Distal Humerus Fractures
These are relatively rare fractures, involving only 2 percent of all fractures. They usually occur among boys in their teens and in females older than age 80. The most common injury in the elderly involves falling from a standing height. Most fractures involve the intercondylar area, which is the part of the bone between the two condyles that make up the elbow joint.
In older people, the fracture can happen with a minimal fall. In younger individuals, these fractures are more commonly associated with motor vehicle accidents and sporting injuries.
Evaluation of Humeral Fractures
There is often a lot of swelling associated with these fractures. It can be hard to identify the landmarks around the elbow. There will be a lot of crepitus in these injuries but it is not a good idea to push much on the fracture site to find crepitus because it involves pushing on nerves and blood vessels that can be damaged during the assessment process. The fracture must be reevaluated on a regular basis for compartment syndrome from excessive swelling and for neurovascular compromise.
X-rays in two views (front and side) will be able to tell if the bone is fractured in most cases. Sometimes an oblique view is necessary. Nondisplaced fractures may just show a swelling of the fat pad in the elbow joint, often called the “sail sign” because of its triangular shape. CT scan can be used if it is not clear exactly where the fracture fragments are located.
Classification of Humerus Fractures
There are many types of distal humerus fractures, including:
- Supracondylar fractures (extension or flexion type)
- Transcondylar fractures
- Intercondylar fractures
- Capitellum fractures
- Condylar fractures
- Trochlea fractures
- Lateral epicondyle fracture
- Medial condylar fracture
- Fractures of the supracondylar process
Treatment of Distal Humerus Fractures
The idea behind the treatment of distal humerus fractures is to put the joint surfaces in as close approximation as possible and to stabilize the articular surface. The alignment of the joint must be in its proper position and there must be early range of motion exercises to keep the joint from becoming stiff.
Treatment can be non-operative or operative, depending on the conditions. If they are treated non-operatively, this can mean ongoing arthritis and limited function of the elbow after the bones have healed. This is more commonly done in the elderly who already have poor expectations of normal function of the elbow, regardless of the type of treatment. Often the fractures are comminuted so that it is difficult to put the bony fragments back into position. A long arm splint is used at 90 degrees flexion for about 1-2 weeks after which range of motion exercises can be done with the elbow in a brace for about 6 weeks.
Surgery is required if the fragments are widely displaced or if there is an open fracture. If the blood vessels have been damaged, then surgery is required to repair the injury. Sometimes closed reduction is attempted and surgery is done if the closed reduction fails.
Plates are used at 90 degrees or 180 degrees from one another and the plates are held on with screws. In some cases, a total elbow replacement needs to be done but this is not often attempted in the elderly population. Range of motion exercises can be used to keep the joint from freezing up. These are usually attempted after the pain and swelling has diminished—about 1-2 weeks after the injury.
Complications of Distal Humerus Fractures
There can be unrecognized compartment syndrome that doesn’t allow for complete vascularity to the forearm so that contractures of the elbow occur. There can be a loss of range of motion of the elbow, particularly loss of complete extension of the elbow due to callus formation in the inner aspect of the elbow. Extra bone can grow at the site of fracture, which can contribute to loss of function of the elbow.
Post traumatic arthritis can happen whenever the joint itself is involved. This can be minimized by surgically aligning the fracture fragments so that the joint heals. It can also be improved by doing early range of motion exercises to keep the joint from stiffening. Joint spurs can form in certain types of fractures, which limit the range of motion of the elbow.