Fractures of the distal humerus are less common than other fractures frequently encountered by orthopaedic surgeons, yet when encountered, often provide significant challenges in management.
Distal humeral fractures occur in a bimodal distribution, with high-energy injuries in young people and low-energy osteoporotic fractures in older adults. With our aging population, the incidence of distal humeral fractures is increasing. Treatment options include non-operative treatment, open reduction and internal fixation (ORIF), and elbow arthroplasty. There have been significant advances in techniques and implants for internal fixation as well as for elbow arthroplasty. In spite of this, complications remain frequent and outcomes, in many cases, suboptimal.
Patients present with typical symptoms of a fracture including pain, swelling, and deformity. While most fractures are closed, open injuries are not uncommon in patients with high-energy injuries. Complete nerve injuries are uncommon; however, numbness and weakness in the distribution of the ulnar nerve is not uncommon and should be carefully documented at initial presentation.
AP and lateral radiographs are sufficient to characterize extra-articular fractures; however computed tomography, preferably with 3D reconstructions, should be considered to better characterize intra-articular fractures and evaluate coronal shear injuries of the capitellum and trochlea, which are often difficult to detect on plain radiographs. A more detailed knowledge of the fracture pattern can be helpful in determining the optimal management, directing the surgical approach, and selecting appropriate implants.
Non-operative treatment is indicated for low-demand patients with severe medical co-morbidities or advanced dementia. A sling with early range of motion is utilized in patients who are not a candidate for surgery and have dementia, cachexia, or poor quality skin that precludes the use of a splint or cast due to potential problems with skin breakdown. An unstable non-union is the expected result; some patients develop pain, while others have little discomfort.
Minimally displaced distal humeral fractures in older adults who are not candidates for surgery can be treated with cast immobilization. Some, but not all, of these fractures will unite with 6 to 8 weeks of cast immobilization; however, residual stiffness is a frequent and expected result of this treatment approach. Frequent follow-up is required during cast treatment to evaluate fracture alignment and the condition of the skin. A stable elbow with a united fracture, even if stiff, tends to be more useful in older adults than an unstable elbow with a non-union. A flail elbow limits the ability to place the hand in space and to provide the support necessary to ambulate with a walker.
Open Reduction and Internal Fixation
Open reduction and internal fixation is typically employed for most distal humeral fractures. The patient can be positioned in the supine, lateral, or prone position depending on surgeon preference and the availability of assistants. Preoperative antibiotics and a sterile tourniquet are recommended.
A posterior elbow incision is made just medial to the tip of the olecranon to protect against flap necrosis, which typically involves the medial side of the elbow. An anterior subcutaneous transposition of the ulnar nerve is recommended. If the fracture is extra-articular or is a simple intra-articular pattern, a paratricipital approach is employed, preserving the triceps insertion on the olecranon (Figures 1a-1d). This approach should be strongly considered for patients in wheelchairs and for those who use walkers to ambulate, as it allows for an earlier return to activity.
Figures 1a-d: Distal humeral fracture, ORIF. AP and lateral radiographs of a 62-year-old woman with a compound grade II distal humeral fracture (Figures 1a-1b). Six months following ORIF with parallel plates using a paratricipital approach (Figures 1c-d). Range of motion was 20 to 140 degrees.
A Bryan-Morrey or triceps splitting approach can be employed for distal humeral fractures where conversion to a total elbow is a possibility. An olecranon osteotomy provides the best exposure for most cases of comminuted intra-condylar distal humeral fractures. The use of pre-contoured plates to fix the olecranon osteotomy is more reliable and has a lower incidence of complications than tension band fixation.
When performing an olecranon osteotomy, visualize the non-articular portion of the ulna by exposing both medially and laterally. Secure a pre-contoured plate to the proximal ulna and then remove it. Perform a transverse or apex distal chevron osteotomy using an oscillating saw, cutting three-quarters of the way to the articular surface. Drill the remaining portion of the olecranon prior to completing the osteotomy with osteotomes. Elevate the triceps with the olecranon tip to gain wide exposure of the distal humerus.
Implants available for internal fixation of distal humeral fractures have evolved in recent years. Pre-contoured plates with or without a locking option are now available; however, evidence has yet to demonstrate improved outcomes with these implants. They are more costly than conventional implants. Medial and lateral column plates can be placed either parallel or in a "90-90" configuration, depending on the fracture pattern. In severely comminuted distal humeral fractures, three plates can be used to improve fixation. The primary advantage of parallel plating is that longer screws can be placed into the lateral column as compared to the use of a posterior plate.
To avoid damaging the lateral collateral ligament (LCL), it is important to avoid soft tissue stripping in the region of the lateral epicondyle when applying a lateral plate. The distal end of the lateral plate should sit on top of the LCL origin to avoid instability. The lateral plate tends to be the most symptomatic for patients due to prominence along the lateral epicondyle. Since most non-unions occur at the supracondylar level, it is critical to apply compression at the fracture site and to achieve sufficient fixation both proximal and distal to the fracture. Robust plates are employed, particularly if there is extension of the fracture proximal to the olecranon fossa. Most pre-contoured plates available today are more rigid than previously used pelvic reconstruction plates.
Three screws should be placed above and below the fracture in each of the medial and lateral plates. The advent of locking plates for the management of distal humeral fractures may improve outcome; however, surgeons should be cautious with their use as many of these plates have fixed angle options that direct screws in orientations that may not be optimal for every fracture. For this reason, a polyaxial locking option is preferable. With a significant supracondylar comminution, humeral shortening should be performed to improve bony contact. This is particularly important in older adult patients and in patients with compound distal humeral fractures.
Most series report 70-80% good to excellent results with open reduction and internal fixation. Most patients achieve a functional arc of motion. The complication rates remain high, varying from 10% to 30% in the literature. These include, but are not limited to:
- Painful hardware
- Post-traumatic arthritis
Ulnar neuropathy is the commonest complication from treatment of a distal humeral fracture.
Total Elbow Arthroplasty
The operative management of distal humeral fractures in older adults is challenging; small distal fragments and poor-quality bone lead to an increased incidence of non-union with ORIF. Prolonged anesthesia and a poor soft tissue envelope increase the risk of surgical and postoperative complications. The choice between ORIF and elbow arthroplasty primarily depends on patient factors such as age, expectations, and functional demands, as well fracture factors including the pattern, comminution, and extent of osteoporosis.
Elbow arthroplasty should be considered for a comminuted distal humeral fracture who is an older, low-demand patient for whom stable fixation and fracture union are unlikely to be achieved. Elbow arthroplasty is also used in older patients with pre-existing rheumatoid arthritis and osteoarthritis. While patient age is less useful than evaluating patient activity and expectations, in general elbow arthroplasty should be considered in females over 65 and males over 70 (Figures 2a-2d).
Figures 2a-d: Distal humeral fracture, total elbow arthroplasty. AP and lateral radiographs of an 88-year-old woman following a fall in her seniors apartment (Figures 2a-b). Four months post-linked total elbow arthroplasty (Figures 2c-d). Her elbow was pain free and range of motion was 30 to 135 degrees.
Elbow arthroplasty is contraindicated if the patient is unable or unwilling to live within the limitations of an elbow arthroplasty, which involves no lifting of more than 5 kg and no upper extremity sporting activities (eg, golf). Elbow arthroplasty should not be performed in patients with severe dementia, high-grade compound fractures, a history of infection, or a poor soft tissue envelope or in those with a non-functional hand. Fracture characteristics, patient expectations, and co-morbidities are more important than absolute age.
Surgical technique depends on the arthroplasty system selected. Most patients are treated with a linked elbow arthroplasty through a paratricipital approach with a concomitant anterior transposition of the ulnar nerve. The distal humeral fragments are removed. Insertion of the humeral component is straightforward; however, access for replacement of the ulnar component can be challenging with the triceps still intact. Careful preparation of the ulnar canal and accurate component positioning are essential for longevity of a total elbow arthroplasty. Due to the severe osteoporosis of patients undergoing a total elbow arthroplasty for a distal humeral fracture, extreme caution must be taken to avoid an intra-operative fracture during component insertion.
A recent randomized clinical trial demonstrated improved short-term outcomes in older patients with distal humeral fractures treated with a linked total elbow arthroplasty when compared wotj ORIF. The objective and subjective outcomes were superior, the surgical duration was shorter, and the complication rates were lower with total elbow arthroplasty. The long-term functional outcome and durability of total elbow arthroplasty in older adults, however, is not yet known, with most of the available literature limited to short-term follow-up.
The complication rates for total elbow arthroplasty remain higher than those reported for other joint replacements. Soft tissue healing problems, ulnar neuropathy, intraoperative fractures, and infection can occur in the short term, while implant wear and loosening are significant concerns in the long term, particularly in younger, more active patients.
Distal Humeral Hemiarthroplasty
The advent of anatomic distal humeral hemiarthroplasty has provided another option for this patient group (Figures 3a-3e). The indications for a hemiarthroplasty versus a total elbow arthroplasty have not yet been clarified. Hemiarthroplasty may have a role in younger patients with an unreconstructable comminuted distal humeral fracture, for whom the longevity of a total elbow arthroplasty may be a concern. Although insertion of the humeral component is straightforward, the challenge is to achieve stability of the elbow by careful preservation or repair of the epicondyles with the associated collateral ligaments. The implant can be inserted using an olecranon osteotomy or a paratricipital approach, with repair of the collateral ligaments and epicondyles to the implant using sutures, tension band wires, or plates as appropriate.
Figures 3a-e: Distal humeral fracture, hemiarthroplasty. AP and lateral radiographs of an 83-year-old woman following a fall while gardening (Figures 3a-b). She maintains her own home and is otherwise well. CT scan shows a comminuted articular fracture of the distal humerus (Figure 3c). Six months post-anatomic distal humeral hemiarthroplasty (Figures 3d-e). Her elbow was pain free and range of motion was 15 to 145 degrees.
The results of distal humeral hemiarthroplasty are preliminary, with small patient cohorts and short-term follow-up. The advent of convertible elbow arthroplasty, where the surgeon can choose between a hemiarthroplasty and linked device intra-operatively with the same system may be helpful to reduce implant inventory. This option should be particularly helpful to manage instability or ulnar wear following a hemiarthroplasty because the humeral stem does not need to be removed to allow conversion to a linked total elbow arthroplasty.
Open reduction and internal fixation of distal humeral fractures is the treatment of choice in most patients. The increasing incidence of comminuted osteoporotic distal humeral fractures in older adults will result in greater utilization of elbow arthroplasty for the management of these fractures in the future. While elbow arthroplasty is highly effective in the short-term, these devices should be avoided in younger and higher-demand patients, as complications such as polyethylene wear and aseptic loosening are challenging to manage for the patient and the surgeon alike.
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Reprinted with permission from the Summer 2010 issue of COA Bulletin