Each type further divided by degree and location of fracture comminution
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Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC.
Which of the following patients is most appropriately treated with a total elbow arthroplasty?
42-year-old laborer with an open T-type supracondylar distal humerus fracture
90-year-old male with a comminuted transolecranon fracture-dislocation of the elbow
66-year old female with a coronal shear fracture of the distal humerus
50-year-old male with a nonunion of a supracondylar humerus fracture
86-year-old female with a comminuted bicolumnar distal humerus fracture
Select Answer to see Preferred Response
Total elbow arthroplasty (TEA) has a limited, but well-described indication for treatment of distal humerus fractures. Due to the postoperative patient limitations inherent to the current prostheses, the current recommendation for use of TEA for distal humerus fractures is only for elderly patients with osteoporotic bone and comminution not amenable to stable fixation.
McKee et al. peformed a randomized controlled trial of 42 patients comparing ORIF to TEA. Patients who had the TEA had better Mayo elbow scores from 3 months until 2 years postoperatively, but DASH scores were only better in the TEA group for the 1st 6 months (equal thereafter). Reoperation rates were not statistically different, but note was made of a 25% intraoperative conversion rate from ORIF to TEA after randomization. They conclude that this elderly population appears to adjust well to elbow limitations regardless of treatment.
Illustration A shows a intraarticular fracture of the distal humerus in a patient with rheumatoid arthritis, severe osteoporosis, and preexisting arthritic changes who was treated with a total elbow replacement.
Answer 1: Dual plate fixation, with placement of a separate strong plate on each column and orientation of the plates either at 90° or 180° to each other, is indicated for all adult fractures involving both columns of the distal part of the humerus.
Answer 2: This fracture pattern requires fixation of the ulna and possible reconstruction/repair of ligamentous injury.
Answer 3: Displaced coronal shear fractures of the distal humeral articular surface require operative fixation, most typically via a lateral approach.
Answer 4: Nonunion of a supracondylar humerus fracture typically requires revision with plate/screw constructs, unless elderly.
McKee MD, Veillette CJ, Hall JA, Schemitsch EH, Wild LM, McCormack R, Perey B, Goetz T, Zomar M, Moon K, Mandel S, Petit S, Guy P, Leung I
J Shoulder Elbow Surg. 2009 Jan-Feb;18(1):3-12. PMID: 18823799 (Link to Abstract)
McKee, JSES 2009
Title: I do Total Elbow Arthroplasty Presenter: R. Kumar Kadiyala, MDColumbia U...
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An 85-year-old woman falls and injures her elbow in her non-dominant arm. Radiographs are shown in Figure A and B. She also suffers from severe osteoporosis, lives independently, and is a low-level community ambulator. Which of the following is the most appropriate treatment?
Hinged elbow brace
Olecranon osteotomy, articular ORIF, locked lateral plating
Triceps-splitting approach with double plate fixation
Total elbow arthroplasty
Casting for 4 weeks then ROM
Total elbow arthroplasty (TEA) is ideal for treating comminuted osteoporotic fractures of the distal humerus in low demand elderly patients. Outcomes are good to excellent with quick return of stability and functional motion but with carrying weight restriction of 5 lbs. ORIF would be the best choice for younger individuals with better bone quality.
Cobb described the outcomes of 21 total elbow arthroplasties in elderly patients all of which had good or excellent results without evidence of component loosening. The mean motion was 25 to 130 degrees. Complications included fracture of the ulnar component in one patient after another fall, ulnar neurapraxia in three, and reflex sympathetic dystrophy in one.
McKee et al. performed a randomized controlled study of TEA versus fixation and found that TEA for the treatment of comminuted intra-articular distal humeral fractures resulted in more predictable and improved 2-year functional outcomes compared with ORIF. They also found that although elderly patients with this injury have an increased baseline DASH score, they appear to accommodate to objective limitations in function with time.
Frankle et al. retrospectively compared TEA to plate fixation for distal humerus fractures in the elderly and found a significant improvement in outcomes and revision rates with TEA as compared to plate fixation. The differences were seen most in women with associated comorbidities, such as rheumatoid arthritis, osteoporosis, and conditions requiring the use of systemic steroids.
Cobb TK, Morrey BF.
J Bone Joint Surg Am. 1997 Jun;79(6):826-32. PMID: 9199378 (Link to Abstract)
Cobb, JBJS 1997
Frankle MA, Herscovici D, DiPasquale TG, Vasey MB, Sanders RW
J Orthop Trauma. 2003 Aug;17(7):473-80. PMID: 12902784 (Link to Abstract)
Frankle, JOT 2003
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Which of the following elbow injuries as found in Figures A-E best characterizes the radiographic "double-arc" sign?
Figure C and Illustration A (below) demonstrate the radiographic "double-arc" finding.
McKee et al described a unique "shear fracture of the distal articular surface of the humerus" which involved coronal fractures of the capitellum and a portion of the trochlea. He described the characteristic radiographic finding as the "double-arc sign" which represents the subchondral bone of the displaced capitellum and lateral trochlea ridge.
Figure A shows a radial head fracture.
Figure B shows an elbow dislocation.
Figure D shows a pediatric lateral condyle fracture.
Figure E shows a pediatric medial epicondyle apophyseal avulsion fracture.
McKee MD, Jupiter JB, Bamberger HB.
J Bone Joint Surg Am. 1996 Jan;78(1):49-54. PMID: 8550679 (Link to Abstract)
McKee, JBJS 1996
Title: I do ORIF Presenter: Mark Baratz, MDColumbia University OrthopedicsNew Yo...
Average 3.0 of 17 Ratings
What is the most common complication of the fracture seen in figure A, if operatively treated as seen in figure B?
Decreased elbow range of motion
Wound healing complications
Iatrogenic ulnar nerve injury
Inadvertent intra-articular hardware penetration
Nonunion of the distal humerus fracture
Decreased elbow range of motion is the most common complication after open reduction internal fixation of distal humerus fractures. Per Galano et al, this loss of motion can arise from "a variety of causes, including articular incongruity or adhesions, capsular contractures, loose bodies, heterotopic ossification, and prominent hardware."
Other complications include nonunion of the distal humerus (2-10%) and ulnar neuropathy (0-12%).
Galano GJ, Ahmad CS, Levine WN
J Am Acad Orthop Surg. 2010 Jan;18(1):20-30. PMID: 20044489 (Link to Abstract)
Galano, JAAOS 2010
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I have a patient that I treated with recon plates for an intercondylar hume...
Title: Distal Humerous Presenter: R. Kumar Kadiyala, MDColumbia University Orth...
video for case C1883 capitellar trochlear farcture thru olecranon osteotomy
Sawbone model of distal humerus C3 fracture ORIF
HPI - LEFT arm wresting injury
What is the most common site of humeral shaft fracture in an arm wresting injury?
HPI - Presented in ER with complaint of left elbow pain after RTA.
What is the best treatment option for this complex elbow fracture-dislocation?
HPI - Right hand dominant female construction worker fell from a height of 15 feet onto her right elbow, developed pain, swelling and decrease range of motion of right elbow. Bleeding was noted from wound around the elbow.
How would you manage this patient?
HPI - He was involved in MVA 2 weeks ago, isolated injury to Lt elbow, he got degluved injury to his soft tissue from mid arm to proximal forearm, bone loss from mid shaft humerus including both condyles, comminuted proximal ulnar, radius is intact.
Post op: He was operated by debridement and external fixator. At the time being, his wound in clean, no discharge and no skin necrosis.
His ESR: 12, CRP:7
what is the defenitife management after eradication infection?
HPI - open floating elbow injury due to MVA
crush between road and car
no other associated injuries like head or chest injuries
How would you treat this injury?
HPI - Motor vehicle collision while she was bicycling
In this multi-trauma patient, how would you treat the SCAPULA fx?
HPI - minor fall
What approach would you use to treat this fracture?
HPI - RTA for 8 weeks ago, operated by ex fix.
HPI - The condition started sense one year when the patient suffered road traffic accident whitch resulted in open grade II fracture of the distal part rt humerus witch was treated at this time by OR and multiple K wires and Ilizarov application. The soft tissue healed without complications. For unknown reason Ilizarov was removed after one and half month and the pt was put in cast.the pt came to me after that, I removed most of the K wires ,with debridement and refreshening of fracture edges and applied Ilizarov frame
How would you treat this patient at this time?
HPI - Patient presents with pain in left elbow after fall. Now has inability to move the elbow thru full range of motion.
How would you treat this patient?
HPI - fall at his work site on outstretched hand.injury rt elbow
How would you treat this patient and injury?
HPI - h/o fal;l at play. injury rt elbow. pain inability to move elbow after fall
milch anatomical classification
HPI - Fall while playing with immediate right elbow pain
lateral condyle fracture or not
HPI - Right hand dominant patient who sustained an elbow injury after a fall from standing height 4 months ago ( August 2013 ) and was treated conservatively.
What is your preferred treatment?
HPI - 77 year old female presents with L arm pain after sustaining a fall down stairs. Community ambulator at baseline.
What is the best form of definitive management for these fractures?
HPI - trauma to lt elbow in childhood.
no treatment was given
no pain, neurological symptoms
How would you choose to treat this patient?
HPI - Bike accident, dominant arm: Very active person.
What type of postop treatment will you offerd to the patient.
HPI - h/o fall injury to the right arm
conservative or operative treatment
HPI - Open distal humerus fx s/p fall from roof. Had I&D and ORIF of arm by outside surgeon. Developed deep infection ~ 6wks postop and had I&D/implant removal with long-arm splint ~ 4wks prior. Complains of significant pain and dysfunction. PICC line in place with IV abx per ID doctor.
What would you do after his initial presentation?
HPI - invoved in a motor vehicle accident.no other injuries
operative or conservative
HPI - fall from bike
in which classification this fracture falls. how should ideally be approach and what should be ideal fixation and post op protocol?