Distal Humerus Fracture Before and after Repair

 

Distal Humerus Fractures

 

 

  Fractures of the distal humerus (Elbow) are a result of a fall on the elbow with the arm in a flexed position. I subdivide these into two main groups: Those that involve the joint surface (intra-articular fractures) and those that do not involve the joint surface (extra-articular fractures).  In addition, the treatment of these fractures in children is different that treatment in adults. In most cases, though, these fractures are unstable and a majority of them need some type of internal fixation to prevent them from healing in a bad position.

 

 

              

 

Two view of a  supracondylar humerus fracture in a 5 year old

 

 

   Supra-condylar humerus fractures are common in children and typically occur from falling off the monkey bars or on a home gym.  Unlike fractures in adults, these are usually a hyper-extension injury.  There is usually an obvious deformity of the arm and they swell rapidly.  Treatment involves lining the bones under live x-ray (Fluoro) and holding them in place with pins placed through the skin (percutaneous) into the bone. In cases where the bone is widely displaced I will sometime make an incision to directly visualize the reduction and make sure there is no tissue interposed between the bones before I put the pins in.  Most children stay overnight in the hospital and are discharged the next day.  I generally take the pins out in clinic after 4 weeks and discontinue the cast altogether after about 6 weeks. Although children tend to have quite a bit of anxiety about having the pins removed, it is essentially painless and doesn't warrant the risk of additional anethestic

 

             

 

X-ray views of the same elbow after percutaneous pinning

 

 

When these fractures occur in adults, I am more aggressive and usually recommend surgical repair. A small percentage of these fractures can be treated in a long arm cast but this often leads to significant stiffness in the joint which is the most common  long-term complication. These fractures typically involve the surface of the joint (cartilage) and in those cases in which the bone is displaced, I recommend surgical repair.  Typically the surface of the joint is smooth allowing the bones to glide past one another with very little friction.  If the surface is incongruent because the bones are not aligned, chronic damage to the joint occurs ultimately leading to arthritis and loss of cartilage.  It is very important to ensure that the surface of the cartilage is repaired as accurately as possible.  Because of this, I recommend surgical repair in any fracture of the distal humerus in which the joint has more than 2 mm of displacement. I have included links to the plating systems that I typically use in repairing distal humerus fractures below

 

Synthes LCP Elbow Plating System

 

Stryker Variax Elbow Plating System

 

Accumed Elbow Plating System

 

 In addition, after surgical repair patients are able to begin moving their arm within 2 weeks of the surgery and the risk of long term stiffness is reduced.  Surgery involves re-aligning the fracture and holding the repair with plates and screws. The surgery takes approximately 2 hours and most patients stay overnight in the hospital.  The most common complications of the surgery are infection (about 2%), stiffness (10%) and nerve injury called neuropraxia (about 2-3%).  Neuropraxia is a condition in which the nerve (ulnar nerve) that runs along the back part of the elbow (funny bone) is irritated and doesn't work properly after surgery. In most cases this is temporary but can take several months to resolve. 

 

 

Extensive Heterotopic bone formation after repair

 

  After surgery, patients wear a split (soft cast) for about 2 weeks and then begin a fairly aggressive protocol with physical therapy to regain range of motion in the elbow. Total recovery time can take 6 months and most patients have very good range of motion and strength after the bone heals. The most common long term complications are joint stiffness, heterotopic bone formation and painful retained hardware or pain over the plates.  Even with aggressive rehabilitation, most patients have some loss of motion in the involved elbow that is most noticable in extension (straightening the elbow).  I will often combine a dynamic splint for patients to use in the evenings as an adjunct to physical therapy.  The dynamic elbow splint applies gentle force to straighten or bend the elbow and patients can adjust the degree and amount of force to their own tolerance.  Most insurance plans will allow for a 3 month lease of the splints.  The most common commercially available design which I recommend is called a Dynasplint.  For more information about Dynasplints, click on the link below

 

Dynasplint Link

 

      

 

Examples of dynamic elbow splints

 

In some cases this stiffness can be severe and is caused by ectopic bone formation (bone forming in places where it usually doesn't occur) along the front capsule of the elbow joint.  This is most common with severe injuries or in patients with concomitant closed head injury.  In some cases I recommend removal of the ectopic bone but I usually wait 6-8 months before excising the bone to lessen the chances of recurrence.  In many instances the plates cause irritation as they sit directly under the skin and next to the nerve that supplies sensation to the ring finger and index finger. The surgery to remove the plates is far less involved than the initial fracture repair and most patients fully recover from the hardware removal in about 4-6 weeks.

 

 

Elbow Flexion (bending) and Extension (straightening)

 

For a more detailed look at my post-operative Elbow Surgery protocol click on the link below.  This instruction sheet answers a number of questions about what to expect after surgery on your elbow including suggestions about medications, what to do if your splint gets wet and exercises you can begin in the first week after surgery.

Elbow Surgery Instruction Sheet