Review Question - QID 220127

Although olecranon osteotomy is preferably avoided if there is suspicion of needing to perform total elbow arthroplasty (TEA), all posterior-based approaches to the elbow are amenable to performing TEA. (Answer 5)

Distal humerus fractures in the elderly, particularly those that are displaced and intra-articular, present a significant treatment challenge due to factors like osteoporosis, comminution, and intolerance for immobilization. These fractures can severely impact daily living and independence. The standard treatment for younger patients is open reduction-internal fixation (ORIF), but outcomes in the elderly are less predictable. Operative fixation of distal humerus fractures remains the mainstay of treatment, but recently acute total elbow arthroplasty has been utilized more frequently. Optimally, a triceps-sparing approach is utilized if arthroplasty is planned, but it can still be performed after an olecranon osteotomy has been taken.

Morrey et al. provide a comprehensive review of the surgical management of distal humerus fractures and nonunions, focusing on both open reduction and internal fixation (ORIF) and total elbow arthroplasty (TEA). They discuss the decision-making process, surgical techniques, and postoperative care, emphasizing the need for individualized treatment and meticulous surgical planning. The authors underscore the importance of adaptability during surgery, particularly the potential intraoperative shift from ORIF to TEA when a fracture is not amenable to reconstruction, even if an olecranon osteotomy has been utilized. They suggest fixation with a Kirschner wire tension band construct in this situation.

McKee et al. performed a multicenter, prospective, randomized, controlled trial compared open reduction-internal fixation (ORIF) with primary semi-constrained total elbow arthroplasty (TEA) for treating displaced, comminuted intra-articular distal humeral fractures in patients over 65 years old. The study found that TEA provided better functional outcomes in the short term, as evidenced by higher Mayo Elbow Performance Scores (MEPS) and early Disabilities of the Arm, Shoulder and Hand (DASH) scores. Although reoperation rates were lower in the TEA group, the difference was not statistically significant. The results suggest that TEA is a preferable treatment option for complex distal humeral fractures in the elderly, with a potential for better early functional outcomes and reduced reoperation rates compared to ORIF.

Figure A is an AP radiograph of an intraarticular distal humerus fracture with radiographic signs of osteopenia

Incorrect Answers:
Answer 1-4: All posterior-based elbow approaches can be utilized for total elbow arthroplasty if required