The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 94, Issue 6

Instructional Course Lecture | March 21, 2012

Distal Humeral Fractures: Role of Internal Fixation and Elbow Arthroplasty

Joaquin Sanchez-Sotelo, MD, PhD¹

¹ Department of Orthopaedic Surgery, Gonda 14, Mayo Clinic, 200 First Street SW, Rochester, MN 55905. E-mail address: sanchezsotelo.joaquin@mayo.edu

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Look for this and other related articles in Instructional Course Lectures, Volume 61, which was published by the American Academy of Orthopaedic Surgeons in February 2012:“Ligament Injury and the Use of Hinged External Fixators at the Elbow,” by Bernard F. Morrey, MDPrinted with permission of the American Academy of Orthopaedic Surgeons. This article, as well as other lectures presented at the Academy's Annual Meeting, was available in February 2012 in Instructional Course Lectures, Volume 61. The complete volume can be ordered online at www.aaos.org, or by calling 800-626-6726 (8 a.m.-5 p.m., Central time).

Disclosure: The author received no payments or services, either directly or indirectly (i.e., via his institution), from a third party in support of any aspect of this work. Neither the author nor his institution has had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, the author has not had any other relationships, or engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

J Bone Joint Surg Am, 2012 Mar 21;94(6):555-568. doi: 10.2106/JBJS.946icl

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Extract

The management of distal humeral fractures has evolved over the last few years. Worldwide application of the AO principles of plate and screw fixation during the late 1980s and early 1990s remained the only breakthrough for quite some time¹. Recent major advancements in the management of these injuries include the widespread availability of computed tomography (CT) scans with three-dimensional reconstruction, recognition of the more complex articular shear fractures², understanding the benefits of the parallel-plate technique³, the availability of precontoured periarticular plates, and the selective use of total elbow arthroplasty⁴. Opportunity for improvement remains, as reflected by the interest in distal humeral hemiarthroplasty for the treatment of these injuries and the controversy regarding the ideal management of the ulnar nerve as a part of this surgery and how to best manage structural bone loss. Unfortunately, insufficient internal fixation with Kirschner wires continues to be performed by some surgeons, greatly compromising patient outcome.

Figures in this Article

Introduction

Evaluation

The general principles of evaluation for musculoskeletal injuries apply to distal humeral fractures, including assessment of the soft tissues (especially in open fractures), the neurovascular status of the upper extremity, identification of associated injuries, and adequate imaging studies. It is important to understand whether there was preexisting elbow pathology, such as inflammatory arthritis, and the anticipated physical demands on the elbow, especially when arthroplasty is considered.

Anteroposterior and lateral radiographs of the elbow may be difficult to interpret because of fracture displacement and comminution (Figs. 1-A and 1-B). Radiographs made with the patient under traction are useful, but often are not made until the patient is under anesthesia and ready for surgery. Three-dimensional reconstructions rendered from a CT scan are extremely useful in understanding the fracture pattern and planning treatment; at the Mayo Clinic, we routinely have this imaging study made unless total elbow arthroplasty has already been selected for treatment (Fig. 2).

Fig. 1-A Fig. 1-B

The precise fracture pattern on anteroposterior (Fig. 1-A) and lateral (Fig. 1-B) radiographs may be difficult to interpret because of fragment overlapping and displacement.

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Fig. 2

Computed tomography (CT) scans with three-dimensional reconstruction are extremely helpful in decision-making and surgical planning.

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Treatment selection should be individualized for each particular fracture and patient, but a few general guidelines may be useful (Fig. 3 and Table I). Internal fixation is the treatment of choice whenever possible; the feasibility of internal fixation varies, depending on the type of fracture, bone quality, surgical technique, and surgeon's experience. Elbow arthroplasty is considered very selectively for older patients with end-stage elbow arthritis prior to the fracture or when the severity of destruction of the articular cartilage surface makes reliable internal fixation impossible. There is a small group of patients with severe fractures at an age when arthroplasty would have an unacceptable failure rate; hemiarthroplasty may be considered in those circumstances⁵. Internal fixation or hemiarthroplasty failures may be revised to a total elbow arthroplasty if needed. Shear fractures of the articular surface may require additional neutralization with use of a temporary external fixator.

Fig. 3

Treatment options for patients with distal humeral fractures. xRs = radiographs, OR = operating room, 3D CT = three-dimensional computed tomography, RA = rheumatoid arthritis, ROM = range of motion, and ExFix = external fixation.

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TABLE I Advantages and Disadvantages of Internal Fixation, Total Elbow Arthroplasty, and Distal Humeral Hemiarthroplasty for Distal Humeral Fractures

Advantages	Disadvantages
Internal fixation
Durable	Risk of nonunion
No restrictions	Risk of posttraumatic degenerative joint disease
No prosthesis-related complications	Risk of stiffness
	Requires intensive physical therapy
Total elbow arthroplasty
Bone union not needed	Mechanical failure
Quick return to activities of daily living	Restrictions
Easier recovery
Avoids nonunion and degenerative joint disease
Hemiarthroplasty
Avoids polyethylene	Still requires internal fixation of columns
Convertible to total elbow arthroplasty	Unpredictable motion
	Unpredictable pain relief

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TABLE I Advantages and Disadvantages of Internal Fixation, Total Elbow Arthroplasty, and Distal Humeral Hemiarthroplasty for Distal Humeral Fractures

Advantages	Disadvantages
Internal fixation
Durable	Risk of nonunion
No restrictions	Risk of posttraumatic degenerative joint disease
No prosthesis-related complications	Risk of stiffness
	Requires intensive physical therapy
Total elbow arthroplasty
Bone union not needed	Mechanical failure
Quick return to activities of daily living	Restrictions
Easier recovery
Avoids nonunion and degenerative joint disease
Hemiarthroplasty
Avoids polyethylene	Still requires internal fixation of columns
Convertible to total elbow arthroplasty	Unpredictable motion
	Unpredictable pain relief

Internal Fixation

Approach

Adequate surgical exposure is critical for anatomic reduction of the articular surface as well as successful internal fixation. The best exposure for most distal humeral fractures is through an olecranon osteotomy. We favor a chevron-shaped olecranon osteotomy aimed to the bare area of the articular surface of the proximal part of the ulna (4). The osteotomy is initiated with a saw and completed with an osteotome to create some irregularity at the osteotomy site, limit bone loss, and avoid inadvertent articular cartilage damage.

Fig. 4

Olecranon osteotomy provides adequate exposure for internal fixation of distal humeral fractures.

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The olecranon osteotomy is typically secured with use of plate fixation or tension band wiring with or without an intramedullary screw. Plate fixation is currently favored by most surgeons, as it provides secure fixation and allows early elbow motion without fear of osteotomy displacement and nonunion. However, when the soft tissues around the elbow are compromised, the risk of plate exposure if wound breakdown were to happen should be balanced against the benefits of plate fixation. Intramedullary olecranon nails have been released to the market recently and may provide the best option for osteotomy fixation, but there is limited published information about their results⁶.

Simple fractures may occasionally be managed by exposing the distal aspect of the humerus on both sides of the triceps; this approach is favored whenever possible. Alternatively, the extensor mechanism may be detached from its osseous attachments with use of the Bryan-Morrey⁷ or triceps-reflecting anconeus pedicle⁸ approaches. These approaches are especially attractive when the decision to proceed with internal fixation or arthroplasty needs to be made intraoperatively, but exposure is more limited, and failure of triceps healing may lead to weakness in elbow extension.

Controversy remains regarding the ideal management of the ulnar nerve at the time of fixation^9,10. We favor subcutaneous transposition to prevent contact of the nerve with the medial plate and to protect the nerve during the procedure. However, some recent studies have suggested a lower rate of postoperative neuropathy when the ulnar nerve is left in its anatomic position at the end of the procedure⁹.

Internal Fixation Technique

Our preferred technique for internal fixation of distal humeral fractures is the so-called parallel-plate internal fixation technique³. The classic AO technique recommended fixation of the articular fragments with one or two screws placed in the coronal plane followed by orthogonal plate fixation. Drawbacks of this fixation technique include limited anchorage of the plates on the distal fragments and limited compression at the supracondylar humeral level.

Biomechanical studies have shown the superiority of the parallel-plate technique, especially when bone contact is compromised (Figs. 5-A and 5-B)¹¹. After preliminary reduction of the fracture fragments with Kirschner wires, parallel plates are placed on the medial and lateral columns of the humerus, fixed distally with four to six long screws, and fixed proximally to the diaphysis after the application of supracondylar compression with clamps. The long distal screws interlock in a fixed-angle structure. Precontoured periarticular plates facilitate this technique, but the same principles may be achieved with standard plates contoured intraoperatively. Locking plates may offer increased stability, but their utility is limited, since locked screws need a fixed trajectory in the bone, which is difficult to do within the complex geometry of the distal end of the humerus.

Fig. 5-A Fig. 5-B

Anteroposterior (Fig. 5-A) and lateral (Fig. 5-B) radiographs show the parallel plating technique for a distal humeral fracture and plate fixation of the olecranon osteotomy.

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Although orthogonal plating may offer enough stability in simpler fractures, the more complex fractures require parallel plating. Most orthopaedic surgeons do not treat a large number of distal humeral fractures each year, which makes it advisable to master one, and not two, techniques.

Management of Bone Loss

Some degree of bone loss is present in many distal humeral fractures secondary to comminution. Open fractures may require removal of additional bone for adequate debridement. Depending on the severity and location of bone loss, selective humeral shortening or bone-grafting may be required.

Metaphyseal Shortening

Bone loss at the supracondylar humeral level may be addressed successfully with a moderate amount of bone shortening¹². Humeral shortening of up to 2 cm has minimal impact on elbow biomechanics¹³, and union is more likely with bone contact in compression. The distal end of the diaphysis is contoured to match the fractured end of the articular segment. Rotational and varus-valgus malalignment of the articular segment is at risk with this technique, and should be checked carefully. With shortening, the distal humeral fossae are lost, limiting elbow flexion and extension. Anterior translation of the articular segment recreates anterior space for the coronoid and radial head in flexion. The olecranon fossa is then recreated, removing bone from the diaphysis posteriorly.

Bone-Grafting

Comminution of the central aspect of the distal humeral articular surface may require bone-grafting. Excessive mediolateral compression during plate fixation leads to excessive joint-space narrowing, incongruence, stiffness, and arthritis. Fortunately, the articular cartilage of the central aspect of the trochlea is not critical, as long as the capitellum and medial trochlear cartilage are preserved. The central aspect of the trochlea may be reconstructed with a structural bone inset so that it does not reach the joint surface but restores the width of the distal end of the humerus (Figs. 6-A, 6-B, and 6-C).

An elbow with comminution of the central aspect of the distal humeral articular surface.

Fig. 6-A

Failure to recognize central comminution as shown on this three-dimensional CT reconstruction view may lead to excessive mediolateral compression of the distal end of the humerus.

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Fig. 6-B

Intraoperative photograph showing placement of a structural bone graft (arrows) in the area of comminution.

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Fig. 6-C

Intraoperative fluoroscopy image showing bone graft.

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Structural Bone-Grafting

When the severity of columnar bone loss cannot be addressed with shortening, structural bone-grafting may be required. This situation is more common in the management of distal humeral nonunion. We favor iliac crest bone autograft, but if there is loss of a major portion of the articular segments as well, we have occasionally resorted to a partial osteoarticular distal humeral allograft.

Postoperative Management

Ideally, internal fixation should be stable enough to allow early unprotected rehabilitation of elbow motion. Continuous passive motion is instituted immediately if the condition of the soft tissues allows¹⁴. Alternatively, active-assisted elbow range-of-motion exercises may be used. Some patients have a propensity for stiffness, and static progressive splinting may be necessary for this subgroup of patients. Currently, heterotopic bone prophylaxis is not used routinely.

Outcome

The published reports on the outcome of internal fixation for distal humeral fractures are difficult to interpret, as the severity of the injuries included cannot be compared, and there may be variations in the accuracy of elbow motion measurements^15-20. Improvements in fixation techniques have resulted in a decreased rate of implant failure and fracture nonunion, but elbow motion is not reliably restored in every patient. Common complications include infection, nonunion, stiffness with or without heterotopic ossification, need for removal of the implants used for fixation of the olecranon osteotomy, and posttraumatic osteoarthritis or osteonecrosis requiring later interposition arthroplasty or elbow replacement.

The outcome of fixation with use of a parallel-plate technique was first reported for a group of thirty-four elbows with severe distal humeral fractures³. Forty-five percent of the fractures were open, and most were classified as AO type C3. At the time of the most recent follow-up, 83% of the patients reported no or mild pain, average elbow motion was from 26° of extension to 124° of flexion, and fracture union was achieved in all but one patient who required bone-grafting. Complications included deep infection in one elbow, heterotopic ossification in five elbows, and osteonecrosis in one elbow. Later studies have confirmed the high union rate achieved with similar fixation constructs^21,22. Higher nonunion rates have been documented with orthogonal plating compared with parallel plating²².

Total Elbow Arthroplasty

Rationale, Indications, and Contraindications

Joint replacement is a well-accepted treatment option for fractures in other locations, such as the femoral neck or the proximal part of the humerus. The good track record of some elbow implants for patients with rheumatoid arthritis prompted the use of elbow replacement for distal humeral fractures⁴. Elbow arthroplasty is indicated only in a selective group of elderly patients who present with either preexistent symptomatic pathology or low comminuted fractures with substantial osteopenia and severe damage to the articular surface²³. It is contraindicated in fractures amenable to stable internal fixation, open fractures, and patients with anticipated high physical demands.

Our preference is to surgically approach the joint on both sides of the triceps, remove the fractured fragments, and use a linked implant. The procedure offers several advantages: the extensor mechanism is undisturbed, no postoperative protection is required, functional elbow motion is easier to achieve, and pain and limited motion secondary to nonunion, malunion, or posttraumatic osteoarthritis are avoided. The main disadvantages are the risk of other implant-related complications and the need to limit upper-extremity use to minimize polyethylene wear and other causes of mechanical failure.

Surgical Technique

The joint is approached on both sides of the triceps muscle after ulnar nerve identification and usually transposition. Subperiosteal resection of the fractured articular fragments provides a working space for broaching and implantation. Bone graft from the resected fragments is placed behind the humeral flange. Antibiotic-loaded polymethylmethacrylate is used routinely for implant fixation. The interconnecting pin can be inserted after fully seating the components. The common origins of the flexor-pronator and extensor-supinator muscles are then sutured to the triceps to seal the joint (Figs. 7-A through 7-D).

Fig. 7-A Fig. 7-B

Figs. 7-A through 7-D A total elbow arthroplasty may be the optimal treatment in some elderly patients. Fig. 7-A The fractured fragments are resected by working on either side of the triceps muscle. Fig. 7-B Canal instrumentation and implant insertion are possible through this working space without violating the extensor mechanism.

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Fig.7-C Fig. 7-D

Postoperative lateral (Fig. 7-C) and anteroposterior (Fig. 7-D) radiographs after arthroplasty.

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Postoperative Management

Postoperatively, the elbow is immobilized with an anterior splint in full extension and the arm is elevated for twenty-four to forty-eight hours. Active range-of-motion exercises are then initiated. Most patients can be discharged from the hospital in two to five days and recover functional painless elbow motion in two to three months. Patients are placed on weight restrictions indefinitely; they are restricted from lifting with the affected side more than 5 to 10 lb (2 to 5 kg) as a single event or more than 1 or 2 lb (0.5 to 1 kg) repetitively.

Outcome

Cobb and Morrey first reported on a series of twenty-one distal humeral fractures in elderly patients treated with use of a semiconstrained total elbow replacement⁴. Mean range of motion was from 25° to 130°, and overall results were graded as excellent in fifteen elbows and good in five elbows. Similar results have been reported from other centers (Table II)^24-26. The Mayo Clinic experience was updated to include forty-three patients followed for an average of seven years²¹. Mean range of motion was from 24° to 132°, and the mean Mayo elbow performance score (MEPS) was high (93 points), but five patients required revision surgery. Interestingly, resection of the humeral condyles as performed routinely in this surgical technique does not appear to adversely affect function. McKee et al. compared sixteen elbow replacements with preservation and sixteen with resection of the condyles and found no differences in motion or strength²⁷.

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TABLE II Results of Total Elbow Arthroplasty for Selected Patients with Distal Humeral Fractures

Study	No. of Elbows	Mean Age (yr)	Mean Duration of Follow-up	Range of Motion (deg)	Mayo Elbow Performance Score	Complications and Reoperations
Cobb and Morrey⁴ (1997)	21	72	3.3 yr	25-130	Excellent for 15 elbows, and good for 5	Ulnar component fracture (1)
Ray et al.²⁶ (2000)	7	82	3 yr	20-103	Excellent for 5 elbows, and good for 2	Superficial infection (1)
Gambirasio et al.²⁴ (2001)	10	84	17.8 mo	23.5-125	94 (80-100)*	No complications
Garcia et al.²⁵ (2002)	16	73	3 yr	24-125	93 (80-100)*	No complications
Frankle et al.²⁸ (2003)	12	72	3.75 yr	15-120	Excellent for 11 elbows, and good for 1	Disengagement (1) and superficial infection (2)
Kamineni and Morrey²³ (2004)	43	67	7 yr	24-132	93*	Revision (5)
McKee et al.²⁹ (2009)	25	77	2 yr	26-133	86*	Reoperations for stiffness (2) and deep infection (1)

*The values are given as the mean points, with the range in parentheses when data available.

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TABLE II Results of Total Elbow Arthroplasty for Selected Patients with Distal Humeral Fractures

Study	No. of Elbows	Mean Age (yr)	Mean Duration of Follow-up	Range of Motion (deg)	Mayo Elbow Performance Score	Complications and Reoperations
Cobb and Morrey⁴ (1997)	21	72	3.3 yr	25-130	Excellent for 15 elbows, and good for 5	Ulnar component fracture (1)
Ray et al.²⁶ (2000)	7	82	3 yr	20-103	Excellent for 5 elbows, and good for 2	Superficial infection (1)
Gambirasio et al.²⁴ (2001)	10	84	17.8 mo	23.5-125	94 (80-100)*	No complications
Garcia et al.²⁵ (2002)	16	73	3 yr	24-125	93 (80-100)*	No complications
Frankle et al.²⁸ (2003)	12	72	3.75 yr	15-120	Excellent for 11 elbows, and good for 1	Disengagement (1) and superficial infection (2)
Kamineni and Morrey²³ (2004)	43	67	7 yr	24-132	93*	Revision (5)
McKee et al.²⁹ (2009)	25	77	2 yr	26-133	86*	Reoperations for stiffness (2) and deep infection (1)

*The values are given as the mean points, with the range in parentheses when data available.

Two separate studies compared internal fixation and arthroplasty. Frankle et al. compared twenty-four fractures in women more than sixty-five years old who were treated with either internal fixation or elbow replacement²⁸. Arthroplasty provided better motion and overall results. McKee at al. described a prospective randomized study on patients over the age of sixty-five years, with twenty elbows assigned to internal fixation and twenty assigned to arthroplasty²⁹. There were five intraoperative conversions from internal fixation to arthroplasty. Elbow arthroplasty was associated with a substantial reduction in the operative time, better elbow scores, and better early disability (Disabilities of the Arm, Shoulder and Hand; DASH) scores. There was a trend to better motion and fewer reoperations in the arthroplasty group, but it was not significant.

Hemiarthroplasty

Some authors have reported good results using a distal humeral hemiarthroplasty with column fixation for distal humeral fractures^30-33. Distal humeral hemiarthroplasty eliminates the potential for complications associated with the presence of polyethylene or an ulnar component. However, it does not eliminate the need for healing of the columns, and may be complicated by instability or symptomatic changes in the articular surfaces of the unresurfaced ulna and radial head.

Approach

Our preferred surgical approach to the joint is either through the lateral column or with an olecranon osteotomy. For supraintercondylar fractures, the fractured lateral fragments may be reflected distally with the common extensor muscle group and underlying lateral collateral ligament complex origin. For low shear fractures of the articular surface, an olecranon osteotomy provides an excellent exposure; alternatively, the joint may be approached through a lateral epicondylar osteotomy.

Surgical Technique

Currently, a very limited number of implants may be used as a distal humeral hemiarthroplasty. The humeral component of the Sorbie-Questor system (Wright Medical Technology, Arlington, Tennessee) has an anatomic design and may be used as a hemiarthroplasty³³. Some authors have reported cases of patients managed with use of the Kudo humeral component (Biomet, Warsaw, Indiana)³⁰. We favor the Latitude hemiarthroplasty prosthesis (Tornier, Saint-Ismier, France), which can be converted to a reliable total elbow arthroplasty, if necessary, and facilitates suture fixation of bone and/or soft tissues through the implant (Figs. 8-A, 8-B, and 8-C). Size is estimated with preoperative templates and confirmed with intraoperative trials. Healing of the columns is required for elbow stability. Column fixation may be achieved with screws, plates, or sutures, depending on the nature of the fracture, surgeon preference, and the implant used.

Distal humeral hemiarthroplasty is best suited for intra-articular fractures with severe destruction of the articular cartilage but with humeral column integrity.

Fig. 8-A

Intraoperative photograph made during a distal humeral hemiarthroplasty.

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Fig. 8-B

Postoperative anteroposterior radiograph.

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Fig. 8-C

Postoperative lateral radiograph.

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Outcome

There are a limited number of studies on the outcome of distal humeral hemiarthroplasty. Adolfsson and Hammer reported on four Kudo humeral hemiarthroplasties performed for distal humeral fractures in elderly female patients³⁰; results were rated as excellent in three elbows and good in one elbow at a mean follow-up of ten months. Malone et al. reported on thirty hemiarthroplasties performed for either an acute distal humeral fracture or failure of fracture fixation³⁴. Implants used included the Sorbie component in fourteen and the Latitude component in sixteen elbows. At a mean follow-up of two years, the mean range of motion included extension to 25° and flexion to 128°, and the mean MEPS was 77 points. Complications included periprosthetic fracture (one elbow), loosening (two elbows), symptomatic laxity (12%), and column nonunion (8%).

Shear Fractures of the Articular Surface

These injuries involve the articular surface of the distal end of the humerus without extension above the roof of the olecranon fossa². Fractures of the capitellum represent the classic example of articular fractures of the distal end of the humerus, including the traditional descriptions of the Hahn-Steinthal fracture (a large fracture involving most of the capitellum) and the Köcher-Lorenz fracture (a small osteochondral fracture). Often, these fractures extend across the whole distal articular surface and may be associated with various amounts of impaction and comminution. The complexity of these fractures may be difficult to appreciate from radiographs, and CT scans with three-dimensional reconstructions are strongly recommended. Depending on the severity of articular cartilage damage, these fractures may require internal fixation or arthroplasty (Figs. 9-A through 9-D).

Fig. 9-A Fig. 9-B

Figs. 9-A through 9-D A simple fracture of the capitellum, as shown in this three-dimensional CT reconstruction of the distal end of the humerus, may be reliably fixed with articular screws through a lateral surgical approach. Fig. 9-A Anteroposterior view. Fig. 9-B Lateral view.

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Fig. 9-C Fig. 9-D

Lateral (Fig. 9-C) and anteroposterior (Fig. 9-D) radiographs made after fixation of the fracture with articular screws.

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Internal Fixation

The surgical approach used for fixation of these fractures depends primarily on the presence of extension into the medial side of the joint. Fractures involving the capitellum and at most a very limited portion of the trochlea are approached through a lateral collateral ligament-preserving lateral approach. However, fractures affecting most of the anterior or posterior aspect of the trochlea, as well as those extending into the medial epicondyle, are best approached by mobilization of the extensor mechanism through an olecranon osteotomy or any of its alternatives. The simpler fracture patterns may be internally fixed with arthroscopically assisted techniques.

Thin osteochondral fractures are usually fixed with bioabsorbable pins, but excision of the fractured fragments may be done in the elderly low-demand patient. Larger fractures require anatomic reduction and multiple articular screws, occasionally supplemented with bioabsorbable pins or threaded Kirschner wires. Plate fixation and/or bone-grafting may be needed in elbows with extensive comminution and bone loss.

External fixation is sometimes considered to distract the elbow and neutralize the forces across the joint, since articular fractures are placed at risk for fixation failure by shearing forces associated with elbow motion. Our preference is to use a hinged elbow fixator for three to six weeks to allow early elbow motion. Successful use of such articulated fixators requires accurate reproduction of the axis of elbow flexion and extension.

The outcome of internal fixation for articular fractures of the distal end of the humerus has been reported by several authors. Ring et al. reported on twenty-one elbows followed for an average of 3.3 years². The mean arc of motion was from 27° of extension to 123° of flexion, and the overall results were graded as good or excellent in 76% of the elbows. Reoperations included contracture release in six elbows, ulnar nerve decompression in two elbows, early loss of fixation in one elbow, and implant removal in one. Dubberley et al.³⁵ reported on twenty-eight elbows followed for a mean of 4.6 years. Average motion ranged from 29° of extension to 138° of flexion, and results were considered satisfactory in 89% of the elbows. Reoperations included contracture release in seven elbows, revision internal fixation in two elbows, revision to an elbow arthroplasty in two elbows, and removal of olecranon hardware in seven elbows. Mighell at al. reported on a selected group of eighteen elbows with large coronal shear fractures of the capitellum and lateral aspect of the trochlea that were treated with open reduction and internal fixation with headless compression screws³⁶. At an average follow-up of twenty-six months, all but one patient had good or excellent results; three elbows showed radiographic evidence of osteonecrosis without clinical importance.

Arthroplasty

Total elbow arthroplasty and hemiarthroplasty maybe indicated when the traumatic damage to the articular surface is severe. A distal humeral hemiarthroplasty may be ideal in these circumstances, since there is integrity of the columns and collateral ligaments. Further studies are required to understand the role of both hemiarthroplasty and total elbow arthroplasty for articular distal humeral fractures.

Overview

The treatment of the distal end of the humerus continues to improve. Better imaging studies, sound internal fixation techniques and implants, and the selective use of elbow arthroplasty have all contributed to a better overall management. However, some areas of controversy remain. Future advances will likely focus on less invasive surgical techniques and improved implants, as well as the prevention of complications that continue to compromise the final outcome of these injuries, such as wound problems, infection, ectopic bone formation, and persistent ulnar neuropathy.

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Topics

bone transplantation ; elbow region ; fracture fixation, internal ; elbow replacement arthroplasty ; humeral fractures, distal

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Joaquin Sanchez-Sotelo; Distal Humeral Fractures: Role of Internal Fixation and Elbow Arthroplasty. The Journal of Bone & Joint Surgery. 2012 Mar;94(6):555-568.

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