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
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.
Available from: Nicholas Beck
- "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.
Available from: Thierry Bégué
- "Articular fractures of the distal humerus in adults are difficult to treat because of their epiphyseal location. Although not a common fracture , approximately 3000 distal humerus fractures in adults and children are treated surgically every year in France . An orthopaedic surgeon in France sees an average of five distal humerus fractures per year. "
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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.
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ABSTRACT: The aim of the present study was to determine the anatomical relationship and evaluate the potential interference of today's common distal humerus plates with the medial and lateral collateral ligaments of the elbow.
The elbow joints of 23 embalmed upper extremities were dissected. Three different brands of distal humerus double-plating systems were applied in a standardized fashion. We used a caliper to measure the amount of absolute overlap of the plates on the corresponding collateral ligaments.
The data show contact and overlap with the medial and lateral collateral ligaments in all tested medial and lateral plates. The posterolateral and posteromedial plates showed no contact with the ligaments, yet they did contact the posterior joint capsules. The medial plates showed less contact/overlap when compared with the lateral and extended medial plates.
Based on the present data, we conclude that distal humerus plating using the perpendicular technique with standard-sized medial plates shows the least amount of overlap over the medial and lateral collateral ligaments. The extent of the overlap of the ligaments by the humeral plates is clearly shown in the present study.
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