Rehabilitation After Distal Humerus Fractures
Gregory N. Nelson Jr, MD
Laura Walsh, MS, OTR/L, CHT
Joseph A. Abboud, MD
Dr. Abboud or an immediate family member has received royalties from Cayenne, DJ Orthopaedics, Globus Medical, Integra Life Sciences, and Wolters Kluwer Health–Lippincott Williams & Wilkins; serves as a paid consultant to Cayenne, DePuy, A Johnson & Johnson Company, DJ Orthopaedics, Globus Medical, Integra, Mininvasive, and Tornier; has stock or stock options held in Mininvasive; has received research or institutional support from DePuy, A Johnson & Johnson Company, Integra, Tornier, and Zimmer; has received nonincome support (such as equipment or services), commercially derived honoraria, or other non-research–related funding (such as paid travel) from Wolters Kluwer Health–Lippincott Williams & Wilkins; and serves as a board member, owner, officer, or committee member of the American Shoulder and Elbow Surgeons, the Journal of Shoulder and Elbow Surgery, the Mid Atlantic Shoulder and Elbow Society, and Orthopaedic Knowledge Online. Neither of the following authors nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Nelson and Dr. Walsh.
Introduction
Fractures of the distal humerus are relatively uncommon injuries. While comprising nearly one-third of all elbow fractures, these injuries make up only 5% to 7% of all fractures. This injury typically has a bimodal distribution occurring from either high-energy trauma in a young population or low-energy injury in the elderly. These two injuries should not be considered as equivalent, however, since each presents with a unique set of challenges. In addition to patient age and injury mechanism, associated traumatic injuries, local soft-tissue condition, medical comorbidities, and fracture pattern are important considerations in the prognosis, timing, and treatment of these injuries. Ultimately, each of these criteria will have an effect on both the treatment and rehabilitation for these patients.
Fracture Pattern
Multiple classification schemes have been used to describe distal humerus fractures. In the end, the primary goal of classification schemes is to provide the health care team with a common vernacular for communication, to guide clinical decision making, and to help predict the prognosis after treatment. Specifics of the most common classification schemes are beyond the scope of this chapter; however, it is important to understand how fracture patterns affect the treatment algorithm.
Distal humerus fractures are generally considered to occur in one of three types: complete extra-articular, partial intra-articular, or complete intra-articular (Figure 20.1). A complete extra-articular fracture involves the distal humeral shaft and variable portions of the columns, but spares the articular surface. Partial and complete articular fractures involve the distal humeral joint surface, but to varying degrees. Each fracture pattern is addressed with different surgical approaches depending on the location of fracture lines and the amount of comminution involved. In all cases, however, the goal of the intervention is to achieve sufficient stability of the fracture in order to allow early range of motion (ROM) and preserve or restore a functional ROM to the elbow joint.
Treatment
Nonoperative Management
Unlike midshaft humeral fractures, conservative management is rarely pursued in the setting of a distal fracture, except in rare cases of nondisplaced fracture that are amenable to supervised immobilization. Some authors have reported good results with bracing extra-articular fractures of the distal one-third of the humerus. Unfortunately, bracing often equates to prolonged immobilization, which can result in periarticular contractures and stiffness of the adult elbow. Factors contributing to the development of elbow contracture include the three articulations within one synovial cavity, the intrinsic congruity of the ulnohumeral articulation, and the close relationship of the joint capsule to the surrounding ligaments and musculature. The sequela of prolonged immobilization (stiffness) can be just as debilitating as those of the injury. In some instances, depending on the fracture pattern, custom orthoses will allow protected safe motion, minimizing postinjury
stiffness. Fracture healing through a brace or orthosis requires adequate overlap and proximity of fracture fragments in order to produce bridging callus. Although this can be achieved in a small subset of injuries, most distal humerus fractures are not amenable to nonoperative treatment. In general, surgical intervention is recommended.
stiffness. Fracture healing through a brace or orthosis requires adequate overlap and proximity of fracture fragments in order to produce bridging callus. Although this can be achieved in a small subset of injuries, most distal humerus fractures are not amenable to nonoperative treatment. In general, surgical intervention is recommended.
 Figure 20.1 Distal humerus fracture patterns and fixation. Fractures that involve the distal humeral shaft and articular surface can present in a variety of patterns. A, Illustration of type I, extra-articular. These fractures separate the articular surface as a single unit from the rest of the humeral shaft. B, Illustration of type II, partial articular. These fractures leave a portion of the articular surface in continuity with the humeral shaft. Note that fractures can occur in axial, sagittal, coronal, or oblique planes. C, Illustration of type III, complete articular. In this pattern, the articular surface is fractured and the entire articulation has been separated from the proximal humeral shaft. D, AP and lateral plain radiographs of a distal humeral transcondylar fracture. The postoperative radiograph demonstrates anatomic reduction of the fracture, bicolumnar plating, multiaxial locking screws, and interdigitating screw paths to maximize fixation rigidity. (Reproduced with permission from Sculco TP, Lim MR, Pearle AD, Ranawat AS. Hospital for Special Surgery Orthopaedics Manual. Philadelphia, Lippincott Williams & Wilkins, 2014. Redrawn with permission from Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium–2007: Orthopaedic Trauma Association classification, database, and outcomes committee. J Orthop Trauma 2007;21(10 Suppl):S1–133.) |
Nonoperative treatment may also be appropriate if there are medical comorbidities or associated traumatic injuries (e.g., soft-tissue compromise, wound contamination, anesthetic risk) that render the risks of surgical intervention greater than the benefit. The most common scenario would be an intra-articular fracture in a low-demand, elderly patient with significant comorbidities. In this setting, the elbow is immobilized in an orthosis, then ROM is instituted once initial pain and swelling have improved. This “bag-of-bones” approach often results in a fibrous nonunion of intra-articular fragments or a pseudo-arthrosis at the fracture site. This is sometimes well tolerated in the low-demand population.
Operative Treatment
Indications
In the vast majority of patients, operative treatment is undertaken in order to maximize chances of achieving a stable extremity with a functional arc of elbow motion. The most common operative strategy is open reduction and internal fixation (ORIF), especially in young or high-demand patients.
Rigid fixation that can withstand physiologic forces transmitted through the fracture site during rehabilitation is the goal. This permits immediate of ROM exercises in order to minimize postoperative stiffness.
Rigid fixation that can withstand physiologic forces transmitted through the fracture site during rehabilitation is the goal. This permits immediate of ROM exercises in order to minimize postoperative stiffness.
Procedure
The vast majority of ORIF procedures are performed through an extensile posterior approach to the elbow. A longitudinal incision is made along the midline of the posterior arm extending distal to the olecranon. Corresponding full-thickness medial and lateral skin flaps are raised. The ulnar nerve is identified next, and in many cases transposed anteriorly, especially if the fracture involves the medial column. In this case, the nerve is moved in order to place the implants from a medial to lateral direction, or to apply a medially based plate and screws.
The next anatomic structure to address is the extensor mechanism. Assuming that the triceps was not injured in the original trauma, it is preferred to leave the extensor mechanism intact and approach the fracture through a paratricipital approach, triceps splitting, or, in rare cases, a V-Y advancement. However, highly comminuted intra-articular fractures will require the increased surgical exposure that an olecranon osteotomy provides. Proximal reflection of the olecranon and triceps improves visualization of the trochlear spool and, in fractures with severe articular comminution, is the preferred method. In this setting, the olecranon osteotomy will also be repaired with rigid internal fixation.
Once the distal humerus is adequately exposed, the bony injury is addressed. The primary goals of surgery are to achieve perfect alignment of all articular surfaces as well as the extra-articular components of the fracture in order to restore the anatomy of the elbow joint. Secondarily, the surgeon must restore and preserve both the bony and soft-tissue stability of the elbow joint. A comprehensive review of techniques for repair of these fractures is beyond the scope of this chapter. However, there are key fundamental principles for fixation that almost always need to be followed. First, adequate and safe exposure with identification, transposition, and protection of the ulnar nerve is paramount. The next goal is to reconstruct the articular surface by recognizing the injury pattern, associated comminution, and articular relationships. These fragments often need to be provisionally reduced through the use of reduction forceps, Kirschner wires, and headless compression screws. Third, fixation of the fracture progresses from distal to proximal, utilizing bicolumnar locked plating (Figure 20.1, D). Finally, an assessment of the stability of the elbow joint is required. Restoring stability may necessitate formal repair of the collateral ligaments and/or (rarely) the application of an external fixator. At the end of the procedure, the elbow is usually splinted in slight extension to protect the healing posterior soft tissues.
Postoperative Rehabilitation
Given that elbow fractures are prone to result in contractures and stiffness, early therapy is advocated. Communication
between the surgeon and therapist regarding stability of the fracture fixation, status of the ulnar nerve, including if the nerve was transposed, and status of the triceps, is imperative. This will enable the therapist to implement a therapy program maximizing early motion while safely protecting the compromised structures and minimizing complications. In the case of ORIF, more often than not, rigid fixation allows the institution of ROM exercises within the first few postoperative days. Lesser rigid fixation may require protected or delayed motion. Due to risk of contracture, elbow motion should be instituted no later than 3 weeks postoperatively, although immediate motion is ideal.
between the surgeon and therapist regarding stability of the fracture fixation, status of the ulnar nerve, including if the nerve was transposed, and status of the triceps, is imperative. This will enable the therapist to implement a therapy program maximizing early motion while safely protecting the compromised structures and minimizing complications. In the case of ORIF, more often than not, rigid fixation allows the institution of ROM exercises within the first few postoperative days. Lesser rigid fixation may require protected or delayed motion. Due to risk of contracture, elbow motion should be instituted no later than 3 weeks postoperatively, although immediate motion is ideal.
Table 20.1 PHASE I (WEEKS 0–2) THERAPY OVERVIEW | ||||||||||||||||||||||||||||||
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Author’s Preferred Protocol
Phase I: Inflammation (Weeks 0–2) (Table 20.1)
Orthoses: The postoperative splint is exchanged for a removable and lighter thermoplastic molded orthosis fabricated by the therapist at the first postoperative visit. The following are orthosis options:
Long-arm orthosis: The injured elbow can be immobilized in a position of protection as determined by the treating surgeon. This type of orthosis prevents all motion when worn (Figure 20.2).
Worn for activities of daily living (ADLs) and sleeping
May be removed to perform protected ROM exercises as instructed by the therapist and approved by surgeon
Hinged orthosis
A hinge design allows the therapist to limit motion while still allowing safe motion. The hinge parameters can be set to block flexion or extension at a specific degree without impeding supination and pronation (Figures 20.3 and 20.4). Additionally, the hinge will provide protection from varus and valgus stress, if needed, for ligament protection.
Does not require removal for ROM exercises or ADLs given that it allows built-in protected motion.
This orthosis is our preference given that the patient does not need to remove it, preventing risk of injury or incorrect reapplication.
Hinged external fixator
Placed on the elbow in surgery in cases of significant instability pattern.
The patient will be able to participate in ROM and functional activities within the parameters of the hinge, which are set by the surgeon during surgery (Figure 20.5).
An orthosis can be designed over the hinge for times when the patient feels that the fixator may get bumped (Figure 20.6).
Over-the-shoulder sling
May be utilized in early stages for extra support in addition to the orthosis, although continuous wear is not recommended due to risk of shoulder stiffness from unnecessary immobilization of the shoulder.
Edema Control
Cryotherapy: 10 to 20 minutes postexercise
Figure 20.2 Photograph of long-arm orthosis.
Figure 20.3 Photograph of elbow flexion in hinged splint.Related posts:
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