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- Distal Humerus physeal separation
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- Tenuous blood supply from posterior!!
- Intra-articular - Bathed in synovial fluid
- Constant pull of common extensor muscles
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- Pull off = varus stress leading to avulsion of lateral condyle
- Push off = impaction of radial head onto lateral condyle
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- Jakob - based on displacement
- Type 1 = Hinge = undisplaced
- 2 = Gap = displaced with extension into articular surface
- 3 = Flip = Completely displaced
- Milch - based on location
- Milch 1 = Through capitellum ossification centre (salter 4)
- 2 = through trochlea (SAlter 2)
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- Internal Oblique XR
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- < 2mm = Non op
- Based on Weiss et al. JPO 2009
- > 2mm = Fix
- Do I need to open? If reduction can be achieved closed, proceed with CRPP/ Screw fixation
- Assess reduction by checking 3 lines
- If cannot - may need to open and reduce under visualisation
- Direct lateral approach between BR and triceps; avoiding posterior dissection (blood supply from posteriorly)
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- "My goal of fixation is to attain reduction and stable fixation with minimal periosteal stripping especially posteriorly to preserve blood supply to the lateral condyle. "
- I will first attempt closed reduction ➔ if successful, proceed with pinning
- If not, Open reduction with a DIRECT LATERAL APPROACH (between BR and triceps)
- Taking care not to dissect posteriorly (Avoid posterior dissection as supply is mainly posterior according to cadaveric studies by Yamaguchi et al. 1997 JBJS ➔ reason why we do not want to elevate posteriorly)
- In my hands, my choice of fixation is that of Percutaneous Pinning though I am aware, one can also use screw fixation also with its advantages and disadvantages
- I will use 2mm wires, divergent with 2 cortices; possible putting one horizontal and one oblique pin
- I will choose not to bury pins, though I am aware this is controversial
- Not burying pins (+) = easy removal, (-) = risk of infection
- Burying pins (+) = lower infection risk, (-) = need another surgery
- Lester Chan et al. 2011 - no difference in infection rates, in exposed vs buried but exposed easier to remove - for 4 weeks only
- Benefits of bury?
- “However, it is likely that unburied wires might be more prone to pin site infection and a after deep infection.
- The duration of unburied fixation for reducing the probability of infection is about 4 weeks; however, a short duration of unburied fixation may provide inadequate time for secure union.
- Conversely, buried K-wires can be left in place until surgeons have explicit radiographic evidence of fracture union.
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5572000/
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- Inject directly through the triceps into the olecranon fossa.
- It is not possible to go laterally due to the joint being very narrow
Surgical_Technique_for_Closed_Reduction_and.11.pdf369.9KB
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- Ideally open because this is an intra-articular fracture that requires anatomic reduction
- However, Closed reduction can be attempted but to assess articular congruity, one can do an arthrogram
- If intact ➔ CRPP
- If involved ➔ ORIF under visualisation
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- Cannulated screws have advantage of compression across fracture site
- Stein et al. 2015 found higher rate of closed reduction, lower infection rate and earlier mobilisation with screw
- Pennock et al. 2015 JPO For type Jakob or Weiss Type 2 with intact cartilage, no difference in outcome but shorter op time and no open incision for CRPP.
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- Fish tail deformity
- Mild AVN of trochlea laterally resulting in deepening of groove between capitella and trochlea
- No functional impairment
- Lateral spurring from overgrowth
- Johanatan Pribaz et al. JPO 2012 73% have lateral spurring but does not affect ROM
- Valgus deformity from arrest or varus from overgrowth
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- SH Type 4 injury in a Milch type 1 lateral condyle fracture
- Because Resting zone of the physis is disrupted, high risk of growth arrest ➔ cubitus valgus