Summary Distal Humerus Fractures are traumatic injuries to the elbow that comprise of supracondylar fractures, single column fractures, column fractures or coronal shear fractures. Diagnosis is made with plain radiographs of the humerus and elbow. CT scan is helpful for intra-articular assessment and operative planning. Treatment is usually open reduction and internal fixation. Epidemiology Incidence accounts for 2% of all fractures accounts for 30% of elbow fractures incidence has been steadily increasing Demographics most common in young males and older females Anatomic location distal intercondylar fractures are the most common fracture pattern Etiology Pathophysiology distal humerus fractures are traumatic injuries that include supracondylar fractures single column (condyle) fractures bicolumnar fractures coronal shear fractures mechanism low energy falls in elderly high energy impact in younger population pathoanatomy elbow position affects fracture type login to view 5 more bullets Associated injuries elbow dislocation terrible triad injury floating elbow Volkmann contracture results from missed forearm compartment syndrome Anatomy Osteology elbow is a hinged joint articular surface is in 6 degrees of valgus 5 degrees of external rotation 30 degrees of flexion trochlea articulates with sigmoid notch allows for flexion and extension capitellum articulates with proximal radius allows for forearm rotation Muscles common flexors (originate from medial epicondyle) pronator teres flexor carpi radialis palmaris longus FDS FCU common extensors (originate from lateral epicondyle) anconeus ECRL ECRB extensor digitorum comminus EDM ECU Ligaments medial collateral ligament anterior bundle originates from distal medial epicondyle inserts on sublime tubercle primary restraint to valgus stress at the elbow from 30-120° tight in pronation lateral collateral ligament originates from distal lateral epicondyle inserts on crista supinatorus stabilizer against posterolateral rotational instability tight in supination Nerves ulnar nerve resides in the cubital tunnel in a subcutaneous position posterior to the medial condyle radial nerve anatomic landmarks login to view 4 more bullets runs between brachioradialis and brachialis proximal to elbow posterior antebrachial cutaneous nerve (PABCN) branches in the posterior arm divides into PIN and superficial radial nerve at the level of the radial head Blood supply intraosseous and extraosseous blood supplies that may be compromised by the injury Classification Anatomic Classification supracondylar fractures single column fractures 5% of fractures subclassified using Milch classification system (see table) lateral condyle more common than medial bicolumnar fractures classified using Jupiter classification system (see table) 5 major articular fragments have been identified login to view 5 more bullets Described Classification Systems AO/OTA Classification of Distal Humerus Fractures Type A Extra-articular (supracondylar fracture), 80% are extension type; epicondyle Type B Intraarticular- Single column (partial articular-isolated condylar, coronal shear, epicondyle with articular extension). Type C Intraarticular- Both columns fractured and no portion of the joint is contiguous with the shaft (complete articular) Each type further divided by degree and location of fracture comminution Milch Classification of Single Column Condyle Fractures Milch Type I Lateral trochlear ridge intact Milch Type II Fracture through lateral trochlear ridge Jupiter Classification of Two-Column Distal Humerus Fractures High-T Transverse fx proximal to or at upper olecranon fossa Low-T Transverse fx just proximal to trochlea (common) Y Oblique fx line through both columns with distal vertical fx line H Trochlea is a free fragment (risk of AVN) Medial lambda Proximal fx line exists medially Lateral lambda Proximal fx line exists laterally Multiplane T (not pictured) T type with an additional fracture in coronal plane Presentation Symptoms elbow pain and swelling Physical exam check for open wounds, especially posteriorly gross instability often present avoid ROM due to risk of neurovascular damage neurovascular exam check function of radial, ulnar, and median nerves check distal pulses login to view 2 more bullets monitor carefully for forearm compartment syndrome Imaging Radiographs recommended views AP login to view 1 more bullet lateral additional views humerus and forearm radiographs wrist radiographs login to view 1 more bullet oblique radiographs login to view 1 more bullet traction radiograph login to view 1 more bullet CT indications often obtained for surgical planning login to view 1 more bullet MRI indications usually not indicated in acute injury Treatment Nonoperative cast immobilization indications login to view 1 more bullet technique login to view 1 more bullet short period of immobilization and followed by early range of motion ("bag of bones" technique) indications login to view 3 more bullets Operative closed reduction percutaneous pinning (CRPP) indications login to view 1 more bullet open reduction internal fixation (ORIF) indications login to view 3 more bullets techniques login to view 2 more bullets total elbow arthroplasty indications login to view 2 more bullets Techniques Cast Immobilization technique immobilize in supination for lateral condyle fractures immobilize in pronation for medial condyle fractures Open reduction internal fixation (ORIF) approach posterior superficial approach exposures triceps-splitting (Campbell) login to view 3 more bullets triceps-sparing (paratricipital, Alonso-Llames, medial and lateral windows) login to view 6 more bullets olecranon osteotomy login to view 14 more bullets triceps-reflecting (Bryan-Morrey) login to view 4 more bullets triceps-reflecting anconeus pedicle (O'Driscoll) login to view 2 more bullets lateral muscles interval login to view 2 more bullets fixation perform provisional reduction with k-wires login to view 1 more bullet perform fixation of articular fragments with countersunk/headless screws login to view 1 more bullet perform fixation of condyles and epitrochlear ridge login to view 7 more bullets locking plates are preferred for poor bone quality or comminution postoperative splint elbow in 70° of flexion remove splint within 7-10 days post-operatively and initiate ROM exercises login to view 7 more bullets start gentle strengthening program at 6 weeks and full strengthening program at 3 months Total Elbow Arthroplasty indications comminuted articular fractures in osteoporotic bone inflammatory conditions (e.g. RA) techniques semi-constrained TEA complications activity restrictions (e.g. can not lift more than 10 pounds) implant loosening polyethylene wear periprosthetic fracture functional outcomes similar to salvage arthroplasty following failed ORIF Complications Elbow stiffness most common (3-42%) mean arc of motion is 90-106 degrees treatment static-progressive splinting Heterotopic ossification seen in 8% routine prophylaxis is not warranted due to increased rate of nonunion in patients treated with indomethacin risk factors head injury floating elbow injury Type A and B fractures delayed surgical fixation Nonunion low incidence (0-11%) risk factors excessive soft-tissue stripping open fractures comminution low transcondylar or intercondylar fractures treatment revision ORIF with bone graft Malunion avoided by proper surgical technique cubitus valgus (lateral column fractures) cubitus varus (medial column fractures) Anterior interosseous nerve injury can be seen with olecranon osteotomy Ulnar nerve injury (10-38%) Postoperative ulnar nerve palsies are most often secondary due to traction during open reduction and internal fixation Wound complications (up to 16%) due to poor soft tissue envelope over posterior elbow Infection occurs in 0-14% of patients Posttraumatic Arthritis Prognosis ORIF majority of patients regain 75% of elbow motion and strength goal is to restore elbow ROM 30-130° of flexion Total elbow arthroplasty has rates of implant survival >75% at 10 years if used with appropriate indications expected ROM is 26-125 degrees in patients > 65 years old functional outcomes were higher with TEA than ORIF at 2-year follow-up TEA led to greater arc of motion and lower reoperation rates than ORIF "Bag of bones" goal is a painless pseudoarthrosis only fair functional outcomes high rate of nonunion and later surgery Unsatisfactory outcomes in up to 25% treatment of these fractures is complex due to low fracture line of one or both columns metaphyseal fragmentation of one or both columns articular comminution poor bone quality