American Shoulder and Elbow Surgeons
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An 88-year-old female presents after a fall onto her left arm. She reports isolated left elbow pain, and radiographs are shown in Figure A. She lives in an assisted living facility, and reports no other major medical problems. The best outcome can be expected with which of the following definitive treatment options?
Open reduction internal fixation of the distal humerus fracture
Nonsurgical management with early passive range of motion exercises
Initial nonsurgical management followed by interpositional arthroplasty when the fracture has healed
Total elbow arthroplasty
Excision of the capitellar fragments and fixation of the trochlear fragments
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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.
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.
Kamineni S, Morrey BF
J Bone Joint Surg Am. 2004 May;86-A(5):940-7. PMID: 15118036 (Link to Abstract)
Kamineni, JBJS 2004
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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A 20-year-old man falls from his bicycle. He is going to be scheduled for open reduction internal fixation. What best describes the injury shown in Figure A and B?
Capitellum fracture with extension into the trochlea
Radial head and capitellum fracture
Isolated capitellum fracture
The radiographs shows a coronal shear fracture of the capitellum with extension into the trochlea, which would be classified as a Type IV fracture under the Bryan and Morrey classification system which was modified by McKee to include this specific injury. The lateral radiograph in Figure B and Illustration A is an example of the "double arc" sign representing an injury to both the trochlea and capitellum. The treatment of choice for a displaced Type IV fracture is open reduction internal fixation.
Dushuttle et al demonstrated that absence of the capitellum did not lead to valgus instability unless the medial collateral ligament was injured, suggesting that excision of highly comminuted fractures could be performed.
The reference by Grantham et al looked at a series of capitellum fractures and recommended the choice of treatment should be selective and individualized depending on age, character of the bone, and type of fracture.
McKee et al in their case review described this coronal injury pattern and their results for ORIF of these fractures.
Dushuttle RP, Coyle MP, Zawadsky JP, Bloom H.
J Trauma. 1985 Apr;25(4):317-21. PMID: 3989889 (Link to Abstract)
Dushuttle, JTACS 1985
Grantham SA, Norris TR, Bush DC.
Clin Orthop Relat Res. 1981 Nov-Dec;(161):262-9. PMID: 7307389 (Link to Abstract)
Grantham, CORR 1981
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
Average 3.0 of 46 Ratings
Title: Elbow Capitellar OCDSpeaker: John E. Conway, MD Length: 11 mins 23 secs
HPI - RHD female who complains of elbow pain after falling off her bike onto her left elbow
What approach would you use?
HPI - fall from bike
How would you fix this coronal shear fracture?
HPI - history of fall on semiflexed elbow
What approach would you use for this particular injury?
HPI - undiagnosed capitellum fracture 7 months ago.
Excision of the capitellum fragment 3 months ago followed by physioteraphy
How would you treat this patient now?
HPI - Fell 3 months ago. No dislocation.
What is the best treatment