with olecranon osteotomy and other posterior approaches like triceps splitting/reflecting. McKee et al in their study concluded that patients who have this injury can be advised that they will lose approximately 25% of extension strength, regardless of the type of posterior approach (olecranon osteotomy or triceps splitting) used for operative repair.⁵ It has been our observation that wound related complications in the region of triceps insertion at the olecranon tip may lead to a clinically significant triceps weakness.¹⁴

Heterotopic ossification (HO): Using TRAP approach, O'Driscoll reported an incidence of 38% (12/32 cases) of HO in his series where excision was required in 5 cases.⁴ Although various authors also have reported this complication following TRAP and other posterior elbow approaches and it is difficult to say whether TRAP approach has increased association with HO.

Hardware breakage: During provisional fixation of the fracture geometry with K-wires is performed, care has to be taken that the wires are placed in a subchondral location rather in the center of the condylar fragments thereby leaving the path and space for future placement of screws through the plate from one column into the intercondylar region. Moreover, when drilling through the distal fragment, drill bit is prone to damage or breakage after striking a screw or screws placed previously. If such a resistance is encountered, the drill should be withdrawn, the path should be changed slightly and a 2 mm K-wire may be used instead for drilling the path for the screw.

Avascular necrosis of the lateral humeral condyle (Figs 7.6A to C). The lateral column is perfused by segmental posterior condylar perforating vessels, which may be stripped away with extensive subperiosteal elevation. Hence at the lateral column extensive subperiosteal dissection should be avoided for plate placement. In all circumstances, the soft tissues should be retained on the articular fragments.

There is paucity of literature on the results of operative fixation of distal humeral fractures utilizing TRAP approach and have been summarized in the Table 7.2.83

Summary of results of some of the studies on fixation of distal humerus using the technique of parallel plating is shown in Table 7.3.84

A 35-year-old male sustained injury to his left elbow due to a road traffic accident. Radiographs revealed AO type C 3 fracture of the distal humerus (Fig. 7.7A). Patient was operated three weeks after injury due to pulmonary complications.

85Internal fixation with parallel plating through TRAP approach was done. Radiographs at one year follow-up showed sound anatomical union (Fig. 7.7B).

A 22-year-old male sustained a low AO type C3 intra-articular fracture of the left distal humerus following a fall (Fig. 7.8A) parallel plating through. TRAP approach was performed. Follow-up radiographs at 2 years showed sound radiological union (Fig. 7.8B). Patient has excellent range of motion and function (Fig. 7.8C).

TRAP approach allows adequate fracture visualization and stable fracture fixation even in comminuted AO type C3 fracture of the distal humerus, with the advantage of intact olecranon that does serve as a template around which critical intra-articular fracture reduction is contoured. The approach permits aggressive postoperative elbow rehabilitation without elbow instability. However, wound related complications and residual triceps weakness may be of concern in some cases. Accurate and strong reattachment of the reflected extensor mechanism is absolutely critical for postoperative elbow rehabilitation and a good functional outcome.

Coronal shear injuries of the distal humeral articular surface are uncommon injuries.¹ The apparently ‘isolated’ capitellar shear pattern is extremely rare.² With newer imaging tools the true ‘complex’ nature of these injuries is now better recognized. The spectrum varies from the classical isolated capitellum shear fracture to the more complex pattern involving the entire anterior distal humeral articular surface with elbow dislocation and radial head fracture. Most of the patients are young and surprisingly, sometimes the injury follows trivial trauma such as simple fall on the outstretched hand.

However, underestimating the injury can lead to inadequate reduction and fixation. CT scan with 3D reconstruction is invaluable in preoperative planning and prognostication³ (Fig. 8.2). The classification offered by Dubberley et al (Fig. 8.3) is prognostic and also helps in guiding the optimum operative intervention.³

Being an intra-articular injury with fragment displacement the only viable option is an anatomic reduction, rigid fixation and early mobilization. Anatomical reduction necessitates an adequate exposure. The CT scan with 3D reconstruction helps in understanding the true personality of the injury^4,5 (Figs 8.4A to C). Digital subtraction of the proximal ulna and radius has been recommended for better injury appreciation.² No single surgical approach is endorsed. Lower grades of injury can be managed well by a lateral approach, with or without epicondylar osteotomy. In higher grades with increasing trochlear involvement and posterior comminution, the olecranon osteotomy provides ample exposure.

The choice of regional or general anesthesia is decided by the patient. The patient is in the supine position with shoulder abducted to 90 degrees and elbow extended. A high arm tourniquet is optional. A lateral skin incision centered on the epicondyle from 6 cm proximal and 3 cm distal to the joint line is made. The proximal dissection is between the Brachioradialis and Triceps and distally between the Extensor Carpi Ulnaris and Anconeous. Greater access to the joint is provided by an epicondylar osteotomy (Figs 8.5A and B). With the elbow flexed, placing the retractors anteriorly under the capsule is facilitated.92

After joint lavage, the articular fragment and its bed are examined. Impaction and comminution is carefully analyzed to prevent malreduction. Reduction is facilitated by identifying the intact wall of the fracture bed and placing the capitellum against it. This is held provisionally with two or three 1 mm K-wires placed peripherally (Fig. 8.6A). The key is maintaining articular congruency. Definitive fixation is achieved with at least two headless compression screws. The screws are placed divergent and adjacent to the highest point of the dome of the capitellum. The range of movement is verified after removing the wires. The osteotomy is repaired by tension banding (Fig. 8.6B). Joint stability is tested. After skin closure the limb is splinted in an above elbow slab to allow for soft tissue healing. Check radiographs are obtained immediate postoperatively and during follow-up (Fig. 8.7)

The patient is placed lateral or prone after general anesthesia. A high arm tourniquet is applied. A longitudinal skin incision in the midline curving ulnar to the olecranon is made. After isolating the ulnar nerve and tagging it, a chevron osteotomy is made after predrilling the proximal ulna with a 3.2 mm drill bit. The olecranon is reflected proximally and the joint opened. The jigsaw is best fixed from the larger to smaller fragments using 1 mm K wires to temporize the reduction. After ascertaining anatomical reduction, definitive fixation is accomplished with small screws. Metaphyseal comminution necessitates further protection of the construct by buttress plating the lateral column.

The limb is rested in a posterior back slab till edema settles down. Active assisted shoulder and active wrist/finger mobilization is begun in the immediate postoperative period. Intermittent elbow mobilization with rest in splint is begun after a week. Stretching is initiated after 6 weeks and exercises against resistance at 12 weeks. The splint is discarded when the patient regains good voluntary control. It is important to reiterate the virtue of persistence and patience. Function that appears to stagnate despite effort surprisingly begins to improve with time.

The elbow is extremely sensitive to injury and intolerant to immobilization. Stiffness is the most common complication reported and the risk is greater in the higher grades.^1,3,4 This partially offsets the concerns of instability. Hardware concerns linger especially with the olecranon osteotomy approach. Heterotopic ossification remains a risk though rarely reported.¹

The isolated coronal fracture of the capitellum is very rare.^1,2 Experience is limited in managing these uncommon but challenging injuries. Vast majority of such injuries also involve the trochlea and/or posterior aspect of the distal humerus.² These are complex injuries with significant osseous and ligamentous disruption. 3D CT scans are invaluable 94in estimating the injury personality.² Retrospective studies report a generally favourable outcome following ORIF. However, loss of terminal extension is commonly observed. As fracture area increases, prognosis worsens. Nonunion and avascular necrosis is rarely reported. Although stiffness is common, motion and function gained is reasonably enduring.¹

A 30-year-old male sustained injury to his left elbow after fall from motorcycle and sustained Dubberley 3B injury (Fig. 8.8).

CT scan with 3D reconstruction revealed separate capitellar and trochlear fragments (Fig. 8.9). The fractures were fixed with an olecranon osteotomy approach (Fig. 8.10). Postoperative radiographs showed satisfactory reconstruction (Fig. 8.11). Follow-up at one-year revealed consolidation on radiographs (Figs 8.12A and B) and excellent functional outcome (Figs 8.13A and B).96

Coronal plane fractures of the distal humerus are uncommon injuries with most of them reported on the capitellar side.¹ Also known as the Laugier's fracture, the trochlea is devoid of any muscle or ligament attachment. Well protected in the olecranon, it is very uncommon to have isolated shear injuries of the trochlea. The history is similar to any other upper limb injury mechanism—a fall on the outstretched hand. The radiographs should be of high quality and examined carefully. The lateral view as shown in Figure 9.1 shows the double crescent sign. Whether the crescent has risen from the medial or lateral column is impossible to appreciate. The AP view as shown in Figure 9.2 may suggest a hint but the images are sometimes difficult to obtain as the elbow is in flexion following pain and spasm. The relevance of traditional clinical examination is underscored in this context. On inspection the bruise on the medial aspect and medial tenderness suggest pathology on the wrong side of the elbow (Fig. 9.3).

The threshold to obtain a CT scan should be very low in intra-articular injuries. It delineates the true pathoanatomy of the injury and also helps in preoperative planning (Figs 9.4 and 9.5). Osteochondral fragmentation is readily identified. The injury is usually more extensive than suggested by the radiographs. The importance of post-surgery rehabilitation should be emphasized as the elbow joint is intolerant to injury, surgery and immobility. Being an intra-articular injury with fragment displacement the only viable option is an anatomic reduction, rigid fixation and early mobilization.

Depending upon the fragment size, a minimum of two screws is necessary to provide the desired stability to allow early mobilization. The elbow is moved through full range of movement to check for any block. The tourniquet is deflated and hemostasis secured. The capsule is closed with 3‘0’ Vicryl^TM. The common extensor origin is anchored to the medial epicondyle either through drill holes or suture anchors. The skin is approximated with 3‘0’ nylon and an above elbow splint applied in about 80 degrees of flexion and neutral forearm position.

Active use of the hand is encouraged immediately after surgery with assisted shoulder mobilisation. Intermittent active elbow movements are commenced within 3-5 days with rest in the splint in between. As active control improves, the splint can be dispensed. The patient is encouraged to use the affected upper limb for activities of daily living like brushing, buttoning, combing of hair. Elbow stiffness is resilient but compliant to persistence. It is important to reassure the patient to persevere with exercises. Serial radiographs are obtained to assess the status of the fixation. Union is difficult to appreciate directly. Absence of symptoms with improving range of movement indirectly suggests satisfactory progress to union. Functional arc is gained earlier if the dominant extremity is involved. Terminal loss of extension is obvious and more disabling than a similar flexion loss. Low load long duration exercises may help in restoration of extension (Fig. 9.7).

Elbow contracture is the most common problem.¹ The injury is unusual and it is difficult to gauge the actual extent of damage. Atraumatic rigid fixation and early active mobilization is the key in realising a satisfactory outcome. Osteonecrosis is a possible concern as the fragment is devoid of any soft tissue attachment. It is imperative to provide compression across the fracture to enable primary bone union.

A 23-year-old air hostess sustained injury to her non dominant following a fall while learning to ski. She presented in the outpatient clinic three days later with her elbow in 101an above elbow splint, an X-ray film and a diagnosis of fracture capitellum.

A diagnosis of trochlear fracture was made (Figs 9.8A and B). The fracture was reduced through medial orthrotomy and fixed with two headless compression screws (Fig. 9.9). The patient had good function at 2 year follow-up barring loss of terminal extension of the left elbow (Fig. 9.10).102

Coronal shear fractures of the distal end of the humerus are uncommon injuries often underestimated on the radiograph.¹ The isolated shear fracture of the trochlea is extremely rare. Very few cases have been reported in English literature.^2-4 CT scan helps understand the pathoanatomy better. Small headless screws enable rigid fixation of the fragment where possible. A good outcome is achievable if the basic tenets of intra articular fracture managements are adhered to.

Coronoid fractures usually occur as a part of unstable elbow dislocations¹; however these can occur in isolation as Brachialis avulsion injury.² Traditionally, large coronoid fracture fragments and the small fragments causing instability require fixation and the small fragments causing no instability are managed conservatively. With increasing understanding of the contribution of the coronoid to stability of the elbow, the trend is increasingly towards operative stabilization of these injuries and initiation of early, protected range-of-motion program to avoid stiffness at elbow. Since it is a part of complex bony and soft tissue injury, the management of these injuries requires a complete diagnosis as to whether the coronoid fracture is an isolated injury or is a part of a complex injury which requires management of bony as well as soft tissue structures.

The elbow is an inherently stable joint consisting of articulations between the humerus, ulna and radius; that has both rotational and hinge motion. The trochlea of the humerus articulates with the trochlear notch of the proximal ulna to form the hinge while the radial head articulates with the capitellum and the radial notch of the ulna to create a joint for rotational motion. The distal humerus has coronoid fossa anteriorly that accommodates the coronoid process during extreme flexion (Fig. 10.1) while posteriorly there is olecranon fossa that accommodates the olecranon process during the extreme extension. The coronoid process provides structural stability to elbow joint against posterior displacement by acting as an anterior buttress³ (Fig. 10.1). Approximately 50% of the elbow stability comes from the congruent bony articulation between the trochlea of humerus and coronoid facet of ulna.⁴

Coronoid fractures account for about 1 to 2% of all elbow fractures and are associated in 2 to 15% of patients with dislocation.^6-8 They also occur as a part of a complex injury, 104known as ‘terrible triad of the elbow’^9-11 that constitutes of elbow dislocation, radial head fracture, and coronoid process fracture.

105In children, coronoid fractures have a bimodal age distribution, with peaks at age 8 to 9 years and at age 12 to 14 years.¹² Coronoid fractures in children are often associated with elbow dislocations, olecranon fractures, medial epicondyle fractures, or lateral condyle fractures.

Fracture of coronoid process take place usually as a part of elbow dislocation which commonly is caused by a fall on the elbow or outstretched hand.^10,13-15 The injury can take place during motor vehicle accidents, sports injuries, activities of daily living or even at work.^13,15 It is a high energy injury associated with severe soft tissue damage.¹⁶

This injury may present as an isolated injury or more commonly as a part of elbow dislocation. The patient usually has history of fall on outstretched hand with hyperextension and twisting forces at the elbow. There is pain, tenderness, and swelling around the elbow.

When there is an isolated coronoid fracture and sometimes after spontaneous relocation of associated elbow dislocation, these clinical signs are not present.^6,23 Varus or valgus stress tests and range of motion may demonstrate pain and instability.^2,6

Radiographs of the elbow in the anteroposterior (AP), lateral, and, if required, oblique views should be obtained to ascertain clearly the extent of bony injury. Oblique views are especially important in minimally displaced fractures, because in a true lateral view of the elbow, the radial head overlaps the coronoid, thus coronoid fractures may be confused with radial head fractures.^24,25 To avoid this problem, Greenspan and Norman described the radiocapitellar view (Figs 10.6 and 10.7).^26,27 This separates the radial head from the coronoid and provides clear visualization of coronoid, radial head, capitello-radial and trochleo-ulnar joints. Sometimes plain radiographs are unable to completely demonstrate the extent of associated injuries and CT scan or MRI is useful.

Regan and Morrey classified coronoid fractures into 3 types:⁸

O'Driscoll described a new classification system as follows:²⁸

Aim of surgery for any injury around elbow should be to achieve stability and start early range of motion exercise. Being an articular fracture, congruent reduction at the time of surgery should be ensured. Role of coronoid as important stabilizer of elbow has been shown in recent studies.^10,28,29 The injuries which pose difficulty in management are the terrible triad, varus-posteromedial injury, and olecranon fracture-dislocations with associated coronoid fractures.²⁸ In all these injuries management of coronoid fracture is critical for elbow stability.

Coronoid is usually fixed through a posteromedial approach in a lateral position (Figs 10.9 and 10.10) preferably under general anesthesia.

The coronoid can be approached posteromedially through a posterior midline incision after lifting the ulnar origin of the extensor carpi ulnaris (ECU) subperiosteally.

Anatomical reduction of a large coronoid process fracture is important for elbow joint stability and congruity. This is particularly true, when the coronoid fracture is part of a comminuted olecranon fracture. Reduction may be visualized through the medially extended posterior incision, through the olecranon fracture site (Fig. 10.12). Alignment must be checked with satisfactory X-rays or image intensifier.

After exposing the fracture site and cleaning the edges, the fragment is anatomically reduced. The fracture is stabilized initially with a large clamp or by Kirschner wire (K-wire) fixation. Definitive fixation can then be achieved with a small plate or with screws. Precontoured coronoid plates are now available .The primary role of the plate is to provide a buttress against posterior subluxation of the ulna in relation to the humerus (i.e. push plate). Coronoid may also befixed by means of an interfragmentary screw (from posterior to anterior, or from anterior to posterior if the fragment is small or osteoporotic) (Fig. 10.13).

After the surgery, the elbow is immobilized at 90° of flexion in a well-padded posterior splint. The elbow is immobilized for about a week, and then the protected immobilization program should be substituted with protected mobilization program in a hinged orthosis is initiated, which prevents varus-valgus stresses on the elbow. Brace use is continued for approximately 4 to 6 weeks to allow the ligaments to heal.

Osteoarthritis, myositis ossificans, parasthesia, stiffness and instability are the most common complications associated with coronoid fractures.

Results of isolated coronoid fracture are not reported in many studies. As these fractures have been associated with elbow dislocation; the complications of elbow dislocation overshadow the results of coronoid fixation. Loss of range of motion is the most common complication that develops because of prolonged immobilization. Stable internal fixation of the coronoid which is difficult to achieve may lower this complication in future. Job N Doornberg et al reported a series of 18 patients with 26 months follow-up; twelve patients who were operated and fixation was done with a plate had good or excellent elbow function; six patients had development of arthrosis and a fair or poor result according to the system of Broberg and Morrey. Malalignment of the anteromedial facet of the coronoid with varus subluxation of the elbow, which was due to the fact that the fracture were not specifically treated in four patients and to loss of fracture fixation in two patients.²¹ Loss of terminal extension is very common but the patients are not very symptomatic as the functional range of motion of elbow ranges 30 to 130 degree. Complex elbow instability is another main reason for the poor outcome of the coronoid fratures.³⁹ O'Driscoll type I fractures are associated with terrible triad injuries; type II fractures are associated with VPMRI injury patterns; and type III fractures are associated with olecranon fracture dislocations.¹⁹ It is difficult to predict the outcome of coronoid fracture alone. Long-term results of radial replacement or repair in terrible triad are not available but short-term results favor a good outcome with replacement or repair of the radial head.⁴⁰ Osteoarthritis of elbow and heterotopic ossification are another complications which may appear more severe in X-rays than clinically.

A 38-year-old man presented with radial head fracture with communited olecranon fracture extending into the coronoid with a communited radial head fracture. He was operated via a posterior approach in lateral position. Open reduction was done with a reconstruction plate with a posteroanterior screw into coronoid through the plate along with radial head replacement. His pre- and postoperative X-rays are shown in Figure 10.15. At the end of 3 months he had an excellent range of motion of elbow and a satisfactory outcome.

Management of Coronoid fractures usually depends on the size of the coronoid and other complex injury patterns of the elbow which has to be dealt simultaneously with as much vigour. Different surgical techniques has been described for its fixation; The aim of all the methods remain the same which is provide stable internal fixation so that early range of motion can be started. Literature favors a lag screw technique with or without a volar buttress plate.

Fractures of the olecranon affect the articular surface of the humeroulnar joint. Thus, the aim of treatment is to restore function of the humeroulnar joint. To achieve that aim, several treatment goals must be attained:

There is no universally accepted classification system. AO groups offers a comprehensive classification system. However, Mayo classification,¹ which classifies these fractures based on stability, displacement and comminution is commonly used. Type I fractures are undisplaced, Type II fractures are displaced and stable (fragments displaced > 3 mm but collateral ligaments intact and forearm is stable in relation to elbow) and Type III fractures are displaced and unstable (displaced fracture fragments, forearm is unstable in relation to the humerus. This is a fracture-dislocation). Each is divided into subtype A (noncomminuted) or B (comminuted).

For simple transverse mid-olecranon fractures as shown in Figures 11.1A to C, the tension band wiring technique offers a simple, cheap and effective fixation.

Olecranon fractures that appear to be simple transverse often come with an inconspicuous intra-articular depressed fragment. These are often not well shown in the injury film unless the olecranon is oriented for true lateral projection. At other times, the depressed fragment is inconspicuous but would not escape the careful scrutiny of an experienced surgeon. Several examples are shown in Figures 11.6 to 11.8. Thus, it is highly recommended that all olecranon fractures should be carefully screened with the C-arm before the patient is positioned lateral.

Simple tension band wiring is not stable enough in these situations. Various anatomic olecranon plates are recently introduced.³ However, they all share one major drawback– they are too thick and bulky for the olecranon which is usually a subcutaneous bony prominence. The author is in favor of using simple one-third tubular plates for this purpose.² The most distal hole in a seven-hole one third tubular plate is cut. The cut ends are then bent into hooks. The end of the plate is slightly contoured to fit the olecranon tip. The hooks are gently tapped to purchase the periosteal soft tissues at the olecranon tip. The distal end of the plate is fixed with cortical screws placed eccentric to generate some compression to enhance stability. The hook plate is further protected with a Figure-of-eight tension band wire loop² (Figs 11.10A to F).

123In comminuted fractures, the fragments must be stabilized and maintained in congruent shape against the trochlea.

Fractures belonging to Mayo Clinic Classification Type III^1,4 constitute around 5% of all olecranon fractures. These are fractures associated instability of the elbow joint. Most of them will remain unstable, and elbow function becomes severely jeopardized, if the olecranon fracture alone was stabilized (Figs 11.15A to D).^3,5,7

Complications of the olecranon fractures are related to the fracture and accompanying trauma, the choice of implant, and surgical technique. The most common complications are related to hardware, namely migration of K-wires, irritating of skin by wires, breakage of circlage wires etc. Most patients will require removal of hardware once the fracture has healed. Loss of movements especially terminal extension, loss of reduction 126and the gap at fracture site, heterotopic ossification, ulnar nerve paraesthesia, non- union and secondary osteoarthritis may occur.

The results of the treatment of uncomplicated olecranon fractures are quite good, with union rate of over 95%. However, long-term follow-up following olecranon fracture shows degenerative changes in more than 50% of cases. Rommens et al¹⁰ evaluated functional results after operative treatment of olecranon fractures. Patients with an unstable elbow (Mayo type III) had a higher loss of elbow function than others. There was correlation between fracture morphology as well as suboptimal osteosynthesis, and, arthrosis. Patients more often had subjective complaint and loss of function in activities of daily-living before hardware removal than after. Authors concluded that primary elbow instability and fracture morphology are prognostic factors for elbow function and development of arthrosis after operative treatment of elbow fractures. Hardware removal after fracture healing was recommended in all cases in view of frequent patient complaints related to the implants.

Olecranon fractures are intra-articular fractures involving a highly mobile joint. Good recovery of upper limb function can only be achieved if articular congruity is restored, and the elbow is allowed mobilization while the fracture healing takes place. Anatomic reduction and stable internal fixation are mandatory. The initial films often fail to reveal the full complexity. Careful scrutiny of fracture with fluoroscopy is an important prerequisite towards appropriate choice and execution of fixation. Stable and undisplaced fractures can be treated nonoperatively while the excision of the olecranon fragment(s) should be reserved for those cases when anatomic restoration cannot be achieved with internal fixation.

A 19-year-old motorcyclist had MVA with multiple injuries including the compound fracture-dislocation of the left elbow (Fig. 11.16A). Examination under anesthesia revealed gross comminution of the olecranon and unstable elbow joint (Figs 11.16B and C). Patient had debridement and suturing of 1 cm size laceration on the elbow and hinged external fixator was applied (Fig. 11.16D). Five days later, double plating Figure- of-eight with wire loop was done while retaining the fixator (Figs 11.16E and F). Fixator was removed at 6 weeks. X-rays taken at 6 month showed satisfactory reconstruction. The elbow range of movements achieved was 40 to 140 degrees.127

The radial head is a very important structure responsible for elbow stability. It plays a vital role in valgus as well as longitudinal stability of elbow.^1-5 This contribution becomes more important if associated with other injuries around elbow like elbow dislocation or other fracture combinations around elbow. Fall on the outstretched hand with elbow in extension and forearm in pronation is the most common mechanism leading to radial head fractures. Radial head fractures constitute 4% of all fractures and around 30% of all elbow fractures.⁶

Mason⁷ classified radial head fractures into 3 types (Figs 12.1A to D):

While conservative management is universally accepted to be the best for Type I fractures, Type III fractures especially in older individuals or if having more than 3 fragments are best managed by radial head arthroplasty. Type II fractures are usually managed with open reduction and internal fixation. Usually mini-fragment screws are enough for isolated radial head fractures, but a plate may be necessary if associated with radial neck fracture.130

The patient is placed in supine position with tourniquet control of upper extremity. The elbow and forearm is kept on a side-table. We prefer general anesthesia, however, a regional anesthesia can also be used.

A standard Kocher lateral approach is used starting from lateral epicondyle to a point over posterior border of ulna, around 6 to 7 cm below olecranon (Fig. 12.3). After cutting the deep fascia, the space between anconeus and extensor carpi ulnaris is identified (Fig. 12.4). It is easier to identify the plane distally as both muscle share a common aponeurosis proximally. A lateral collateral ligament is identified (Fig. 12.5) and a longitudinal incision is made in its anterior aspect. The annular ligament and capsule are cut in the same line. It is important to keep the forearm pronated to avoid injury to the posterior interosseous nerve. It is also important to dissect carefully if one needs to expose around radial neck or below.131

Usually cutting the capsule leads to drainage of fracture hematoma. All loose small fragments not amenable to fixation are discarded. Attempt is made to preserve all soft tissue attachments. All fracture fragments are identified (Fig. 12.6) with the help of forearm supination and pronation. Areas of impaction are also identified. These impacted areas, if any should be elevated carefully (Fig. 12.7).

All fracture fragments are reduced anatomically and fixed provisionally with K-wires (Fig. 12.8). One should be careful with their retractors as posterior interosseous nerve run very close to bone specially just opposite to bicipital tuberosity (Fig. 12.9).

In case of more than two fragments, this K-wire fixation may be staged fixing one fragment first, followed by reduction and fixation of another fragment. Sometimes one may have to reconstruct the radial head on table if big loose fragments are present. In case of any bony defect (Fig. 12.9), bone graft from tip of olecranon or bone substitutes may be used to fill the gap (Fig. 12.10).

There is a 110-degree arc zone on the posterolateral aspect of the radial head, which does not enjoy contact with ulnar notch during forearm rotation. This area provides a safe zone for placement of hardware whether screws or plate as it does not cause any 134proximal radio-ulnar impingement.⁶