Review Question - QID 4555

This elderly, low demand patient is presenting with a distal and comminuted distal humerus fracture in the setting of poor bone quality. These are extremely difficult to reconstruct and rehabilitate from, and therefore in this particular case total elbow arthroplasty is the best option.

Total elbow arthroplasty has become the treatment of choice for complex, comminuted distal humerus fractures in patients older than age 70. It yields a faster recovery with more predictable functional outcomes, although limitations of lifting weight more than 10-15 pounds must be followed to avoid loosening.

Kamineni et al. retrospectively reviewed 49 acute distal humerus fractures in 48 patients who were treated with total elbow arthroplasty as the primary option. Forty-three of these fractures were followed for 2 years. At the latest follow-up examination, the average flexion arc was 24 degrees to 131 degrees and the Mayo elbow performance score averaged 93 of a possible 100 points. This review supports a recommendation for total elbow arthroplasty for the treatment of an acute distal humerus fracture when strict inclusion criteria are observed.

Frankle et al. compared open reduction and internal fixation (ORIF) with total elbow arthroplasty (TEA) for intraarticular distal humerus fractures in women older than 65 years of age. Follow-up was a minimum of two years. Using the Mayo Elbow Performance score, the outcomes of the 12 patients treated with ORIF were as follows: 4 excellent, 4 good, 1 fair, and 3 poor. Outcomes of the 12 patients treated with TEA were as follows: 11 excellent and 1 good. There were no fair or poor outcomes in the TEA group, and no patients treated with TEA required revision surgery.

The AP and lateral elbow radiographs shown in Figures A demonstrate a severely comminuted and displaced distal humerus fracture.

Incorrect Answers:
Answer 1: Stable ORIF is nearly impossible to attain in the setting of a very distal fracture of the humerus with comminution and poor bone quality.
Answer 2: Although nonsurgical management of these injuries showed some favor in the past, range of motion and pain control are ultimately better with TEA in the appropriate patient.
Answer 3: Interpositional arthroplasty is indicated in younger patients who may not be able to comply with the strict weight lifting restrictions of a TEA.
Answer 5: Fixation of the trochlear fragments would be extremely difficult in this case, and capitellar excision would likely lead to an unstable elbow joint in the setting of a compromised ulnohumeral articulation.