Distal Humerus Fractures - Trauma (2024)

• accounts for 2% of all fractures

• accounts for 30% of elbow fractures

• incidence has been steadily increasing

• most common in young males and older females

• distal intercondylar fractures are the most common fracture pattern

• distal humerus fractures are traumatic injuries that include

  • supracondylar fractures

  • single column (condyle) fractures

  • bicolumnar fractures

  • coronal shear fractures

• mechanism

  • low energy falls in elderly

  • high energy impact in younger population

• pathoanatomy

  • elbow position affects fracture type

    • elbow flexed < 90°

      • axial load leads to transcolumnar fracture

      • direct posterior blow leads to olecranon fracture with or without distal humerus involvement

    • elbow flexed > 90°

      • may lead to intercondylar fracture

• elbow dislocation

• terrible triad injury

• floating elbow

• Volkmann contracture

  • results from missed forearm compartment syndrome

• elbow is a hinged joint

• articular surface is in

  • 6 degrees of valgus

  • 5 degrees of external rotation

  • 30 degrees of flexion

• trochlea

  • articulates with sigmoid notch

  • allows for flexion and extension

• capitellum

  • articulates with proximal radius

  • allows for forearm rotation

• common flexors (originate from medial epicondyle)

  • pronator teres

  • flexor carpi radialis

  • palmaris longus

  • FDS

  • FCU

    See Also

    Fractures of the Distal HumerusDistal Humerus Fractures of the Elbow - OrthoInfo - AAOST-Intercondylar Distal Humerus FractureDistal Humeral fractures

• common extensors (originate from lateral epicondyle)

  • anconeus

  • ECRL

  • ECRB

  • extensor digitorum comminus

  • EDM

  • ECU

• medial collateral ligament

  • anterior bundle originates from distal medial epicondyle

  • inserts on sublime tubercle

  • primary restraint to valgus stress at the elbow from 30-120°

  • tight in pronation

• lateral collateral ligament

  • originates from distal lateral epicondyle

  • inserts on crista supinatorus

  • stabilizer against posterolateral rotational instability

  • tight in supination

• ulnar nerve

  • resides in the cubital tunnel in a subcutaneous position posterior to the medial condyle

• radial nerve

  • anatomic landmarks

    • in the spiral groove 15cm proximal to distal humeral articular surface

    • 10cm from the medial edge of the olecranon

    • 7.5cm from the lateral edge of the olecranon

    • 3.9 cm (two finger-breadths) proximal to the triceps aponeurosis
      

  • runs between brachioradialis and brachialis proximal to elbow

  • posterior antebrachial cutaneous nerve (PABCN) branches in the posterior arm

  • divides into PIN and superficial radial nerve at the level of the radial head

• intraosseous and extraosseous blood supplies that may be compromised by the injury

• supracondylar fractures

• distal single column fractures

  • 5% of fractures

  • subclassified using Milch classification system (see table)

  • lateral condyle more common than medial

• distal bicolumnar fractures

  • classified using Jupiter classification system (see table)

  • 5 major articular fragments have been identified

    • capitellum/lateral trochlea

    • lateral epicondyle

    • posterolateral epicondyle

    • posterior trochlea

    • medial trochlea/epicondyle

• elbow pain and swelling

• check for open wounds, especially posteriorly

• gross instability often present

  • avoid ROM due to risk of neurovascular damage

• neurovascular exam

  • check function of radial, ulnar, and median nerves

  • check distal pulses

    • brachial artery may be injured

    • if pulse decreased, obtain noninvasive vascular studies and consult vascular surgery if abnormal

• monitor carefully for forearm compartment syndrome

• recommended views

  • AP

    • ideally taken with 40 deg of flexion

  • lateral

• additional views

  • humerus and forearm radiographs

  • wrist radiographs

    • obtain if elbow injury present or distal tenderness on exam

  • oblique radiographs

    • specifically used to evaluate if there is continuity of the trochlear fragment with the medial epicondylar fragment, this can influence hardware choice

  • traction radiograph

    • may assist with surgical planning

• indications

  • often obtained for surgical planning

    • especially helpful when shear fractures of the capitellum and trochlea are suspected

• indications

  • usually not indicated in acute injury

• cast immobilization

  • indications

    • nondisplaced Milch Type I fractures

  • technique

    • above elbow cast with close follow-up due to risk of displacement

• short period of immobilization and followed by early range of motion ("bag of bones" technique)

  • indications

    • elderly patients

      • with significant medical comorbidities precluding surgery

      • unable to comply with postoperative protocol

        See Also

        Supracondylar Humerus Fractures: Practice Essentials, Anatomy, Etiology

• closed reduction percutaneous pinning (CRPP)

  • indications

    • displaced Mich Type I fractures

• open reduction internal fixation (ORIF)

  • indications

    • supracondylar fractures

    • intercondylar / bicolumnar fractures

    • Milch Type II fractures

• total elbow arthroplasty

  • indications

    • distal comminuted bicolumnar fractures in low demand elderly patients

      • must be able to comply with weightbearing restriction

• technique

  • immobilize in supination for lateral condyle fractures

  • immobilize in pronation for medial condyle fractures

• approach

  • posterior superficial approach

• exposures

  • triceps-splitting (Campbell)

    • technique

      • split triceps tendon in midline down to olecranon

    • for open fractures, approach using the defect leads to better results than an osteotomy

  • triceps-sparing (paratricipital, Alonso-Llames, medial and lateral windows)

    • indications

      • extra-articular fractures

      • fractures with a simple articular split

    • technique

      • elevate triceps from the humerus using medial and lateral windows

      • can be converted to olecranon osteotomy if needed

  • olecranon osteotomy

    • indications

      • complex intra-articular fractures

      • fractures with a coronal splint

    • contraindications

      • total elbow arthroplasty is planned/may be required

    • technique

      • perform chevron (apex distal) osteotomy

      • fixation of osteotomy performed using a combination of screws, K wires, tension band or plate

    • complications

      • AIN nerve injury

        • check ability to flex thumb interphalangeal joint in recovery

      • symptomatic hardware (6-30%)

      • osteotomy nonunion (0-9%)

  • triceps-reflecting (Bryan-Morrey)

    • technique

      • reflect triceps tendon, forearm fascia, and periosteum off the olecranon from medial to lateral

      • repair through transosseous drill holes

      • immobilize to protect triceps repair for 4-6 weeks postoperatively

  • triceps-reflectinganconeuspedicle (O'Driscoll)

    • technique

      • elevate anconeous subperiosteally from proximal ulna

  • lateral muscles interval

    • technique

      • elevate the ECRB and part of the ECRL off of the supracondylar ridge

• fixation

  • perform provisional reduction with k-wires

    • if metaphyseal injury is not comminuted, reducing one column to the metaphysis first may be beneficial

  • perform fixation of articular fragments with countersunk/headless screws

    • consider using positional screws when reducing trochlea to avoid narrowing it with compression

  • perform fixation of condyles and epitrochlear ridge

    • fix the lateral epicondyle using a tension band wire or plate

    • fix the articular segment to the shaft using two plates in orthogonal planes

      • new literature supports parallel plates for increased biomechanics strength

      • no difference in clinical outcomes between 90-90 and parallel plating

    • if the ulnar nerve contacts medial hardware during flexion/extension, can perform an ulnar nerve transposition

      • no difference between rates of post-operative ulnar neuritis with in situ release compared to transposition

      • no difference in patient-reported outcomes between transposition and in-situ release

  • locking plates are preferred for poor bone quality or comminution

• postoperative

  • splint elbow in 70° of flexion

  • remove splint within 7-10 days post-operatively and initiate ROM exercises

    • if osteotomy performed

      • active and active-assisted flexion and extension for 6 weeks

      • no active extension against gravity or resistance

      • no restrictions to rotation

    • if osteotomy not performed

      • active motion against gravity without restrictions

      • no restrictions to rotation

  • start gentle strengthening program at 6 weeks and full strengthening program at 3 months

Semiconstrained Total Elbow Arthroplasty

• indications

  • comminutedarticular fractures in osteoporotic bone

  • inflammatory conditions (e.g. RA)

• complications specific to this treatment

  • activity restrictions (e.g. can not lift more than 10 pounds)

  • implant loosening

  • polyethylene wear

  • periprosthetic fracture

• functional outcomes similar to salvage arthroplasty following failed ORIF

Elbow stiffness

• most common (3-42%)

• mean arc of motion is 90-106 degrees

• treatment

  • static-progressive splinting

• seen in 8%

• routine prophylaxis is not warranted due to increased rate of nonunion in patients treated with indomethacin

• risk factors

  • head injury

  • floating elbow injury

  • Type A and B fractures

  • delayed surgical fixation

Nonunion

• low incidence (0-11%)

• risk factors

  • excessive soft-tissue stripping

  • open fractures

  • comminution

  • low transcondylar or intercondylar fractures

• treatment

  • revision ORIF with bone graft

• avoided by proper surgical technique

  • cubitus valgus (lateral column fractures)

  • cubitus varus (medial column fractures)

• can be seen with olecranon osteotomy

• Postoperative ulnar nerve palsies are most often secondary due to traction during open reduction and internal fixation
  

• due to poor soft tissue envelope over posterior elbow

• occurs in 0-14% of patients

• majority of patients regain 75% of elbow motion and strength

  • goal is to restore elbow ROM 30-130° of flexion

• has rates of implant survival >75% at 10 years if used with appropriate indications

• expected ROM is 26-125 degrees

• in patients > 65 years old functional outcomes were higher with TEA than ORIF at 2-year follow-up

• goal is a painless pseudoarthrosis

• only fair functional outcomes

• high rate of nonunion and later surgery

• treatment of these fractures is complex due to

  • low fracture line of one or both columns

  • metaphyseal fragmentation of one or both columns

  • articular comminution

  • poor bone quality