Well, good to be here as we near the end of the meeting. I would just comment, and I would challenge my friend Chai, that I think some of these bad radial head fractures that are displaced still can be fixed, and it's not, the head is not dead if it's out, it's different than the femoral head. So for young patients, I try to put them together, and I think they can do well, but I tell them it's a two-stage operation. I say, we're going to fix this, we're going to put the plate on, but then we have to take the plate out and release it, and 50% of the time I do that. So I spend a lot of time trying to fix a native radial head in a young patient. Okay, I'm going to talk about distal, distal humerus. There's my disclosure. So the elbow, Chai talked about it briefly, so the elbow, we finally are starting to understand the elbow joint. When I was a resident not that long ago, we didn't understand the elbow, right? We thought the coronoid didn't matter, the radial head didn't matter, but it does, right? So I look at the elbow as the humeral ulnar joint is critical. If you don't have your humeral ulnar joint, you're hosed, the elbow's gone. Radial capitellar joint, the radial head is more important than we thought. At times, it's expendable. I probably excise a radial head once every three years, so I either replace it or fix it. And don't forget about the PRUJ, the PRUJ is important. So now we're looking at the distal humerus. So when I look at the distal humerus, I think of the trochlea sits in the middle, and that's that hinge joint, the humeral ulnar joint. So that is critical. And the trochlea has to line up with the center of the coronoid, and the tip of the coronoid has to be centered in that trochlea. And sometimes it gets a little fuzzy with some translation, but you need that alignment. And that is really centered in the shaft of the humerus. The capitellum, which I just talked about nicely, the capitellum's all in the front. It's an anterior structure, right? So if you look at the back of the humerus, you don't see the capitellum because it hangs on the front. So it's good to think about that anatomy. And this is from one of Jesse's chapters. So we think of columns. And I think of a humeral shaft as a column that splits into two columns on the ulnar and radial aspect, medial and lateral aspect, and then it holds those two columns hold the joint surface. And this fossa in the middle really doesn't matter. Some people have a perforate fossa that's open. So you don't want any hardware in there, and that really is not critical for any healing. So when we look at the back, the door to the elbow, this humerus fractures through the back. So look at the columns, the medial column and your lateral column, and where do we put our plates? We'll talk about that. But the key is the lateral column comes all the way down because the capitellum sits in the front. So you have all this bony architecture to plate. Medial column comes around. Everybody's got different epicondyle. Some people have a huge epicondyle, and the question is how long do you have to make this plate? And the answer is as long as needed, right? So sometimes you can stop here, but it's your screw trajectory that matters, but sometimes you have to come all the way around and bend the plate, and there's some precontoured plates. So the distal articular surface of the humerus is complex, and David Ring and Sean O'Driscoll have written up the different facets, but basically the trochlea is anterior to posterior. The capitellum sits in the front, but you want to make it look like normal. So these classifications are helpful for research, but basically I look at this and I say, how common is it in the joint, and how common is it in the metaphyseal-diaphyseal junctions? I want to have to hang it on the humerus. How bad is it? So, and that tells me how much work I'm going to have to do. Now, you say, how are you going to get there, right? And it depends how bad the fracture is and how distal it is, but how are you going to get there? So if you look from, again, from the back, the triceps is in our way. So when I look at this, I say, what do we do with the ulnar nerve? And the first thing you do is you always find the ulnar nerve, protect it, and then at the end you can transpose it or not transpose it. I tend to transpose it all the time. There's data either way. But then what do we do with the triceps, right? The distal humerus is here and the triceps is sitting in the way, so there's different ways to get there. So I look at it in kind of broad strokes. Triceps attaches on the electron in the middle, right? So I can go medial and lateral and get to those columns, because I don't want to get to the middle of the distal humerus, except for the joint, so I can go medial lateral. That's a nice approach. If it's a supracondylar fracture, I'll show you a case. And I can extend that to an electron in the osteotomy if I need to, and it's not, it's just down the sequential path of that surgical procedure. So if I need to, I can just keep coming down, flip up the electron, and that's the best exposure to get to the distal humerus. Other tricks, other ways not to do an electron in osteotomy, and if you need to do it, is you can split the triceps, but the old standard split the triceps to the electron to get to the humerus is a terrible approach, you know, because you see the nerve in the middle. If you come up high, you can't trace the nerve, and you can't get very distal. So Mike McKee has taught us, you can peel that triceps off the electron, basically take it off, and then flex the elbow up and see pretty distal. You can't see as distal as a electron in osteotomy. Brian Moore is a medial, an ulnar-sided approach to peel off the triceps that I use for total elbows. Some people use it for fractures. So the goal is restore that articular surface and hang it on the distal humerus, protect the ulnar nerves. At the end, look at the ulnar nerve, and you know what I tell my trainees is, make sure the ulnar nerve's happy, and if it's laying on top of a plate, for me, it's not happy, so I move it, but make sure it's in a happy place. So where do we put these plates? People argue companies go back in way, but you need to be able to put the plates where they need to be. So this is an old case. So the medial column, pretty much we've sorted out that you put it on the medial side, because you can't go posterior, because you have to stop here. You can put a little plate here, but the trochlea gets in the way. But the lateral column, the lateral column, the options are posterior, lateral, posterior, all the way down. The advantage is you can get very distal, and the other option is what? Is lateral, lateral, where you can put your plate on the lateral side of the lateral column. Why would you do that? Some of the companies came out with it, some people espouse it. The advantage is that you can take your screws and bring them all the way across. So the advantage of the posterior lateral is you can get your plate distal, but your screws are going towards the capitellum. So you can't go very long, but the locking screws have helped us there. So think about orthogonal versus parallel plates, and there's biomechanical studies that show both are good, so that doesn't matter. But that being said, you need to be able to put the plates wherever they need to go. So at times I put three plates on. So this is the lateral lateral plate, and you can put your screws across. Now people hate this plate because it's on the lateral column, but sometimes you need to put it there, and then you take it off. So we'll do a couple cases. So simple case, extra articular supracolon, a 24-year-old. This is an older case of mine. So early on in your practice or training, you say, oh, that's a hard fracture. Then you realize it's not, because you've got a big block of bone here that you're going to hang off here. And all this comminution, we don't have to get it perfectly aligned, but we want to make the elbow look like an arm, right? You want to make the arm look like an arm. So look at the valgus of the other side. When you're done, make sure that you have the appropriate valgus, and then how do you get this? So what are we going to do with the triceps? Well, we can probably leave it on. So with this case and with all of the cases, but especially these cases, the positioning and your x-ray is critical, because if you're positioned well, you can get to it. If you're positioned wrong and you're draped and you're in the middle of it, it's a disaster. So this is what I do, and I bring the arm up even farther. This is a little like knee holder. I hang it off. So I want to look right at that elbow, especially with the bad distal articular fractures, distal uterine articular fractures, and have full access to it. So I make sure C-arm can come in, and I get a good image and make sure I have the elbow flexed at 90 degrees. So now I'm looking right at the posterior triceps. So big incision, triceps is there, and I go basically in the gutters, the medial side. So you find the ulnar nerve and bring the triceps over. So your ulnar nerve dissection dictates the medial side of the triceps. So that's kind of easy. And I tend to transpose that because, and again, you can do it either way, but if somebody's putting a drill over here, and hopefully it's not me that does it, you can wind up that nerve well. So if you have a trainee there, you can wind up the nerve. So I get it out of the way. And it's a little weird when you're upside down the first time. Find the flexor pronator, and you find anterior, and I just put it in that pocket, then it's there. So lateral plate is fairly straightforward, but distally you have to define this interval. So now when I'm coming here, there's no nerve down here, but I worry about triceps insertion. So I keep looking at this thing. Triceps is there, I'm not going to take it off. And I come down, and don't go too far. You can come down the column, but don't go in the front. You know, David Ring and I wrote up five patients where people peel too much, and you get instability. So if you go in the front, you can take the LCL off, or the MCL. So don't go in the front. Now you have to, up top, you have to say, where's the radial nerve? So if it's a standard fracture, you don't have to find the nerve, but a long plate like this, you can see it up top. So this is, again, an older case, not bad. You know, I'd probably try to pull this fragment, and I wouldn't peel it off. But older technique, this is a recom plate. I never use a recom plate by itself now. I use DC-type plates. The key is, the plate could come down farther, but my screw in the trochlea, this is a good screw. So get this screw in the trochlea. And if you're putting screws up here, say, oh, this is a column. I'll go bicondylar here, bicortical here. And then this plate should come down farther, right? So you know, luckily, reasonable reduction. You look at the lateral, and he healed. But so that distal humerus, that's a big block, is pretty easy. So now, is there any way we can turn the lights down so we can see these a little bit better? I don't know if anybody can hit the button back there. Thanks, Brian. So this is a different fracture. We're going to talk about distal humerus. So this is, you know, and again, the column to the shaft. So when does a distal humerus behave like a distal humerus, and when does a shaft behave like a shaft? So it extends up top, and then is there a split distally? So this is a distal third humerus fracture. So if you put one plate on it, where are you going to put it? If you put it in the front, you can't get that distal, right? So do you need two plates like a distal humerus? Well, it's a little more proximal. Maybe I can make it easier. So, approach. Now, this is another approach that you need to know, and if you get this approach down, it makes everything easier for these fractures. So this is the JBGS article. It's the Gerwin-Hodgkiss approach, and it's a great article, but they make it a little bit too complicated. So it's the lateral side of the triceps, so they're showing it from the lateral side, but I do this in a, you know, a lateral decubed position, so you're looking at the back of the arm, but you're coming on the lateral side of the triceps, that's it, and you find the radial nerve. And it's described to find the cutaneous branch, and I think that's overrated a little bit. I look for it, find it, but I don't spend a lot of time. If I can't find it, the thought is it goes right to the radial nerve. So I protect any cutaneous branches. Sometimes I find them, they don't go to the radial nerve, but find the radial nerve. Now this is nice. This approach, which is over here, gets you really the longest span of the humerus that you can get with anything. So you can get down all the way, even farther than this to the column, and you can get up to the neck. And you can get further up into the head from this approach. So if you just split it, no good. If you split it with the peel, it's a little better. So this is supine, I'm sorry, decubed, looking at it. So this is radial nerve, and this is this plate coming all the way down from the shaft down to the lateral column. So the good thing is you can extend this all the way up the top. So this case actually had, I put interphrags in here, oh this is good, and I saw a crack up here, so I just kept coming farther up with the plate. So this is very extensile, and this is where you want to put the plate far down. So this is a J-type plate, but you can use any plate for this. So this is a nice exposure for those distal humeral fractures that are shaft going distally. All right, so now the bad ones. When do we replace these? So this is an 84-year-old lady, and she has a bad distal humerus, and as Chai said, look at the patient. So she, the residents tell me from the year she's 84, I meet her, she drives. She drives, she has bridge club totally with it. So now, am I going to replace this? Maybe. But I'm ready. You have to have the distal humerus arthroplasty in the room. So comma-nuded. So I'm going to do this sequentially. So posterior, going out of either side, then decide if you're going to take the elecron off. Because if you're going to do a total elbow, you want to just, you can, and we'll show you this, take out the fragments and replace it. So now it's looking a little better, and again, it's hard to see for you guys, but, so I said let's fix this. So I pre-drilled my osteotomy. And so technique, make a chevron osteotomy, use the saw about two-thirds, then crack it, then flip it up, and you're looking right at everything. So I started to put this together, and it worked, right? So she's 84, but she had better bones, so this is a posterior lateral plate. Put the joint together. This is a pre-contoured medial plate, and it actually looked pretty well, and she was stable in the OR. So I think, you know, you don't by default do an arthroplasty. So she looked pretty good, and she healed, and her plate is a little prominent, but she's fine with it. She still has it four-and-a-half months, and this is her. This is her at about four-and-a-half months, and she's great, and she's driving home, and, you know, I don't, if I did an arthroplasty, I could get that range of motion, but if I can save the bone, I'll save the bone. Okay, so sometimes these are bad, right? So this is worse. This is a 71-year-old, and this is a different type of fracture, right? So you say, is this a distal humerus? It is, but it looks like that medial trochlea is intact, right? So am I going to do an electrodon osteotomy? Now I want to get to the front. So what is this? This is the classic, and again, Jesse taught us this, like he taught us so much. This is a coronal shear, so the fracture is cracked off the front, and this came in as a capitellar fracture. They said, oh, this lady has a capitellar fracture. I don't know if I've ever seen, I've seen, I think, one just capitellar fracture, because it always comes over to the trochlea. So this comes over to the medial side, and there's comminution. So this is hard. How do you get there? So difficult fracture to visualize. If you come from the back, you can't see it. If you take the electrodon off, some people say they can flex it up and fix it. I find that difficult. So how do you get there? I like to come from the lateral side, so a big lateral approach with kind of a posterior skin incision in case I have to swing over medially. So now what's over there, the LCL. So this is the lateral condyle, and I look in the front. So I look in the front, and I look at that capitellum, and I say, oh, I can't fix that. And then also problematic is the posterior column is comminuted. So now I look in the back. So this is kind of a Kaplan approach. This is the posterior triceps, and I can't figure it out. I mean, I can't put it together. So basically, I take the LCL off. And you can take it off with bone. A lot of times, there's a fracture. You can take that down, and then I book the whole thing open, and it's still hard, because there's a coronal split. There's sagittal splits. So now you're booking the whole thing open, and you can reduce everything and then close it down. The problem is, in supination, the radial head is out. And then if I pronate that, I tighten it up, and then I repair the LCL. And I actually went through the plate on this to repair it, and a reasonable result. So this, for me, Chai, this is the kitchen sink. I need the bioabsorbable pins, all the headless screws, the suture anchors. So sometimes you can't fix it, right? And I look at it. And it depends. If somebody's real sedentary, we'll replace it. But replacing, a total elbow replacement for dishumors is a great case. And that being said, I probably do one a year, because it's not indicated as much. So this is a little, a less demanding or active woman, rheumatoid, and I can't fix that. So we take that apart. And once you decide to do a total elbow, it's an easy case. So again, post-year approach, I look at the triceps, and what I do is look around the corner and say, can I fix it? Yes, no. And if I do, then I do the olecranon osteotomy. But when you did that, you kind of bought the farm, as they say. You can do a total elbow after, but it's a little tricky. So once, if you decide to fix it, easy. You leave the triceps on the olecranon, and you kind of sneak on both sides and just take out the fragments. And then you can put your elbow in, and then roll your olecranon out and put your ulnar component in, and then engage them. And now your tricep sleeve is intact. And they do well. This is, I think, an arthritic case. But people do well because it's stable, it's cemented, the triceps is intact, and you can move them right away. So for those bad ones, good result. And Mike McKee has a randomized study that show they do a little better, but I think you have to pick the right patient. And with some of the new plating technology, we're doing less arthroplasty. So different case. Fracture dislocation. What's going on here? I don't know, really. So they showed me this. I was in the OR, and somehow my resident reduced this. I don't know how. But it looks pretty good. So we probably could wait, but I still can't tell what's going on. I have a CT scan. I don't have it here. But basically, capitella fracture, dislocation, highly unstable, and it's a problem, right? So what am I going to do? Kitchen sink again. Go to the OR. I want to fix all these little fragments. Unstable. So I have an X-Fix ready. I put this patient supine, and I use it on the hand table and go lateral, medial. So just a different technique. So once I look at this, and the capitella was just shattered, I didn't think I could fix it, but we did. And I knew it was unstable, and I was going to have to do the X-Fix. I put the X-Fix pins in first. Put the X-Fix pins in. Close those wounds. Then fix it. Then I can lock my X-Fix. Because I don't want to fix all these little fragments that I have to put X-Fix pins in. So do that first. Still unstable. And this is the lateral column, and this is the capitellum. And it's basically knocked off. And this is a big piece that has the LCL on it. So I just flipped that piece down and could look in. And for me, this is a really small headless screw. So kind of like threaded K-Wires, which are good, I use, now they're small headless screws. 1-5, 1-7. So these are very small headless screws that I'm putting in. And I actually could put this capitellum together, reduce it, static X-Fix. And again, we used to do a lot of hinges, but we find that it's hard to do, and people do reasonably well with the release or motion. So keep him concentrically reduced. I took the X-Fix off in the OR and did a gentleman up, and I actually released him. So he got good motion and did pretty well. So concepts. All right. So now, arthroplasty. So do you have to do a total elbow? If it's dusted and it's the distal humerus, do we have to do both sides? In the States, we kind of have to, because it's not FDA approved. But once in a while, you can get an indication. But can we replace just the distal humerus? Now these are cases from Graham King in Canada where you can get the implant. So it makes sense to do a HEMI. So bad distal humerus, HEMI arthroplasty. The question is, what is the implant that you can use? It's hard to get, right? There used to be the Ewald that worked pretty well. That's off the market. And this is one of the other companies, and they have a component that's just for the distal humerus that's available in Canada and Europe. But here we'd have to use the HEMI part of the total, so it doesn't work as well. But it's still appealing. I just want to show you this case. So again, preserve your triceps. Sometimes you can split it and repair it. This, you can't fix this. And it looks pretty good, right? This is Graham's case. Nice alignment. The radial head's a little high, but that's okay. The humerolin joint is fine. And it's like anything else with metal on cartilage. Radial heads, HEMI arthroplasty in the hip, it's not going to last forever. But he's got a four-year follow-up, and they're doing pretty well. So I think in the right patient, this makes sense. And then the question is always, what can you let them do, right? Total elbow, they can't play much, you know, sporting activities. They can't lift much. With this, maybe a little bit more, but we haven't sorted that out. So in conclusion, these are bad elbow fractures. And I think they're bad elbow fractures, but at least we can get to them. So with the right approach, you're looking right at the fracture. And I think, you know, make sure you have enough time, you have the good team, you have good CRM, you have the right implants, and usually you can get a pretty good result, right? You get a good look at it. You want to line that joint up. And as long as the joint is on the distal humerus in a reasonable, you know, a reasonable fashion, it can actually be shortened a little bit. That's okay. Some of these pre-contoured plates and small screws are helpful, but when indicated, arthroplasty works very well. Thanks very much.

complex elbow fractures

treatment options

surgical procedures

plates and screws

total elbow replacements

surgical management