Distal Humerus Fractures
Shoulder Anatomy
Description
- The shoulder joint is a multi-axial joint with muscles crossing it to allow shoulder range of motion (ROM)
- The rotator cuff muscles are important in allowing shoulder ROM
- The rotator cuff muscles consists of Subscapularis, Supraspinatus, Infraspinatus and Teres Minor
- Other important shoulder muscles that allow shoulder ROM include long head of Biceps and the Deltoid muscle
Upper Limb Anatomy
Right shoulder and arm, posterior view
Medial aspect of right forearm
Blood supply around the elbow joint
Blood supply and anastomosis around the right elbow. Anterior view
Distal Humerus Biomechanics
The triangular structure of distal humerus at elbow joint provides structural strength.
Anterior view right distal humerus bone
The elbow joint is a hinge joint with axis of rotation around throchlear axis
Elbow joint structural stability structures
Distal Humerus Fractures
The mechanism is an axial compression with varying elbow ROM. Flexed elbow < 90° usually results in a transcolumnar fracture while > 90° result in an intercondylar fracture pattern.
Associated injury:
- Elbow dislocation and instability (exclude Terrible Triad Elbow injury)
Presentation:
- Pain with supination and pronation
- Swelling
- Deformity
- Block to elbow range of motion
Clinically:
- Bone tenderness
- Haemarthrosis
- Flexion/extension painful
- Avoid ROM to avoid neurovascular injury
- Assess neurovascular status and exclude compartment syndrome
Investigations:
- X-ray: AP & Lateral & Greenspan views.
- CT: often required especially for intra-articular fracture evaluation and surgical planning.
Classification
- Supracondylar (AO classification)
- Distal single column (Milch classification, AO classification)
- Bicolumnar (Jupiter classification, AO classification)
AO Classification for Distal Humerus Fractures
AO Classification for Distal Humerus Fractures
Milch Lateral Condyle Fracture Classification
Milch Ⅰ: fracture line lateral to capitello-trochlear groove
Milch Ⅱ: fracture passes through the capitello-trochlear groove, unstable elbow
Jupiter & Mehne & Matta Classification Distal Humerus Fracture
Management
Non operative:
-
- Stable and nondisplaced Milch Type Ⅰ fracture
- Cast: Forearm in supination for lateral condyle fractures while in pronation for medial condyle fractures
Operative treatment:
-
-
- Supracondylar fractures
- Elbow dislocation with associated displaced fracture
- Ligamentous disruption with elbow instability with associated fracture
- Intercondylar
- Open fracture
-
Surgery options:
-
-
- ORIF plate and screw fixation: supracondylar and intercondylar
- External fixator
- Total elbow joint replacement: elderly with bicolumnar fractures
-
Plate and Screw Fixation
Elbow external fixator for fractures around the elbow joint area
Indication consideration:
-
-
- Open fracture
- Unstable fracture or additional support after ORIF
- Major bone loss
- Vascular injury
-
Hinged elbow external fixator
Elbow Joint Replacement
Total joint replacement a consideration for elderly patients with significant comminuted fractures.
Surgery Technique
Posterior Approach to Distal Humerus/Elbow/Proximal Ulnar
Nerves posterior to elbow joint
Posterior approach to right distal humerus, Radial nerve at risk
Radial nerve is responsible for motor elbow and wrist extension. Sensory distribution shown on pic.
Skin Incision Approach to Distal Humerus/Elbow/Proximal Ulnar
Distal humerus to curving around the lateral olecranon to 2-4cm along ulnar crest
Deep posterior approach to distal humerus/elbow:
Fascia release or olecranon osteotomy
Medial window: Medial fascia release
- Ulnar nerve exploration along medial intermuscular septum and followed to the cubital tunnel, isolate and retract with latex loop
- Retract triceps laterally
- Medial attachment of triceps along olecranon is partially released
Lateral window: Lateral fascia release
- Free triceps on lateral side
- Split triceps fascia & mobilize from lateral intermuscular septum &
- partially release triceps tendon on lateral side of olecranon with 1mm sliver of cartilage
- Retract triceps medially
- Distally partially release anconeus
Midline Window: Midline fascia release
- Split triceps tendon in midline to to upper limit of olecranon fossa to proximal triceps muscle area with caution to Radial nerve for more proximal muscle splitting
- Medial incision along medial ulnar border ± cartilage/periosteum sleeve
- Retract the split triceps
Olecranon Osteotomy Principles
- Osteotomy
- Final bone incision with osteotome
- Olecranon fixation options: plate & screws/tension band wire
Distal Humerus Fracture Plate and Screw Fixation
Elbow External Fixator
Hinged external fixator can supplement unstable elbow fracture ORIF and ligament repair.
Safe Zones for Pin Sites for External Fixator around Elbow Joint
Arc for safe zone for application of external fixator pins of right arm
Elbow Joint Replacement
Post Operative Rehabilitation
-
-
- Rigid fixation: arm sling for 7-10 days then elbow range of motion, non-weight bearing
- Suboptimal fixation may require extended splintage
- Strengthening exercises after fracture union
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Arm sling
Hand grip exercises with arm in splint
Download ASSIC Performance Fingerprint or Strength & Conditioning apps for rehab guideline routines or create own under professional supervision
Complications
- Elbow stiffness
- Non union
- Malunion
- Volkmann contracture due to missed initial compartment syndrome at time of injury
References
- A comparative Biomechanical Analysis of 2 Double-Row, Distal Triceps Tendon Repairs. Matthew A Dorweiler, Rufus O Van Dyke, Robert C Siska, Michael A Boin and Mathew J DiPaola. The Orthopaedic Journal of Sports Medicine May 2017, 5(5): 23259671177080.
- Traumatic elbow injuries: what the orthopedic surgeon wants to know. Sheehan S.E. Radiographics 33(3(: 869-888.
- A follow-up of one hundred cases of fracture of the head of the radius with a review of the literature. Johnston GW. Ulster Med J 31: 51-56.
- Management of severely comminuted distal radius fractures. David M Brogan, Marc J Richard, David Ruch, Sanjeev Kakar. J Hand Surg Am. 2015 Sep; 40(9): 1905-14.
- Surgical management for olecranon fractures in adults: a systematic review and meta-analysis. Koziarz A, Woolnough T, Oitment C, Nath S, Johal H. Orthopedic. 2019 Mar 1;42(2): 75-82.
- Classifications in Brief: Mayo classification of olecranon fractures. Sullivan CW, Desai K. Clin Orthop Relat Res. 2019 Apr;477(4): 908-910.
- Elbow fractures. Midtgaard KS, Ruzbarsky JJ, Hackett TR, Viola RW. Clin Sports Med. 2020 Jul;39(3): 623-636.
- Comparison of outcome between nonoperative and operative treatment of medial epicondyle fractures. Petra Grahn, Tero Hämäläinen, Yrjänä Nietosvaara, Matti Ahonen. Acta Orthop. 2021 Feb;92(1): 114-119.
- A narrative review on avulsion fractures of the upper limb and lower limbs. Christopher Vannabouathong, Olufemi R Ayeni, Mohit Bhandari. Clin Med Insights Arthritis Musculoskelet Disord. 2018;11: 1179544118809050.
- Outcome after ORIF of capitellar and trochlear fractures. JH Dubberley, KJ Faber, JC Macdermid, SD Patterson, GH King. J Bone Joint Surg Am. Vol. 88 2006: 46-54.
- Coronal plane partial articular fractures of the distal humerus: current concept in management. DE Ruchelsman, NC Tejwani, YW Kwon, KA Egol. J Am Acad Orthop Surg. Vol 16 2008: 716-728.
- Complex elbow dislocations and the “terrible triad” injury. Allistair D R Jones, Robert W Jordan. Open Orthop J. 2017 Nov 30;11: 1394-1404.
- Articular fractures of the distal humerus. T. Bégué. Orthopaedics & Traumatology: Surgery & Research 100(2014) S55-S63.
