History and Physical Examination

An 81-year-old woman presents 1 day following a fall onto an extended arm. She complains of pain and crepitation in her elbow. She denies any numbness or other injury.

Range of motion is limited from 30 to 80 degrees, with pain to supination and pronation. She has moderate swelling and ecchymosis about the elbow, but is neurovascularly intact. Crepitation is also present with motion and manipulation of the elbow.

Figure 35–1. Anteroposterior (AP) (A) and lateral (B) radiographs of the elbow.

Differential Diagnosis

1. Distal humerus fracture

2. Elbow dislocation

3. Radial head fracture

4. Olecranon fracture

Radiologic Findings

Intercondylar Distal Humerus Fracture. Limited range of motion, pain, and crepitation point toward a distal humerus fracture as the etiology of this patient’s complaints. Radiographs confirm the suspected diagnosis. Treatment of inter-condylar distal humerus fractures must be individualized. Young adults should almost always have an open reduction and internal fixation performed to restore the articular congruity. However, one can safely assume that young adults have adequate bone stock to accept metal plates and screws and thus achieve adequate stability to allow for early range of motion exercises. Elderly patients, on the other hand, often have osteopenic bone, making fracture fixation with plates and screws very challenging, if not impossible. For this reason, alternatives to open reduction and internal fixation should be considered, depending on the quality of bone and fracture pattern. Other options include closed treatment with a total elbow arthroplasty.

Total elbow arthroplasty as a treatment for highly comminuted intraarticular distal humerus fractures in the elderly is a reasonable alternative. Such treatment obviates the necessity for plate and screw fracture fixation, but still allows for immediate postoperative range of motion exercises. Stability is achieved with the use of a semi-constrained total elbow arthroplasty. Total elbow arthroplasty is a technically demanding procedure particularly when normal anatomic landmarks are absent. Such is the case with a comminuted distal humerus intraarticular fracture. Nevertheless, a properly placed semiconstrained total elbow arthroplasty can lead to a functionally useful and painless elbow.

Surgical Management

The patient is placed in the supine position with a sandbag under the scapula. The arm is draped free and brought across the chest. The authors use the Bryan-Morrey approach. A 15-cm incision is centered just lateral to the medial epicondyle and just medial to the tip of the olecranon. The ulnar nerve is identified, tagged with vessel loops, and protected throughout the remainder of the procedure. An incision is made over the medial aspect of the ulna, and the ulnar periosteum is carefully elevated. Likewise, the medial aspect of the triceps is elevated along with the posterior capsule. Fracture fragments are identified at this time, and those devoid of soft tissue attachments are removed. Irrigation of the elbow joint is accomplished and subperiostial dissection around the ulna is continued. The radial and ulnar collateral ligament complexes are released if necessary so as to allow for adequate exposure of the ulna and distal humerus. The tip of the olecranon is then removed and the humerus externally rotated. The medial and lateral condylar fracture fragments are retracted, taking care to preserve their soft tissue attachments. The medullary canal of the humerus is then identified with a reamer if it is not already apparent following the fracture. The medullary canal is entered and a cutting block for the semi-constrained prosthesis is used to make any additional cuts that are necessary following the fracture. Trial implants are then inserted. Great care must be taken to maintain the appropriate position of the humeral components due to the lack of normal anatomic landmarks. Also, proper depth of insertion of the humeral component is important to establish.