Fracture of the distal humerus is one of the most challenging injuries that confront the orthopedic traumatologist. Given the relative rarity of these fractures, most surgeons have only limited experience in their management. Because of the complex regional anatomy, fracture comminution, and limited points for secure fixation, even experienced surgeons find it challenging to achieve stable fixation leading to early return of range of motion. Injuries of the distal humerus include extracapsular fractures in the supracondylar region, extraarticular intracapsular (transcondylar) fractures, isolated unicondylar fractures, partial or complete articular fractures, and, most commonly, combined supracondylar-intercondylar fractures. We also address infrequent patterns, which have different demands.
General Considerations in Distal Humerus Fractures
Preoperative Evaluation
Fractures of the distal humerus occur in a bimodal age distribution, with distinct patient characteristics. Fractures that occur in physiologically young patients are typically the result of high-energy mechanisms, such as motor vehicle collisions or falls from a significant height. Open wounds, other ipsilateral upper extremity injuries, and general systemic injuries frequently coexist because of the higher-energy mechanism. As the elderly population increases, there is a concomitantly increasing incidence of low-energy falls resulting in fractures of the distal humerus. This distinctive version of the fracture is characterized by poor bone quality and may be associated with poor general health or preexisting arthritic changes. There is an increasing incidence of higher-energy injuries in active, higher-demand elderly patients with poor bone quality; therapeutic decisions are more difficult for the surgeon to make with these patients.
History and Physical Examination
The history should focus on the mechanism and time of injury and the identification of other sites of injury. It is also necessary to recognize prior elbow injuries or surgical procedures or preexisting medical conditions that may have affected the entire upper extremity. In addition, assessment of preexisting medical comorbidities, medication use, and function is necessary to determine optimal management. An understanding of the patient’s type of employment and physical demands at work will assist in planning the goals and duration of rehabilitation, subsequently facilitating the timing and implementation of modifications at the workplace.
In addition to a complete physical examination, particularly in the setting of a high-energy mechanism, a detailed and focused examination of the injured extremity should be performed. Inspection of the limb may reveal swelling, bruising, and deformity, particularly angulation and shortening. A complete circumferential inspection of the elbow is done to avoid missing open wounds that occur most commonly on the posterior aspect. Patients are typically unable to perform any significant elbow range-of-motion movements because of pain.
The distal vascular status is evaluated by inspecting the color of the distal extremity and by palpation of the radial and ulnar pulses. Poorly palpable pulses are checked using noninvasive Doppler ultrasound or pulse oximetry. If there is a questionable pulse and gross malalignment of the arm, gentle traction can often realign the limb and restore the distal pulse. Angiography or urgent operative vascular exploration is necessary in patients who continue to show an abnormal vascular examination. Any concern for vascular injury should also prompt a careful assessment for compartment syndrome and the necessary surveillance prior to and following surgery. A detailed neurologic examination of the hand and digits, including motor function, sensation, and two-point discrimination, should be performed and recorded to identify injury to the median, radial, ulnar, anterior interosseous, or posterior interosseous nerves. Gofton and coworkers noted that approximately one quarter of the patients in their series exhibited incomplete ulnar neuropathy at the time of injury. These findings, particularly with two-point discrimination, are recorded for later reference in case there is a change before or after surgery. At the conclusion of the physical examination, a sterile dressing is placed over any open wounds and a lightweight above-elbow splint is applied.
Radiographic Examination
Standard anteroposterior and lateral radiographs are generally sufficient to make the diagnosis of a fracture of the distal humerus and to provide a reasonable assessment of the fracture pattern. Radiographs of significantly displaced fractures may be incomprehensible, however, because the normal radiographic landmarks become distorted. Gentle traction can substantially improve alignment to provide more understandable anteroposterior and lateral images. Some sedation may be needed if traction images are performed in the emergency department. Alternatively, traction images in the operating room can be obtained when complete anesthesia has been achieved. Invariably, the previously bizarre appearance of the distal humerus becomes much more understandable ( Figure 18.1 ). Computed tomography (CT) is helpful for fractures distal to the olecranon fossa or fractures primarily occurring in the coronal plane ( Figure 18.2 ). In particular, fracture comprehension and preoperative planning seem to be improved when the CT scan is obtained with three-dimensional reconstruction. CT may also be useful in older patients to assess the degree of comminution and to aid in deciding whether internal fixation or total elbow arthroplasty (TEA) should be attempted. The complexity of these fractures is underscored in a recent article that describes the number of articular fracture fragments related to fracture type as defined by three-dimensional CT. Bicolumnar patterns were associated with 19 fracture fragments; isolated capitellar and trochlear fractures were associated with 6.5 fracture fragments.
Anatomy
When viewed from an anterior or posterior position, the distal humerus appears to be shaped like a triangle. The humeral diaphysis diverges into medial and lateral bony columns in the metaphyseal portion of the distal humerus ( Figure 18.3 ). The trochlea (a word derived from a Greek term meaning “pulley”) is covered anteriorly, inferiorly, and posteriorly with articular cartilage, creating an arc of approximately 270 degrees. The spatial relationships of the medial column, lateral column, and trochlea are conceptually similar to a spool of thread being held between the thumb and index finger.
The blood supply to the distal humeral diaphysis is entirely dependent on a single nutrient vessel that terminates in the distal humeral metaphysis approximately 3 to 4 cm proximal to the olecranon fossa. Vascular watersheds are areas of poor blood flow that occur between the lateral trochlea and capitellum and in the supracondylar area, specifically the olecranon, coronoid, and radial head fossa ( Figure 18.4 ). This latter finding may partially explain why this area is relatively more prone to nonunion than other regions of the distal humerus.
The posterior aspect of the lateral column is covered by the distal origin of the medial head of the triceps muscle and, distally, by the origin of the anconeus. The brachioradialis and extensor carpi radialis longus originate from the lateral supracondylar ridge. The common extensor mass, consisting of the extensor carpi radialis brevis, extensor digitorum communis, and extensor carpi ulnaris, and the cephalad portion of the anconeus muscle originate from the lateral epicondyle, immediately posterior to the origin of the lateral collateral ligament complex. The lateral ligament complex and the common extensor origin blend together and do not have discrete origins.
Most surgical exposures of the distal humerus are performed using a posterior approach; an understanding of the anatomic relationships and paths taken by the ulnar and radial nerves is essential to the safe management of these injuries ( Figure 18.5 ). In the intact humerus, the radial nerve can be found crossing the posterior aspect of the humeral shaft approximately 20 cm proximal to the medial epicondyle (74% of the length of the humerus) to 14 cm proximal to the lateral epicondyle (51% of the length of the humerus). At the lateral aspect of the humeral shaft, the radial nerve trifurcates into a branch to the medial head of the triceps, the lower lateral brachial cutaneous nerve, and the continuation of the radial nerve into the forearm (the posterior interosseous nerve and the superficial cutaneous nerve). After the trifurcation, the posterior interosseous continuation of the radial nerve pierces the lateral intermuscular septum approximately 10 cm proximal to the lateral epicondyle (the distal 36% of the humerus) ( Figure 18.6 ).
At the level of the distal attachment of the coracobrachialis to the humerus, approximately 10 cm proximal to the medial epicondyle, the ulnar nerve courses from the anterior compartment to the posterior compartment of the arm by piercing the medial intermuscular septum. The nerve travels along the anteromedial border of the medial head of the triceps along the medial intermuscular septum, ultimately traveling posterior to the medial epicondyle of the distal humerus ( Figure 18.7 ). In approximately 70% of the population, a thick fascial band (arcade of Struthers) connects the medial head of the triceps to the intermuscular septum crossing the ulnar nerve approximately 8 cm proximal to the medial epicondyle. An anatomic clue to the presence of this fascial band is to identify muscle fibers of the medial head of the triceps crossing superficial to the ulnar nerve. As the nerve passes posterior to the medial epicondyle, it becomes enclosed in a fibrous sheath, the roof of the cubital tunnel. As the nerve exits the cubital tunnel, it courses between the two heads of the flexor carpi ulnaris, passes beneath the fibrous origin of the flexor digitorum superficialis, and travels distally through the anterior compartment of the forearm on the anterior surface of the flexor digitorum profundus. The first branch of the ulnar nerve provides sensory innervation to the elbow capsule. After exiting the cubital tunnel, motor branches to the flexor carpi ulnaris can be identified. The remaining branches of the ulnar nerve are encountered in the distal forearm and hand.
Classification of Distal Humerus Fractures
For decades, fractures of the distal humerus were collectively referred to as “T” or “Y” fractures, when they involved both columns, or as unicondylar fractures, when they involved only one column. With improvements and refinements in operative management over the past 30 years, a greater understanding of the complexity and variability of fracture patterns affecting the distal humerus has occurred. Ideally, a classification system should provide a basis for reporting results and permitting comparisons among surgeons and cohorts of patients. In addition, the classification should guide decision making and enable some degree of prognostication for each patient. Finally, the classification system should be easy to use, widely accepted, and reproducible.
At the present time, there is no fracture classification system for the distal humerus that fulfills these objectives adequately. The problem of intraobserver and interobserver variability has been found in classification systems for many types of fractures; this problem does not seem to be unique to classification systems for fractures of the distal humerus. In addition, some patterns of fractures are more common in persons of a certain age than in others. Older patients often exhibit extensive comminution of the articular surface without the same pattern of column fracture described in the classification schemes (see section on fractures in elderly adults ). The use of three-dimensional CT scanning may improve observer variability in the currently used distal humerus fracture classification systems.
Comprehensive Classification Systems
Column Concept of Classification.
Jupiter and Mehne recommended that the distal humerus be described as two diverging columns supporting an intercalary articular surface, the trochlea, rather than as rounded projections known as condyles. Conceptualizing the distal humerus as medial and lateral columns more accurately describes the injury patterns and allows consistency in the general fracture categories. The Mehne and Matta classification is based on surgical anatomic findings and the columnar concept and helps in formulating effective preoperative surgical tactics. The basic surgical aim is to restore all three elements of the distal humerus triangle (medial column, lateral column, and intervening trochlea) with enough stability to allow early functional movement. Using this classification system, there are three basic fracture categories: intraarticular, extraarticular intracapsular, and extracapsular. Intraarticular fractures are subclassified as single-columnar or bicolumnar injuries, capitellar fractures, or trochlear fractures. Extraarticular intracapsular fractures traverse both columns of the distal humerus without involving the articular surface and are uncommon fractures more likely to be seen in pediatric patients. Extracapsular fractures include injuries to the medial or lateral epicondyles.
Intraarticular Fractures
Single-column fractures.
Single-column injuries are uncommon ( Figure 18.8 ). These injuries are divided into medial or lateral column fractures, rather than medial or lateral condyle fractures as previously described by Milch. Lateral column fractures are reportedly more common than medial column fractures. Rather than emphasizing the involvement of the lateral trochlear ridge, as Milch suggests, this classification system differentiates two types of single-column fractures: “high” fractures and “low” fractures. High fractures have the following characteristics:
- •
The fractured column contains the bulk of the trochlea.
- •
The ulna and radius follow the displacement of the fractured column.
- •
Internal fixation is predictable because of the size of the fragment.
Low single-column fractures have the opposite characteristics for each of the above-mentioned items. Originally, these injuries were thought to be the result of abduction or adduction forces, with involvement of the lateral trochlear ridge being a major determinant of elbow stability. Conversely, Jupiter and Mehne suggested that extensive capsular injury and collateral ligament rupture are more likely to be responsible for the ultimate displacement of the fragment than involvement of the lateral trochlear ridge.
Bicolumnar fractures.
Fractures that involve both columns are seen in most injuries to the distal humerus and, by definition, affect all three “sides” of the distal humerus triangle. In this classification system, bicolumnar fractures are classified in a descriptive fashion, with comminution being a variant superimposed on the basic fracture pattern ( Figure 18.9 ). The main patterns include the following:
- 1.
“T” pattern, which may be high or low, depending on whether the transverse component of the fracture is above or below the superior limit of the olecranon fossa
- 2.
“Y” pattern
- 3.
“H” pattern
- 4.
Lambda pattern, described as medial if the obliquely oriented supracondylar fracture line travels from proximal medial to distal lateral or as lateral if the fracture line travels from proximal lateral to distal medial
The value of this classification system is in differentiating fracture patterns that occur at or below the level of the olecranon and coronoid fossae. More distal fractures produce small articular fragments that challenge secure fixation. The “H”-type injury produces a small trochlear fragment that may be completely devoid of soft tissue attachments. This fragment is frequently difficult to secure, and the potential for avascular necrosis exists.
Extraarticular Intracapsular Fractures.
In contrast to supracondylar fractures, transcolumnar fractures lie partially or entirely within the joint capsule of the distal humerus. Transcolumnar fractures display a main fracture line that crosses the distal humerus without involving the distal humeral articular surface. The lack of articular involvement differentiates these fractures from the more common bicolumnar (intraarticular) patterns. Transcolumnar fractures are distinguished from one another on the basis of the location and orientation of the major fracture line; this gives rise to four basic transcolumnar fracture patterns: high, low, abduction, and adduction ( Figure 18.10 ). The high and low patterns can be subdivided further into flexion and extension subgroups. These fractures are uncommon in adults, and the literature specifically discussing this injury type is limited. Several authors have suggested that this fracture, when encountered, is usually more common in elderly adults with osteopenic bone. Important surgical considerations for management of this fracture type include the following:
- 1.
The more distal the fracture is (low types), the more difficult neutralization of the articular fragment becomes. This situation is worsened in the presence of osteopenic bone.
- 2.
Fractures that are managed nonoperatively or with nonrigid fixation may develop excessive callus formation that obliterates the olecranon, coronoid, and radial fossae, resulting in a loss of motion.
AO/ASIF Classification.
The AO/ASIF classification is a comprehensive alphanumeric fracture classification system that distinguishes extraarticular injuries, partial articular injuries (where continuity is maintained between the shaft and a portion of the articular surface), and complete articular injuries. In the three main categories, types A, B, and C, injuries are grouped according to increasing severity, intuitively suggesting that a partial articular injury is more severe than an extraarticular injury, and that a complete articular injury is more severe than a partial articular injury. Within each type, emphasis is placed on the comminution of the supracondylar metaphysis or the articular surface, or both. All three types are extensively subdivided to include most fracture patterns. Type C3 fractures are the most severe, with significant comminution of the articular surface and supracondylar area.
Classification of Fracture Patterns Unique to the Articular Surface
Although involvement of the articular surface is an integral component of most injuries of the distal humerus and a component of the classification systems already described, identification of fracture patterns unique to the articular surface continues to evolve. Conceptually, injuries of the articular surface of the distal humerus may be considered as a spectrum, rather than as discrete entities, because the components of the articular injury may be found in isolation (pure articular injury) or in association with supracondylar injury.
Fractures of the Capitellum.
Fractures of the capitellum have been recognized since the mid-19th century. Despite their rarity, two types of fractures have traditionally been described. Type I, or Hahn-Steinthal fracture , is a fracture of the capitellum that involves a large portion of the osseous structure of the capitellum. The fragment varies in size and usually contains a part of the adjacent ridge of the trochlea. Type II, or Kocher-Lorenz fracture , is superficial and mainly involves the chondral surface of the capitellum with very little bone attached. This fracture type essentially results in a shell of capitellar articular cartilage with minimal subchondral bone. Subsequently, capitellar fractures have been classified into three types. Type I fractures are complete fractures of the capitellum (similar to the Hahn-Steinthal fracture), type II fractures are superficial (corresponding to the Kocher-Lorenz fracture), and type III fractures are comminuted. A fourth type of capitellar fracture, described by McKee and associates, is termed the coronal shear fracture . This fracture involves the capitellum but also extends beyond the lateral trochlear ridge to include a variable, but significant, portion of the trochlea ( Figure 18.11 ). The radiographic hallmark of the coronal shear fracture pattern is the double-arc sign on the lateral radiograph, which represents the subchondral bone of the capitellum and lateral trochlear ridge.
Dubberley and colleagues proposed a classification system that aids with preoperative planning and the formulation of a surgical plan. Type 1 fractures primarily involve the capitellum with or without the lateral trochlear ridge, type 2 fractures involve the capitellum and trochlea as one piece, and type 3 fractures consist of fractures of the capitellum and the trochlea as separate fragments. Within each fracture type, the presence or absence of posterior condylar comminution is noted ( Figure 18.12 ). Medial visualization and exposure are increasingly required with increasing fracture type, and the potential need for bone graft and plate fixation increases with posterior condylar comminution.
Despite the different fracture patterns and variations that exist, fractures of the capitellum are essentially shearing coronal plane injuries. The mechanism of these fractures seems to be an axial load, with the final fracture configuration determined by the degree of elbow flexion at the time of loading.
Fractures of the Trochlea.
Isolated trochlear fractures are exceedingly rare injuries. Although a formal classification system has not been developed, the two main patterns are fractures of the entire trochlear process and osteochondral fractures. Jupiter and other authors have suggested that the rarity of these injuries may be due to the trochlea lying protected within the depth of the semilunar notch of the olecranon, without capsular, muscular, or ligamentous attachments. The mechanism of injury remains speculative because of the rarity of the injury, but may involve the coronoid acting as a fulcrum when a force is applied to the flexed elbow. The osteochondral patterns may be associated with elbow dislocations, however, implying the involvement of a shearing force.
Other Articular Fracture Patterns.
Emphasizing the fact that articular fractures of the distal humerus may represent a continuum of injury, Ring and associates evaluated 21 patients with pure articular fractures of the distal humerus. The fracture fragments included and extended beyond the capitellum but did not extend above the base of the olecranon fossa. Five different patterns of injury were identified with increasing involvement of the posterolateral articular surface and medial articular surface ( Figure 18.13 ), as follows:
Type 1 injuries are the coronal shear fractures previously described by McKee and colleagues.
Type 2 fractures are type 1 fractures with involvement of the lateral epicondyle.
Type 3 fractures have associated impaction of the metaphyseal bone posterior to the capitellum.
Type 4 fractures have the additional feature of a fracture of the posterior aspect of the trochlea.
Type 5 fractures are type 4 fractures with a fracture of the medial epicondyle.
These specific fracture types represent a progression of injury severity extending from an isolated articular component displaced in the frontal plane to combinations of shearing and impaction injuries of the capitellum and trochlea with a limited zone of metaphyseal bone support. Because of the difficulty in appreciating some of the potential fracture fragments with standard radiographs, CT scanning with three-dimensional reconstructions may enhance comprehension and preoperative planning.
Davies and Stanley proposed a unifying classification system emphasizing clinical applicability and a management algorithm. Type I fractures are extraarticular and are analogous to AO/ASIF type A injuries. Type II injuries are single-columnar and bicolumnar fractures where the fracture lines begin in the distal humerus metaphysis and propagate into the trochlea or capitellum, or both. Type III fractures are fractures in which the fracture lines lie predominantly within the articular surface of the distal humerus but may extend proximally into the distal metaphysis below or at the level of the olecranon fossa ( Figure 18.14, A ). This classification system was noted to be reliable and reproducible and the observer variability was superior to that of either the AO/ASIF or the Mehne classification system. Although simplistic, the proposed management algorithm when used in conjunction with the proposed classification system may be useful for determining basic therapeutic options (see Figure 18.14, B ).
Historical Review
The history of fracture care was marked by a significant change in management philosophy during the 1960s. The group responsible for the change is known as the Arbeitsgemeinschaft für Osteosynthesefragen (AO), or Association for the Study of Internal Fixation (ASIF) in English-speaking regions. The general fracture principles developed during the early AO days remain true today and are particularly applicable to fractures of the distal humerus. These principles include the following:
- 1.
Fracture reduction and fixation to restore anatomic relationships, particularly of the articular surface
- 2.
Stability by fixation or splintage, as the type of fracture and injury requires
- 3.
Preservation of the blood supply to soft tissues and bone by careful handling and gentle reduction techniques
- 4.
Early and safe mobilization of the part and the patient
Before the development of the AO and before their principles were widely accepted, strong opposition to operative management of distal humerus fractures existed. Reich recognized, however, that open reduction was the only procedure that offered any hope of complete functional restoration. He also recognized that the unsatisfactory results seen with open treatment were due to the “frank exposure” and the difficulty in reducing and then maintaining reduction. In the decades preceding the AO advances, numerous publications debated the superiority of results in patients treated with open versus conservative methods. Numerous closed techniques were described, including manipulation and casting, olecranon traction, cast traction, and condylar reductions using ice tongs or clamps. Influential authors such as Watson-Jones and the contradictory views of the 1964 and 1966 Instructional Course Lectures from the American Academy of Orthopaedic Surgeons on these fractures continued the controversy. Although known for their classification system, Riseborough and Radin concluded their article by noting that open reduction and adequate internal fixation are not easy and would seem to offer little chance of a good outcome. These authors believed that open reduction was very rarely indicated. Advocates of either closed or open management recognized that the inability to obtain and maintain a reduction and the subsequent need for rigid immobilization ultimately resulted in poor outcomes ( Table 18.1 ).
| Author | Year | Description |
|---|---|---|
| Hitzrot | 1932 | Described 25 patients treated with traction. Based on his results, Hitzrot strongly advised against open reduction, stating that anatomic reduction was of secondary importance. Eastwood would later agree, stating that perfect anatomic reduction is unnecessary to obtain a good result. Few agree with this view today. |
| Reich | 1936 | Described reduction technique using ice tongs to compress condylar displacement, with portable traction to allow the patient to be ambulatory. In six patients, the results were noted to be good in three, fair in two, and poor in one. These outcomes were believed to be better than complications and results shown by ORIF. |
| Eastwood | 1937 | Reviewed 14 patients treated with a collar-and-cuff support followed by early elbow mobilization (credited to Thomas). The results were so satisfactory that Eastwood believed it was unwise to use any other technique. Eastwood concluded by stating that function was more important than radiographic appearance. |
| Watson-Jones | 1944 | Classic fracture textbook concluded that, “Operative reduction and internal fixation is not justified by the results.” Surgical dissection, avascularity of fragments, and use of metallic implants were believed to result in dense adhesions and stiffness. Manipulative reduction, brief casting, and motion were recommended. |
| Riseborough and Radin | 1969 | Unveiled Riseborough-Radin classification system. The authors suggested that this classification allowed therapeutic decision making based on amount of rotatory deformity and comminution. Despite this therapeutic classification system, Riseborough and Radin believed that ORIF was rarely indicated. This classification system was used for approximately 2 decades. The best results were obtained in 22 of 29 patients treated with casting or traction. |
| Brown and Morgan | 1971 | Described “bag of bones” technique for closed management of intercondylar “T”-shaped fractures of the distal humerus. Flexion-extension arc in 6 of 10 patients was >105 degrees. Better motion seemed to be obtained in elderly patients, with younger adult patients having restricted arcs <85 degrees. These results continued to challenge the results obtained by proponents of ORIF. The role of the “bag of bones” technique in elderly patients was strengthened. |
| Horne | 1980 | Review of 50 patients with supracondylar, condylar, and supracondylar/intercondylar fracture patterns. Of 29 patients treated surgically, 16 had poor results compared with 6 of 21 patients treated with casting. Inadequate internal fixation and prolonged postoperative immobilization were responsible for the poor results. Horne recommended conservative treatment for supracondylar/intercondylar distal humerus fractures, particularly when comminuted. |
During the late 1960s and early 1970s, an increasing number of publications reported satisfactory results with operative reduction and fixation of distal humerus fractures. A review of the operative techniques contained in these reports shows an increasing use of plate and screw fixation, rather than Kirschner wire fixation, and recommendations of early postoperative mobilization. The importance of proper technique was illustrated by Johansson and Olerud, who suggested that “The osteosynthesis demands as stable fixation as possible, and in our experience this is best obtained by screws, but at the same time exact apposition of the fracture surfaces is required.” They further noted that stable osteosynthesis eliminated the need for postoperative immobilization.
The 1980 report by Horne underscored the poor results that are obtained when the goals of open reduction and internal fixation (ORIF) are not met. Horne wrote, “The availability of excellent equipment for the internal fixation of fractures is not an indication for its use,” ultimately concluding that except for simple fractures and unicondylar fractures, conservative management is the recommended treatment. Shortly thereafter, Jupiter and colleagues published the results of 34 intercondylar fractures of the humerus managed operatively using the techniques advanced by AO/ASIF. The high proportion of good or excellent results, using a score incorporating range of motion and pain, finally solidified the advantages of ORIF for these fractures.
The last 3 decades of the 20th century have shown tremendous advances in understanding of the various fracture patterns, the techniques used to obtain anatomic reduction and fixation, and the evaluation of these results. Improved appreciation of fracture patterns and techniques combined with substantial progress in understanding the surgical anatomy of the elbow has allowed dramatic advances in posttraumatic management of stiff or arthritic elbows. Advances in arthroplasty and newer fixation techniques are options for the management of comminuted fractures of physiologically sound but elderly patients. The optimal implant remains unknown, however. The use of tensioned-wire fixators, allograft materials, and vascularized autografts has permitted salvage of the most challenging acute high-energy injuries in younger patients. Last, outcome-scoring instruments may further assist in the assessment of treatment ( Table 18.2 ).
| Author | Year | Description |
|---|---|---|
| Van Gorder | 1940 | Reported eight patients with fractures of distal humerus operatively managed using posterior “triceps-turndown” approach (credited to Campbell) where an inverted “V” of the triceps aponeurosis is incised and reflected distally to gain exposure. Subsequent authors used it for open reduction of similar fractures. |
| Cassebaum | 1952 | Used olecranon osteotomy for management of nine “T” and “Y” fractures of distal humerus. This is apparently the first report of the transolecranon approach for management of distal humerus fractures. The original description was credited to MacAusland in 1915. |
| Milch | 1964 | Classic early work on isolated fractures of humeral condyles, their injury mechanism, and their relationship with elbow dislocation. It was hypothesized that involvement of the lateral wall of the trochlea was associated with injuries that also led to elbow dislocation. In elbows with dislocations, Milch recommended open treatment. |
| Miller | 1964 | This Instructional Course Lecture reviewed a 3-year experience of distal humerus fractures treated with closed means versus ORIF. In one of the first comparative series of distal humerus fractures, Miller noted that the operative group had a substantially greater elbow range of motion than the closed treatment group (111 degrees vs. 47 degrees). Miller was convinced that ORIF was the procedure of choice, but recognized the following limitation: “If the arm requires immobilization after open reduction and fixation, then the advantage of surgery is lost.” |
| Cassebaum | 1969 | Reported 36 distal humerus “T” and “Y” fractures treated with internal fixation using transolecranon approach. Recognized elbow arc of 50 to 165 degrees as excellent because most tasks could be completed within this range. Cassebaum’s range-of-motion criteria for excellent, good, and fair were used extensively in subsequent reports. |
| Bryan and Bickel | 1971 | Reviewed 25 operatively managed distal humerus fractures treated through posterior approach. Bryan and Bickel preferred screw fixation rather than Kirschner wires and recommended early mobilization after secure internal fixation. They suggested that their patients would not have done as well with closed methods but that the open technique should be done by an experienced surgeon. They also warned that occasionally the difficulties encountered during ORIF of comminuted distal humerus fractures “may be mortifying.” This article was presented during a period when there was no consensus in the literature regarding the best method of treatment for these fractures. |
| Scharplatz and Allgower | 1975 | Review of 105 fracture-dislocations of elbow. Principles of AO operative treatment of the distal humerus were outlined: reconstruction of the joint surface first, the trochlea being the most important part, and then connection to the shaft of the humerus. |
| Jupiter et al | 1985 | Results of 34 intercondylar fractures of distal humerus treated with operative fixation using AO techniques; 27 of 34 patients obtained good to excellent results at a mean of 5.8 years. Jupiter and colleagues confirmed the ability to achieve improved and more predictable results with operative treatment even in a comminuted fracture. |
| Zagorski et al | 1986 | Compared results of 42 intraarticular fractures of the distal humerus; 29 were treated operatively with screws or plate and screw constructs, and 13 were treated nonoperatively. Of patients, 76% treated with open techniques had a good to excellent result compared with 8% in the conservatively treated group. Zagorski and associates believed that final fracture reduction was related to functional end results. |
| Jupiter et al | 1988 | Jupiter and coworkers managed 22 unicondylar fractures operatively; 18 had good to excellent results. This article illustrated AO principles applied to unicondylar fractures. |
| Helfet and Hotchkiss | 1990 | Biomechanical study evaluated implant configurations and distal humerus fracture stability. The 90-degree orthogonal plate construct was identified and proven to be mechanically superior. Helfet and Hotchkiss could not find a difference between tubular plates, 3.5-mm reconstruction plates, or mixed plates. |
| John et al | 1994 | First large series evaluating contemporary ORIF techniques in distal humerus fractures in elderly patients. Average age was 80 years (range 75 to 90 years); 85% were thought to have a functional arc of motion (>90 degrees); 66% had no pain. Implant failures were related to use of tubular plates. |
| Garcia et al | 2002 | Consecutive series of 19 patients all >60 years old treated with primary TEA for nonreconstructible fracture of distal humerus. There was no associated inflammatory illness; 3-year follow-up showed 68% with no pain and a mean Mayo score of 93 (excellent). This article shows early advantages of TEA in this patient population. Long-term data are lacking, however. ORIF versus TEA in elderly patients continues to be debated. |
Operative Management of Distal Humerus Fractures
Operative management of specific fractures of the distal humerus requires identification of fracture and soft tissue injury and patient characteristics, including age, associated injuries, comorbidities, and functional level before injury. These considerations are used to determine the reconstructive tactics, including patient positioning, operative approach, and choice of fixation implants. Important preoperative decisions include the following:
- 1.
Determination of whether the fracture is reconstructible or if the patient is better served by elbow arthroplasty
- 2.
Estimation of the need for visualization of the articular surface to determine the surgical approach and handling of the extensor mechanism
- 3.
Identification of a stable fixation construct that would allow early unrestricted range-of-motion movement
Timing of Operative Intervention
Fractures of the distal humerus are best managed early, but as with most complex intraarticular fractures, definitive treatment should be delayed until optimal surgical resources and personnel and the necessary implants are available. Preoperative planning is essential and should include imaging studies necessary to request the resources mentioned earlier. Patients with isolated injuries are managed at the discretion of the surgeon and based on readiness of the operating suite and the availability of implants. Elderly patients or patients with associated comorbidities must be stabilized before fracture reconstruction. Patients who are managed within 24 hours seem to have fewer complications associated with heterotopic ossification and elbow stiffness and may be more likely to return to work.
Polytrauma Patients
Patients with trauma of multiple bones or associated multisystem trauma are managed according to their overall status and prioritization of their other injuries. This situation may result in a significant delay in definitive management ranging from days to weeks. Such delays ultimately make fracture reduction and fixation more difficult and jeopardize the long-term outcome. Close collaboration with the trauma team leader, general surgeon, or intensivist allows these team members to appreciate the importance and benefits of early fracture fixation. Similarly, the treating orthopedist should be available to proceed with fixation when the patient has been stabilized and cleared for surgery.
Open Fractures
Open fractures are managed urgently with irrigation and débridement. Definitive internal fixation should be applied when the wound is free of contamination and the general condition of the patient permits the procedure. McKee and coworkers reviewed the results of 26 open intraarticular supracondylar fractures managed with a posterior exposure and medial and lateral column plating. The overall infection rate in this series was 11% (3 of 26); however, only one patient developed a deep infection requiring surgical débridement. Other authors have noted a deep infection rate of 28% in high-energy fractures. A much larger proportion of Gustilo type III fractures was noted in the latter study compared with McKee’s report (45% vs. 15.4%) and may account for the apparent discrepancy in infection rates. Not surprisingly, open fractures have been shown to have worse functional outcomes than their closed counterparts.
Fractures in Elderly Adults
Successful execution of the principles of ORIF becomes increasingly more difficult in elderly patients because of fracture comminution, poor bone quality, inadequate fracture stability, and a relative intolerance of joint immobilization. Although good results have been shown in many series, complication rates approaching 30% have also been documented. In response to these poor outcomes, some authors have advocated TEA as a primary treatment method. Although early results of TEA for distal humerus fractures are encouraging, long-term data regarding loosening rates, periprosthetic fracture, and functional outcomes are scant. It is nearly impossible to carry out successfully a truly randomized clinical trial because often the reason for abandoning internal fixation is the practical limitation imposed by the bone quality and degree of comminution. In addition, a failed total elbow replacement in an otherwise active patient can be devastating.
Open Reduction and Internal Fixation in Elderly Adults.
The ideal of stable ORIF followed by early joint mobilization and rehabilitation is usually achievable in younger patients, but elderly patients with fracture of the distal humerus may require different strategies to obtain a satisfactory result. In response to the difficulties in achieving adequate fixation in osteopenic elderly patients with distal humerus fracture, modifications to the traditional dual-plate fixation techniques have evolved, including the use of a supplemental third plate, locking plates, Kirschner wire augmentation, and parallel plating techniques. A review of ORIF in elderly patients has revealed satisfactory results for the most part. Pereles and colleagues showed an average arc of motion of 112 degrees, a functional Mayo Elbow Performance Score, and no difference in the SF-36 score compared with normal data in 14 patients with distal humerus fractures treated with ORIF. Good or excellent results were achieved in 12 patients, but only 25% of patients reported no pain. The mean age in this group was 70 years.
John and associates evaluated 49 older patients (mean age 80 years) an average of 18 months after ORIF. Good or very good results were achieved in 85%, with 85% having a range of motion of 90 degrees or greater; 66% of these patients reported no pain. This group included extraarticular fractures (16%), unicolumnar fractures (27%), and bicolumnar fractures (57%). Huang and coworkers retrospectively reviewed 19 patients older than 65 years with distal humerus fractures treated with ORIF. In this series, all fractures united with a mean time to union of 14.6 weeks, and all patients showed a good-to-excellent result based on the Mayo Elbow Performance Score. Other more recent studies have shown far less satisfactory results, however, with higher complication rates and additional surgeries ( Table 18.3 ).
| Reference | No. Patients (Mean Age) | No. Good-to-Excellent Results | Mean Postoperative Flexion-Extension Arc | No./Type of Complications | No. Secondary Procedures |
|---|---|---|---|---|---|
| John et al | 49 (80 yr) | 31/39 complete follow-up (79%) | 85% with minimum of 30 to 120 degrees | 10 (20%)/1 wound infection, 1 nonunion, 2 broken plates, 6 transient ulnar neurapraxias | 2: 1 wound débridement for infection, 1 broken implant removal |
| Pereles et al | 18 (71 yr) | 12/12 complete follow-up (100%) | 18 to 130 degrees | 2 (11%)/2 loose implants | 1: revision for loosened implants |
| Huang et al | 19 (72 yr) | 19 (100%) | 17 to 128 degrees | 2 (10.5%)/1 superficial wound infection, 1 ulnar nerve injury | None |
| Srinivasan et al | 21 (85 yr) | 12 (57%) | 22 to 100 degrees | 7 (25%)/4 wound infections, 2 nonunions, 1 heterotopic ossification | 1: removal of implants secondary to infection |
| Korner et al | 45 patients (73 yr) | 58% | Median arc 100 degrees | 13 (29%)/12 implant failure and screw loosening, 1 persistent ulnar neuropathy | 7: all secondary to implant failure or loosening |
Total Elbow Replacement in Elderly Adults.
Early clinical experiences with elbow arthroplasty for various degenerative conditions showed variable results, with high rates of unsatisfactory outcomes related to loosening and instability. Advances in implant technology and surgical technique have led to predictably good outcomes in properly selected patients. The available literature evaluating elbow arthroplasty in older patients with acute distal humerus fractures shows excellent early results, with a satisfactory flexion-extension arc of approximately 110 degrees and excellent relief of pain. The length of follow-up in these studies is 2 to 4 years and does not address the long-term concerns of implant loosening, mechanical failure, revision requirements, and functional implications.
More recently, Kamineni and Morrey evaluated the results of 49 distal humerus fractures in 48 elderly patients treated with TEA after an average of 7 years. The authors showed high functional outcome scores, but with a relatively higher rate of postoperative complications than seen in other studies. They noted a regression of the initial flexion-extension arc by 25 degrees, ultimately still averaging a functional arc of 24 to 131 degrees. Although long-term results in patients with TEA for inflammatory arthritis do seem durable, the results of TEA in patients with posttraumatic arthritis show lower patient satisfaction and possibly greater mechanical failure rates than in patients with inflammatory arthritis. A patient seeking to engage in high-demand activities is a poor choice for TEA ( Table 18.4 ).
| Reference | No. Patients (Mean Age) | No. Good-to-Excellent Results; Mean Mayo Elbow Score | Mean Postoperative Flexion-Extension Arc | No./Type of Complications | No. Secondary Procedures |
|---|---|---|---|---|---|
| Cobb and Morrey | 20 (72 yr) | 20 (100%); 95 | 25 to 130 degrees | 5 (25%)/1 ulnar component fracture, 3 ulnar neurapraxias, 1 reflex sympathetic dystrophy | 1: revision fractured ulnar component |
| Ray et al | 7 (82 yr) | 7 (100%); 92 | 20 to 130 degrees | 1 (14%)/1 superficial wound infection | None |
| Gambirasio et al | 10 (85 yr) | 10 (100%); 94 | 23.5 to 125 degrees | 1 (10%)/1 heterotopic ossification | None |
| Garcia et al | 19 (73 yr) | 16/16 complete follow-up (100%); 93 | 24 to 125 degrees | 1 (5%)/1 superficial wound infection | None |
| Kamineni and Morrey | 49 (67 yr) | 40/43 complete follow-up (93%); 93 | 24 to 131 degrees | 17 with at least 1 complication (35%)/11 wound infections, 3 neurologic symptoms, 3 periprosthetic fractures, 3 loose implants | 10: 5 wound débridements, 2 revisions for periprosthetic fracture, 3 revisions for loose components |
In one of the few comparative studies, Frankle and associates compared the results of TEA with ORIF in women older than 65 years with distal humerus fractures. Patients treated with TEA showed significantly better results using the Mayo Elbow Performance Score than patients treated with ORIF. The authors suggested that women older than 65 years with significant associated comorbidities (e.g., rheumatoid arthritis, osteoporosis, and conditions requiring systemic steroids) and the presence of articular comminution be managed with TEA. Provided that the articular fracture components are large, however, these authors recommended ORIF as long as the patient’s physiologic age is less than 90 years.
McKee and colleagues, in a prospective randomized controlled trial of ORIF versus TEA for displaced intraarticular distal humerus fractures in elderly patients, concluded that in patients who are not amenable to stable fixation with ORIF, TEA is the preferred alternative treatment modality.
We agree with the previously mentioned studies of Frankle and associates that successful management of these patients must take into account the patient’s physiologic age, functionality, associated comorbidities, and fracture characteristics. Specific fracture characteristics in this patient population that are unreliably stabilized with internal fixation include the following:
- •
Significant comminution of the trochlea
- •
Associated coronal plane fracture patterns
- •
Fractures that occur almost entirely below the olecranon fossa
In these injuries, the small fragments combined with frequently coexisting osteoporosis make TEA an attractive alternative ( Case Study 18.1 ). CT is particularly useful in assessing the presence of coronal plane fracture fragments. Patients who are unable or unwilling to refrain from strenuous physical activity must be extensively counseled regarding the risks of implant loosening and periprosthetic fracture and the potential for a poor outcome. In these patients, ORIF with techniques to obtain union of the distal humerus, including postoperative immobilization, should be strongly considered, rather than TEA.
A 74-year-old woman has a low-energy distal humerus fracture that occurred when she fell from a standing position ( eFigure 18.1 ). She has no significant associated comorbidities.
Your preferred treatment method is:
- A.
Open reduction and external fixation (ORIF) via olecranon osteotomy
- B.
ORIF via a triceps-sparing exposure
- C.
Total elbow arthroplasty
- D.
Cannot determine without CT scanning
Correct answer:
- C.
Total elbow arthroplasty
The injury pattern is that of a very low, comminuted distal humerus fracture with significant osteopenia. CT scanning is likely to confirm the comminution but is not essential. ORIF is extremely challenging and if performed should be done using a triceps-mobilizing exposure rather than an osteotomy because of the difficulty in switching to an arthroplasty in the setting of an osteotomy.
The degree of comminution is displayed in eFigure 18.2 .
A cemented total elbow arthroplasty procedure was performed using the Bryan-Morrey triceps-sparing approach to the elbow ( eFigure 18.3 ).
Patient Position and Anesthesia
Fractures of the distal humerus can be managed with the patient in the supine, lateral, or prone position, with the choice based on the anticipated exposure, the presence of other injuries, and surgeon preference. The lateral and prone positions ( Figure 18.15 ) are most commonly employed when proceeding with posterior exposures of the elbow. The supine position is typically reserved for lateral elbow exposures or for patients with multisystem trauma that precludes lateral or prone positions.
ORIF of fractures of the distal humerus is typically a lengthy procedure requiring a general anesthetic. Postoperative pain control may include the use of selective upper extremity nerve blockades; however, the postoperative neurologic examination of the hand would be impaired for the duration of the block. Consideration should be given to postoperative block placement, which allows for examination of nerve function after completion of the case. A sterile tourniquet may be employed but is used infrequently, only if it can be placed proximal enough on the arm to avoid interference with fracture reduction and fixation.
Operative Exposures
Virtually all fractures of the distal humerus treated operatively can be approached through a midline posterior skin incision ( Figure 18.16 ). An effort should be made to deviate the incision a full 2 cm away from the tip of the olecranon. The lateromedial plane of dissection is directed between the triceps muscle and its investing fascia. The next step in any exposure of the medial column is identification and protection of the ulnar nerve. The nerve is mobilized and protected throughout the procedure. Instruments are not attached to any loop or Penrose drain around the nerve to prevent accidental traction on the nerve. A Penrose drain is looped about the nerve and sutured to itself. No instruments should be attached to the drain to avoid accidental traction injury to the nerve. The medial intermuscular septum is incised if fracture management requires exposure of the anteromedial elbow. Similarly, the laterally directed dissection leads to the lateral intermuscular septum.
