Distal Humerus Fractures Treatment & Management

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Distal Humerus Fractures Treatment & Management

Author: Edward Yian, MD; Chief Editor: Harris Gellman, MD more... Updated: Nov 2, 2011

Medical Therapy
Nonoperative treatment depends on the fracture type. Casting and immobilization can be used for nondisplaced fractures, particularly with medial, lateral, and supracondylar process fractures (extra-articular and extracapsular). Medial epicondylar fractures can be immobilized for 7 days, with the elbow flexed at 90, the forearm pronated, and the wrist flexed at 30 to relax the common flexor-pronator muscle group. If more than 3 mm of displacement is present or the fragment is trapped in the medial joint, attempts at closed reduction often fail, and open reduction with internal fixation is necessary. Lateral epicondylar fractures can be immobilized with the elbow in 90 of flexion, the forearm in supination, and the wrist extended slightly to relax the extensor muscles. Stable, nondisplaced, extra-articular distal humerus fractures can be treated with a short period of splinting or casting in a long arm cast (usually for approximately 2 wk), followed by use of a hinged functional brace with early elbow motion. Often, gentle closed reduction consisting of axial traction in neutral rotation with correction of the deformity can be attempted for maximal anatomic reduction. An olecranon K-wire traction apparatus with later brace conversion has been described, with use depending on the patient's medical status (ability to tolerate an operative procedure) and soft-tissue condition. Although the outcome after nonoperative treatment may include reduction imperfections with prominent callus formation and slight varus angulation, good elbow function is generally obtained if early range-of-motion (ROM) exercises can be instituted. Articular involvement or fractures with significant comminution, displacement, or both are poorly tolerated and require open reduction and internal fixation. In the pediatric population, only nondisplaced supracondylar humerus fractures are treated closed. The patient's arm can initially be placed in a posterior splint, with transition to a long arm cast when soft-tissue swelling has diminished. For extension-type fractures, the elbow is placed at 90 of flexion, with the forearm in neutral rotation. Type II and III extension-type fractures often require stabilization with percutaneous pins in order to maintain reduction. If closed treatment for a stable type II fracture is desired, then reduction is maintained by keeping the elbow in at least 120 of flexion and full pronation. However, if any concern exists about circulatory impairment or swelling, then percutaneous pinning is recommended. Stable, nondisplaced, flexion-type supracondylar humerus fractures should be immobilized in a long arm cast with the elbow in extension. Lateral condylar fractures often require treatment with operative stabilization due to their unstable fracture pattern. Minimally displaced, stable type I fractures can be treated with immobilization and close monitoring to prevent late displacement. Pirker and colleagues studied 51 pediatric lateral condylar fractures that had minimal displacement and found that 9.8% of these later became displaced.[15] Fracture separations of the distal humeral epiphysis must be recognized early, and closed reduction should be attempted. The reduction maneuver involves flexion and pronation of the forearm to prevent medial translocation of the distal fragment.

Surgical Therapy
Studies have supported the notion that distal humerus fractures in adults are optimally treated with open anatomic reduction and stable fixation to allow for early anatomic restoration and upper extremity ROM. While operative intervention is not without complications, detailed attention to anatomic reduction, soft-tissue handling and preservation, stable fixation, and early mobilization can reduce complications. For articular fractures and unstable nonarticular fractures, operative treatment with direct visualization of the joint surface and anatomic reduction and stabilization can prevent accelerated arthritis associated with articular incongruity. If the injury involves significant contamination from external sources or bone devitalization, then osteosynthesis is delayed following serial irrigations and debridements. Temporary fixation with a bridging external fixator, however, can be performed. Olecranon skin traction is an option for persons who have fractures with excessive soft-tissue swelling and in patients with multiple traumatic injuries who require rapid, temporary skeletal stabilization. Other reconstruction options include autograft or allograft support and fascial arthroplasty. In relatively inactive elderly patients with poor bone quality, total elbow arthroplasty (TEA) is indicated for comminuted distal humerus fractures when open reduction and internal fixation are not feasible.[16, 17] Elbow arthrodesis is a severely limiting alternative and is very rarely performed.

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Distal Humerus Fractures Treatment & Management

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Preoperative Details
Preoperative planning is essential prior to operative treatment of a distal humerus fracture. Proper imaging studies and physical examination findings help to determine the appropriate surgical approach and techniques necessary for a functional outcome. Contralateral distal humerus radiographs may be required to create a template of the restored anatomy of the injured extremity. The soft-tissue involvement may dictate the location of the incision. Tracing paper can be used to mark the fracture fragments and lines as well as the anatomic reduction. The steps of the procedure, including patient position, surgical approach, provisional fixation, and definitive treatment, should be discussed and documented. Discussion has begun regarding the timing of operative treatment for closed pediatric supracondylar humerus fractures. Typically, if the patient is neurovascularly stable, the arm is splinted and the patient is taken to the operating room as soon as possible. Mehlman and colleagues provided strong evidence that no difference exists in perioperative complication rates for displaced supracondylar humerus fractures treated before or after an 8-hour period.[18]

Intraoperative Details
Images of distal humerus fracture repair are provided below:

Radiograph of a supracondylar-intracondylar distal humerus fracture. Note the posteromedial and posterolateral column plate placement used for reconstruction with the chevron osteotomy.

Lateral radiograph of a supracondylar-intracondylar distal humerus fracture. Note the distal extent of the contoured plate placed extra-articularly.

Radiograph of a supracondylar-intracondylar humerus fracture. Note the ipsilateral radial head fracture fixed through a posterior incision.

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Distal Humerus Fractures Treatment & Management

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Lateral radiograph of a supracondylar-intracondylar distal humerus fracture with an ipsilateral radial head fracture.

Anteroposterior radiograph of a pediatric type III supracondylar humerus fracture. Note the lateral pinning.

Lateral and medial pinning of a type III extension-type supracondylar humerus fracture.

Lateral radiograph after open reduction and pinning of a type III supracondylar humerus fracture.

Patient position
The patient should be positioned to allow adequate exposure and visualization of the entire involved area. Previous authors have supported a wide range of positions, from supine to prone to the lateral decubitus position. For single column or shear fractures, the supine position is helpful in order to use the lateral approach to the elbow. An arm board or hand table can be placed at the side of the operating table for support of the medial portion of the arm. The authors prefer to use the lateral decubitus position with a beanbag for support and a padded, sterile arm holder under the proximal humerus. The hip-holder attachment to the Jackson table also can be used as an arm holder. This allows adequate access to the posterior portion of the elbow joint and also permits the arm to be freely rotated proximally for more accurate positioning. The hand and forearm are draped with a sterile stockinette. The

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Distal Humerus Fractures Treatment & Management

shoulder is placed at 90 of abduction, and the elbow is flexed over the arm holder at 90. The lateral position also allows access to either the anterior or posterior iliac crest in case a bone graft is needed. The prone position is rarely used. Other considerations for positioning should include associated injuries, simultaneous procedures that will be performed during the same anesthetic administration, and the patient's overall systemic demands (such as those resulting from closed head injuries). A tourniquet should be applied as far proximally on the brachium as possible. With supracondylar or high column fractures, a sterile tourniquet is needed. The entire arm should be prepared and draped.

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Surgical approaches
Several different surgical approaches, with variations, have been described. For isolated single column or epicondylar injuries, a lateral or straight medial approach is recommended. The lateral (Kaplan) approach involves an incision proximal to the lateral epicondyle that is extended distally across the radiohumeral interval. Dissection is carried down between the extensor carpi radialis brevis and extensor digitorum communis (EDC) interval or between the EDC and extensor carpi radialis longus interval until the supinator muscle is visualized. Detachment of the heads of the supinator reveals the annular ligament and lateral column of the distal humerus. If the incision is to be extended distally, the posterior interosseous nerve must be protected. The posterolateral (Kocher) approach may be safer for exposure of the lateral column because it uses the anconeus and extensor carpi ulnaris (ECU) interval, better protecting the posterior interosseous nerve. An incision is started just proximal to the lateral epicondyle and ends obliquely across the proximal ulna. The arm is kept pronated during the dissection to keep the posterior interosseous nerve away from the dissection field. Blunt dissection through the ECU fascia and through the anconeus-ECU interval leads to the elbow joint capsule. Exposure distal to the annular ligament leads to the posterior interosseous nerve. The lateral collateral ligament (LCL) is visualized by retracting the ECU and EDC anteriorly. The capsular incision should be made anterior to the radiohumeral ligamentous complex to avoid injury to the posterior fibers of the LCL complex and to prevent resulting instability. If truly necessary for exposure, the LCL may be detached from the lateral epicondyle and then reattached with nonabsorbable suture or suture anchors. The medial approach involves the interval between the brachialis and medial collateral ligament. Proximal extension is made through the brachialis and triceps interval. A similar posteromedial approach has been described as well for fracture fixation and medial placement of a single plate. This allows dissection of the radial nerve to be avoided but may not be appropriate in settings with preoperative radial nerve injuries.[19] The posterior (Campbell) incision is most often used for nonarticular supracondylar fractures or intra-articular fractures. The incision can be curved gently, either medially or laterally, at the olecranon to avoid impingement directly over the apex. The ulnar nerve should be isolated carefully and at least 6 cm mobilized both proximally and distally to the cubital tunnel to allow the nerve to lie within the subcutaneous tissues anteromedially to the cubital tunnel (transposition).[20, 21, 22] Careful attention should be paid to the release of the medial intermuscular septum and distal dissection of the nerve within the flexor carpi ulnaris (FCU). A triceps-splitting approach is most commonly used for exposure of the distal humerus. This technique involves deep dissection down the middle of the arm over the olecranon, along with fascial and periosteal flap elevation along the sides of the bone. Medial triceps insertion avulsion has been reported and must be carefully avoided. The anconeus muscle fibers and the FCU muscle fibers are elevated off the bone laterally and medially for improved distal exposure. Proximally, the radial nerve crosses within the deep muscle fiber origin of the medial triceps head 13-15 cm above the joint line. The triceps insertion should be preserved as much as possible and should be reattached through drill holes if released. This approach has been reported to lead to devascularization-induced triceps rupture and may increase adhesion formation. The triceps-sparing approach described by Bryan and Morrey is particularly advocated for use in intra-articular fractures of the distal end of the humerus when conversion to an elbow arthroplasty or to a TEA is necessary as the primary treatment.[23] The ulnar nerve is isolated and is transposed anteriorly. The triceps is dissected subperiosteally and is elevated from medial to lateral for exposure of the distal humerus. It is kept in continuity with the forearm fascia and periosteum, and the triceps insertion is directly from the ulna. Variants of this technique have described a lateral to medial reflection of the triceps mechanism. The ulnar collateral ligament may be released from the distal humerus to improve exposure. Reattachment is necessary after fracture repair, but reattachment is not necessary following TEA. Some authors prefer a nonarticular olecranon osteotomy, with proximal retraction of the triceps with its insertion for visualization of the distal humerus. This involves an osteotomy performed distal to the articular olecranon. The osteotomy can be directed transverse (modified MacAusland technique) or obliquely (Mueller technique). Because of the inherent risk of fracture nonunion, many authors prefer a triceps-sparing approach or an intra-articular olecranon osteotomy. For improved exposure for intra-articular fractures, the posterior approach is often combined with an intra -articular osteotomy. Direct visualization allows accurate reduction of the joint surfaces. Both transverse and chevron osteotomies have been described. The authors prefer a chevron osteotomy with direct fixation using a tension band wire technique and K-wires. The osteotomy can also be fixed with an intramedullary 6.5-mm cancellous screw, which can be predrilled and tapped before the osteotomy for easier placement of the screw. The curvature of the proximal ulna may make accurate placement of the screw down the intramedullary canal difficult.

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Distal Humerus Fractures Treatment & Management

The olecranon is sharply dissected along the medial and lateral portions to better view the semilunar notch. Typically, an oscillating thin-blade saw is used, with the osteotomy cuts converging obliquely and distally, just distal to the midportion of the semilunar notch. The amount of articular cartilage is least here. The osteotomy is completed with an osteotome. Use of the osteotome allows improved engagement of the fragments after reduction. The remaining capsular attachments and the soft tissue bordering the triceps are cut to allow proximal retraction of the olecranon tip with the triceps insertion. The olecranon tip is elevated off the posterior aspect of the humerus. The ulnar nerve is isolated and transposed with this approach. After distal humerus fracture fixation, the proximal ulna can be reattached using standard AO-ASIF tension band wire technique and either 2 parallel 0.0625-mm K-wires or a 6.5-mm partially threaded cancellous screw, as described previously. The tension band wire should be placed underneath the triceps, against the bone periosteal surface, and secured with either the K-wires or the cancellous screw. The transverse distal wire hole should be placed well distal to the osteotomy site.

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Reduction and stable fixation

A methodical approach should be taken to reduction and fixation of the fracture fragments. All of the fracture fragments should be identified initially. Hematoma should be removed, and the fracture planes should be identified and restored. If one column remains intact, the reduction can be simplified by assembling the fragments against the intact column. For bicolumn involvement, some physicians prefer to first stabilize one column and then to reduce the second column to the first column. A more common approach is to start with the articular surface and to anatomically reduce the joint surface. The metaphyseal fragments are then separately reduced and fixed. This effectively converts the fracture into a 2-part fracture. Others prefer a "best-fit" method of anatomic restoration. By starting with the portion that can be best anatomically aligned and is least comminuted, errors in reduction can be minimized. Provisional reduction can be accomplished with K-wires or bone-holding forceps. Most surgeons begin with reconstitution of the trochlea and work proximally. The trochlea can be stabilized back to the shaft and the leastfractured column. With articular comminution, it is important to restore the normal articular surface depth and width. Central comminution or missing articular fragments should be replaced with bone graft obtained from the iliac crest. Fixation should be obtained with interfragmentary 4.0 cancellous lag screws crossing both the medial and lateral column to maintain reduction. For more extensive comminution, a fully threaded, nonlagged 4.0 cancellous screw should be placed across the trochlea to prevent narrowing across the gap. Retrograde drilling through one of the fracture fragments is recommended to maintain a central position of the screw. The screw can then be placed from the capitellar fragment across the fracture site and into the trochlear fragment. Low columnar fragments may also be fixed with small, cannulated differential pitch screws buried beneath the articular surface or small, threaded K-wires buried under the articular surface. Once the articular fragments have been reduced, the stabilized distal fragment is reduced to the shaft. Precontoured plates can be placed onto the shaft over K-wires that stabilize the construct. A metaphyseally placed screw can hold the plate initially for stability. Various implants are available today for the diverse fracture patterns observed in the distal humerus. Some plates are contoured specifically for the anatomy of the distal humerus. Several companies have developed anatomically based precontoured condylar plate systems that can assist with fracture reduction. Screws ranging from cannulated to noncannulated and varying in size from 2.7 mm (mini-fragment screws) to 3.5 mm and 4.5 mm (small- and largefragment screws) may be needed. Most small-fragment implant sets have 3.5-mm and partially threaded 4.0-mm screws up to 50 mm in length. If longer screws are needed, 3.5-mm screws up to 110 mm in length are available. Newer, minimally invasive, percutaneously inserted bridge plates also have been described and have been used to avoid extensive dissection and potential nerve injury. Some have shown good results in their utilization, even with prior radial nerve palsy anticipating eventual nerve recovery.[24] Plate placement is the keystone of fracture reduction. Once articular reconstruction is completed, the lateral column is fixed with a molded 3.5-mm dynamic compression plate, or a reconstruction plate is placed posterolaterally. The posterior aspect of the lateral condyle has a bare surface immediately proximal to the articular surface, making it safe for plate placement. However, the posterior capitellar articular surface limits distal placement of the plate. Screws can be directed anterosuperiorly, above the capitellum, or directed anteriorly, gaining fixation distally only by the near cortex (in order to avoid joint penetration) and gaining bicortical fixation proximally. The medial column is stabilized with a one-third tubular plate or a 3.5-mm reconstruction plate placed in an orthogonal fashion with respect to the lateral plate. The medial column of the distal humerus is nonarticular, and a plate can be contoured into a semicircle along its distal end to cradle the medial epicondyle. The most distal screw can be oriented superiorly at a 90 angle to the more proximal screws, enhancing stability, or obliquely, to engage the lateral column.[25] Orthogonal plate placement has been demonstrated to provide the greatest stability for avoiding a variety of failure loads. However, Schemitsch and colleagues demonstrated that with cortical contact, plates placed medially and laterally were as rigid as those placed orthogonally.[26] Care must be taken to prevent olecranon hardware impingement in elbow extension. Jupiter has described placing a third plate laterally along the lateral column for added fixation.[27, 20] Basic principles for internal fixation of these fractures include the following: All distal screws from one column should pass through a plate. All distal screws should pass into a major fragment on the opposite column.

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Distal Humerus Fractures Treatment & Management

All screws should be as long as possible to engage the opposite cortex. All screws should engage as many fragments as possible. Screws approaching the articular surfaces and fossae should be avoided. O'Driscoll has described the use of "contact with compression" in order to obtain increased stability across the fracture site. Fixation of the articular fragments onto the proximal supporting columns creates the weakest link. By obtaining compression across the fracture sight, the limb is shortened slightly. This leads to overlap of fragments, which improves overall stability and the ability to institute early range of motion to prevent elbow stiffness. Fixation of distal humerus fractures often is determined by the fracture pattern. With divergent single column injury patterns, 2-5 lag screws placed percutaneously from side to side may be employed for adequate fixation. For coronal shear fractures, small cannulated screws placed anterior to posterior through the articular surface anteriorly may be used. Partially threaded 4.0-mm cancellous bone screws also can be placed from posterior to anterior through the fracture line, gaining unicortical fixation. After fixation is achieved, it is important to carefully assess the entire range of motion of the elbow to evaluate stability. If olecranon impingement limits extension, hardware may need to be modified or the tip of the olecranon may be excised. Other options to improve stability include bone autograft or allograft, bicortical interpositional grafting for bone loss (often for malunions), and polymethylmethacrylate with screw augmentation. If this fails, then a hinged external fixator may be considered as a salvage procedure. TEA is an option for comminuted distal humerus fractures in the elderly. A drain is placed, and the soft tissue and skin should be closed in layers. The elbow joint is immobilized in a wellpadded, well-molded splint that is in full extension to limit swelling. For pediatric supracondylar humerus fractures, extension-type fractures are initially manipulated with the patient completely relaxed in order to achieve stable anatomic reduction. Traction is established, and then the limb is hyperextended with varus or valgus correction and hyperflexed to stabilize the fracture. Finally, forearm pronation is recommended to stabilize the distal fragment in the coronal plane. Similarly, with flexion-type fractures, the elbow is reduced in extension and the previously mentioned reduction technique is performed. Careful attention should be paid to applying pressure posteriorly onto the distal fragment through the forearm when flexing the elbow to maintain reduction of the distal fragment. Type III flexion-type injuries are notorious for requiring open reduction. Several authors have described various closed methods of reduction for this type of fracture. If open reduction is needed, an anteromedial approach is often used due to the anterolaterally displaced fragment. The proximal fragment is usually impaled within the triceps mechanism. Controversy has persisted concerning the benefits of crossed percutaneous pinning versus those of lateral pinning for stable fixation of supracondylar humerus fractures. Lee and colleagues, among others, have provided biomechanical evidence that cross pinning provides a stronger construct.[28] Skaggs and associates have shown in retrospective studies that the configuration of the pins does not affect final fracture reduction of type II or III supracondylar humerus fractures.[13] The lateral pins are placed first with the elbow in hyperflexion and pronation. The pin or pins should be placed in the center of the lateral condyle and directed at 30 to the humeral axis. The medial pin or pins should be started at the medial epicondyle and directed anterolaterally. Before pin insertion, the ulnar nerve should be palpated or soft tissue should be dissected and the epicondyle visualized. Studies have shown a high incidence of ulnar nerve subluxation with flexion of the elbow during the reduction maneuver. Attention should be paid to preventing pins from crossing at the fracture site. The pins are cut outside of the skin and bent back. The arm should be placed in a long arm splint postoperatively, with transition to a long arm cast (worn for at least 3 weeks). Open reduction with pinning is the treatment of choice for displaced pediatric lateral and medial condylar fractures. Rotational displacement is very difficult to evaluate with closed reduction maneuvers. A direct lateral approach to the elbow is recommended for lateral fragments through the brachioradialis-triceps interval. Posterolateral dissection should be avoided in order to preserve the vascularity from the posteriorly located vessels. A posteromedial incision is used for medial fragments. The fracture site should be carefully debrided, and 2 smooth K-wires are inserted through the condyle or metaphyseal fragment and into the medial humeral metaphysis. The pins can be kept under or external to the skin but require removal after 3 weeks. The arm is protected in a long arm splint, with transition to a long arm cast (worn for 3 weeks). Fracture separation of the epiphysis can be treated with open reduction and pinning if recognized early. Separations are often missed, and if they are discovered after 5-7 days, they should be splinted and allowed to heal with remodeling.

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Postoperative Details
The entire extremity should be elevated above the level of the heart to reduce swelling. The drain can be removed after 24-48 hours, when drainage diminishes. Once the swelling abates, the elbow can be placed in a supportive brace or sling, and gentle, active ROM exercises can be initiated. Passive ROM exercises are delayed 6 weeks to allow for early fracture healing. In patients who have undergone a triceps-sparing approach, active extension is prevented for the first 6 weeks. Instead, elbow extension is achieved through gravity. Six weeks after surgery, passive ROM, including dynamic flexion and extension splints as needed, is instituted. Strengthening is begun 10 weeks after surgery.

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Distal Humerus Fractures Treatment & Management

Most pediatric elbow fractures can initially be treated in a long arm posterior splint for comfort after surgery, with transition to a long arm cast. The pins are removed after 3 weeks, and the cast is removed after 3-4 weeks. Protected ROM can be initiated at this time.

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Follow-up
Inpatient care is recommended for 2-3 days, with the wound carefully examined 48-72 hours after surgery. In addition, excessive swelling and signs of compartment syndrome should be monitored. The wound should be examined again by 14 days after surgery, and the sutures should be removed. Fracture healing should be assessed with serial radiographs to examine callus formation, alignment, and hardware integrity. Bony union is anticipated by 3 months after surgery. With pediatric fractures, bony union is expected sooner and ROM can be initiated earlier.

Complications
The most commonly observed complication after operative treatment is loss of elbow motion. Physical therapy, including active and passive ROM, as well as static progressive splinting, is useful treatment. Nonoperative treatment is usually successful only for an extrinsic elbow contracture that has been present for less than 6 months. If nonoperative treatment fails, operative release is recommended. Most often, an open approach is used. Mansat and Morrey have described a limited lateral approach to both the anterior and posterior capsule called the column procedure.[29] This involves elevating muscles from the lateral supracondylar osseous ridge. Mansat and Morrey had an 11% complication rate; hematoma formation and ulnar nerve paresthesia were the most common complications. Other authors have described arthroscopic approaches to capsular release. Anatomic reduction with stable fixation of fracture fragments, careful handling of the ulnar nerve, and adequate fixation of an olecranon osteotomy can improve results of surgical treatment. Failure of fixation is most often the result of poor preoperative planning and poor operative technique, although bone quality may limit stable fixation. Careful rehabilitation progression can optimize the opposing forces of motion maintenance and fracture healing. Nonunion rates for surgically treated distal humerus fractures range from 2-7%. Infection, bone osteoporosis, age, open fractures, multiple injuries, and inadequate fixation have been implicated as factors leading to nonunion. Symptoms include persistent pain, weakness, and instability, although most patients maintain up to an 80 arc of motion. If surgical treatment is chosen, options include revision open reduction and internal fixation, allograft reconstruction, and resection or distraction arthroplasty.[30] TEA may be considered in elderly, less active patients.[31] With pediatric elbow fractures, nonunions of the lateral condyle are the most common. Compression fixation and bone grafting are recommended as treatment. Heterotopic ossification can occur in up to 50% of cases after acute treatment of distal humerus fractures. It typically occurs in the posterolateral aspect of the elbow, from the lateral humeral condyle to the posterolateral olecranon. Hastings and Graham have described a functional classification system for elbow ectopic ossification that assists in clinical evaluation, treatment, and operative planning, as follows[32] : Class I - These fractures are associated with no functional limitations. Class II Class IIA - These fractures are associated with functional limitation of flexion and extension; they result in anterior or posterior ossification or ossification involving both sides of the elbow joint. Class IIB - These fractures involve functional limitation of supination and pronation and also may involve ossification of the interosseous membrane or distal radioulnar joint. Class III - These fractures are associated with ankylosis that eliminates elbow ROM. Some studies have found a lower incidence of heterotopic ossification formation when open reduction and internal fixation are performed within 24-48 hours of injury. Heterotopic ossification incidence is increased with associated injuries, such as burns, head injuries, high-energy injuries, and open injuries. In these patients, prophylactic treatment should be considered. Forced passive manipulation also may increase the development of heterotopic bone formation. Preventive measures include the use of nonsteroidal anti-inflammatory drugs (NSAIDs), low-dose radiation therapy, and continuous passive ROM exercises. Most studies have looked at heterotopic ossification treatment around the hip. Regardless, the treatment of heterotopic ossification continues to be controversial. Low-dose radiation with single doses of 600-700 cGy to the elbow has been successful at preventing further progression. The timing of the irradiation (preoperative vs postoperative) does not seem to affect operative outcomes. Some authors have recommended irradiation within 72 hours of elbow trauma. The concerns of neoplasm development after radiation treatment are evident. NSAIDs have been used with success against heterotopic ossification. Indomethacin is the most commonly used drug for heterotopic ossification prevention and has been shown to decrease heterotopic ossification incidence and severity. The recommended dose is 75 mg orally 2 times per day for 3 weeks. Sucralfate, at a dose of 1 g orally 4 times per day, has been recommended to prevent gastrointestinal disturbances in patients taking indomethacin. Operative excision of heterotopic ossification is recommended 12 months after the injury, although studies have shown good results with treatment 3-6 months following injury. Declining levels of serum alkaline phosphatase and the radiographic confirmation of mature heterotopic bone can be used to help predict timing for heterotopic bone

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Distal Humerus Fractures Treatment & Management

excision. However, studies have shown no difference in serum alkaline phosphatase levels in matched populations with or without ectopic ossification. As a result, they are not routinely indicated. Combined medial and lateral approaches are recommended for removal of heterotopic bone. Cut bone surfaces should be cauterized and covered with bone wax, and extensive capsular release should be performed. Patient complaints related to ulnar nerve dysfunction are among the most frequent findings after surgical treatment of distal humerus fractures, affecting up to 15% of patients. Revision operative procedures have revealed extensive fibrosis and fracture healing that causes the ulnar nerve to adhere to the medial epicondylar area. Mobilization and anterior transposition at the time of index surgery decreases the incidence of this complication. Further, a 2011 study suggests that performing intramedullary antegrade nailing, rather than crossed K-wire fixation, as the index surgery for supracondylar humeral fractures reduces the risk of ulnar nerve injury.[33] Instability after distal humerus fracture fixation is rare. It is most often observed with untreated type II single column injuries or radial head or coronoid fractures. With comminuted intra-articular fractures, it may not be possible to reconstruct associated ligamentous injuries. Hall and colleagues described the use of a hinged external fixator to treat associated posterolateral instability of a severely comminuted distal humerus fracture after having been unable to stabilize the joint following open reduction and internal fixation.[34] Although the distal humeral condyles may be fractured, the medial and lateral ligamentous attachments typically remain preserved, lending stability to the elbow after operative stabilization. Avascular necrosis is extremely rare after distal humerus fractures. Isolated studies have reported an increased risk after H-type intra-articular distal humerus fractures of avascular necrosis of the free-floating fragment. The most common nerve injuries that are associated with open reduction and internal fixation of distal humerus fractures are ulnar nerve injuries. Ulnar neuropathy has been reported to occur in 7-15% of cases. The ulnar nerve, because of its proximity to the dissection, should be exposed and identified with eventual anterior transposition. Postoperative ulnar nerve dysesthesia symptoms with intact motor examination findings are common and can be closely monitored. With more proximally involved fractures, the radial nerve should be identified upon exposure. It can be damaged by retraction, plate impingement, or tissue dissection during the operation. If a change in baseline motor nerve function on postoperative examination occurs, reexploration is recommended. Brachial artery injuries have been described and are more common with extension-type elbow injuries. The brachial artery can be damaged by the sharp ends of the proximal fragment penetrating its wall. Dormans and colleagues, along with Cramer and associates, have studied the high incidence of anterior interosseous nerve injuries that have been associated with closed pediatric supracondylar fractures.[35, 36] Return of function occurred within 10 months without surgical intervention. Overall, the authors found a 9.5% incidence of nerve injury. Radial nerve injuries have been found to be more common with posteromedial displaced fractures, while median nerve injuries have been associated with posterolateral angulated fractures. Avascular necrosis of the trochlea is associated with more distally based pediatric humerus fractures. Injury to the physeal vasculature of the medial trochlea can lead to avascular necrosis, resulting in a fishtail deformity. Malreduction of a lateral condylar fracture can lead to development of a bony bar within the physis and to development of a fishtail deformity. Angular deformities, such as cubitus varus and cubitus valgus, are rare complications after pediatric supracondylar humerus fractures. Often, anatomic reduction prevents development of these deformities. Cubitus valgus is very rare and often occurs with posterolateral fracture patterns. It often leads to more functional loss (typically of extension) than does cubitus varus. Lateral condylar fractures can lead to cubitus varus angulation. A combination of nonanatomic reduction and physeal growth stimulation leads to this deformity. Most of the time, the degree of deformity is of little consequence. Oh and colleagues described 7 of 12 young children in whom fracture separation of the distal humeral epiphysis led to cubitus varus deformity, with development of avascular necrosis of the medial humeral condyle occurring in 6 of the 7 patients.[37]

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Outcome and Prognosis

Loss of terminal extension is frequently observed after distal humerus fracture. Chronic exertional pain can be observed in up to 25% of patients who have suffered such injury. Henley and other authors have reported good to excellent results in 92% of treated patients at 1.5-year follow-up.[38] Other studies have reported similar numbers, with a range of 60-90% and good to excellent results. Wang and colleagues reported that most poor results tend to occur with complex group C3 fractures and are related to associated injuries and complications.[21] In their study of 20 patients, 4 complications occurred: 1 nonunion, 1 malunion, 1 deep infection, and 1 brachial artery laceration. McKee and colleagues studied functional outcome following surgical treatment for displaced intra-articular distal humerus fractures.[39] After 37 months of follow-up, they found a mean flexion contracture of 25 and an arc of motion of 108. Significant decreases in mean muscle strength were found in both elbow flexion and extension (75% of normal). Outcome studies have reported healing rates of 80-100% postoperatively. Jupiter reported postoperative arc of motion improved to 100, with 83% good or excellent functional results.[27, 20] Regarding surgical exposure for distal humerus fractures, a nonunion rate of up to 40% has been reported from chevron osteotomy outcomes, although some authors contend that poor technique is often the source of the

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Distal Humerus Fractures Treatment & Management

complications. Contributory factors include lack of interdigitation of the osteotomy site, malposition of the intramedullary fixation screw, infection, and broken implants.

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Future and Controversies

Distal humerus fractures remain a challenging reconstructive problem for orthopedic surgeons. However, future technology may hold many solutions. With the advent of newer, stronger biocompatible materials, diverse hardware options allow improved reduction and fixation of distal humerus fractures. Lower profile plates and smaller screws allow the surgeon to maintain the original articular congruity needed to prevent posttraumatic arthrosis, which allows for faster and progressive postoperative rehabilitation. In addition, for the unreconstructable elbow, primary TEA is slowly gaining acceptance. Significant improvements in its design and surgical technique have produced reliable pain relief and functional restoration. While rigid patient selection criteria should be adhered to with this surgical option, TEA may help elderly patients with severe bone loss and comminution.

Contributor Information and Disclosures

Author Edward Yian, MD Consulting Staff, Department of Orthopedic Surgery, Southern California Permanente Group Orange County Edward Yian, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons Disclosure: Nothing to disclose. Coauthor(s) Madhav Karunakar, MD Consulting Surgeon, Section of Orthopedic Surgery, Department of Surgery, University of Michigan Medical Center Madhav Karunakar, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons and AO Foundation Disclosure: Nothing to disclose. Specialty Editor Board Peter M Murray, MD Professor of Orthopedic Surgery, Mayo Clinic College of Medicine; Director of Education, Mayo Foundation for Medical Education and Research, Jacksonville; Consultant, Department of Orthopedic Surgery, Mayo Clinic, Jacksonville; Consulting Staff, Nemours Children's Clinic and Wolfson's Children's Hospital Peter M Murray, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for Hand Surgery, American Orthopaedic Association, American Society for Reconstructive Microsurgery, American Society for Surgery of the Hand, Florida Medical Association, Orthopaedic Research Society, and Society of Military Orthopaedic Surgeons Disclosure: Nothing to disclose. Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Medscape Salary Employment Thomas R Hunt III, MD John D Sherrill Professor and Director of Orthopedic Surgery, Director of Hand and Upper Extremity Fellowship, University of Alabama at Birmingham School of Medicine; Surgeon-in-Chief, UAB Highlands Hospital Thomas R Hunt III, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for Hand Surgery, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, American Society for Surgery of the Hand, AO Foundation, Mid-America Orthopaedic Association, and Southern Orthopaedic Association Disclosure: Tornier Royalty Independent contractor; Tornier Ownership interest None; Lippincott Royalty Independent contractor Dinesh Patel, MD, FACS Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons Disclosure: Nothing to disclose. Chief Editor Harris Gellman, MD Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard M

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Distal Humerus Fractures Treatment & Management

Miller School of Medicine Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society Disclosure: Nothing to disclose.

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