Intra-Articular Distal Humerus Fractures

Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1070, USA.
Orthopedic Clinics of North America (Impact Factor: 1.25). 01/2013; 44(1):35-45. DOI: 10.1016/j.ocl.2012.08.010
Source: PubMed


Distal humeral fractures are relatively rare and complex injuries. With appropriate preoperative planning and execution of surgical technique, good outcomes may be obtained in most patients. Patients should be counseled regarding loss of motion in these injuries, and elderly, osteoporotic patients with extensive comminution should be considered for total elbow arthroplasty as an alternative to open reduction and internal fixation.

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    • "First, we found that immobilization <3 weeks had a favorable association with motion at the 3-month and 6-month time periods, but this effect was not significant at 1 year. Early motion after fixation is advocated by many authors as a standard of care in adult distal humerus fractures because it affects the final ROM [14–16]. Interestingly, in our pediatric and adolescent population, the duration of immobilization did not seem to affect ROM at the 1-year follow-up. "
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    ABSTRACT: T-condylar fractures of the distal humerus are infrequent injuries in children. There are little data regarding outcomes in this age group. The adult literature demonstrates a high rate of postinjury stiffness. We describe a large series of T-condylar fractures in children and set out to identify factors that influence the postoperative range of motion (ROM) in children. Our hypothesis was that starting motion early (<3 weeks) would favorably influence the postoperative ROM. Patients were identified based on the Current Procedural Terminology (CPT) code for ORIF of supracondylar distal humerus fractures with intracondylar extension (24546). Patient records and radiographs were reviewed to determine the demographics, fracture characteristics, surgical approach and fixation, and postoperative immobilization time. Our outcome measure was ROM in flexion/extension at 3 months, 6 months, 1 year, and final follow-up. Patients were analyzed by Morrey's criteria of -30° extension and 130° flexion to assess for postoperative elbow stiffness. Thirty-eight potential patients from 1992 to 2010 were identified with specific T-condylar patterns. Twelve patients were excluded due to insufficient follow-up or lack of final ROM data. Our cohort included 26 patients (average age 13.4 years). The average postoperative immobilization time was 3.4 weeks (range 0.9-12 weeks). At the final follow-up, patients had -12° average extension and 130° average flexion. Nine patients (35 %) were stiff and 17 patients (65 %) had functional motion postoperatively. At 3 and 6 months, starting motion early yielded better flexion and extension ROM. Late-motion patients obtained similar results at the 1-year follow-up. Open fractures, gender, and age were all not significantly associated with elbow stiffness in our series, given the limited numbers. Early ROM was associated with an earlier gain of functional motion without clear adverse consequences. Despite similar findings at the final follow-up, practitioners should consider instituting early ROM protocols to decrease the duration of stiffness and potential disability for the child and the family.
    Journal of Children s Orthopaedics 03/2014; 8(2). DOI:10.1007/s11832-014-0576-1
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    ABSTRACT: Distal humeral fractures represent 2% of all adult elbow fractures. Injury mechanisms include high-energy trauma with skin involvement, and low energy trauma in osteoporotic bone. Treatment goals are anatomical restoration in young, high-demand patients and quick recovery of activities of daily living in the elderly. Complete fractures are relatively easy to diagnose, but partial intra-articular fractures are not. The clinical diagnosis must take into account potential complications such as open injuries and ulnar nerve trauma. Standard X-rays with additional distraction series in the operating room are sufficient in complete articular fracture cases. Partial intra-articular fractures will need CT scan and 3D reconstruction to fully evaluate the involved fragments. SOFCOT, AO/OTA and Dubberley classifications are the most useful for describing fractures and selecting treatment. Surgery is the optimal treatment and planning is based on fracture type. Complete fractures are treated using a posterior approach. Triceps management is a function of fracture lines and type of fixation planned. Constructs using two plates at 90° or 180° are the most stable, with additional frontal screw for intercondylar fractures. Elbow arthroplasty may be indicated in selected patients, having severely communited distal humerus fractures and osteoporotic bone. Open fractures make fixation and wound management more challenging and unfortunately have poorer outcomes. Other complications are elbow stiffness, non-union, malunion and heterotopic ossification.
    Orthopaedics & Traumatology Surgery & Research 01/2014; 100(1). DOI:10.1016/j.otsr.2013.11.002 · 1.26 Impact Factor