Treatment Options for Distal Humeral Fractures

Graham J.W. King, M.D., FRCSC
Hand & Upper Limb Centre
St. Joseph's Health Care London
London, ON

Background

Fractures of the distal humerus are less common than other fractures frequently encountered by orthopaedic surgeons yet when encountered, often provide significant challenges in management. Distal humeral fractures occur in a bimodal distribution with high energy injuries in young people and low energy osteoporotic fractures in the elderly. With our aging population, the incidence of distal humeral fractures is increasing. Treatment options include non-operative treatment, open reduction and internal fixation, and elbow arthroplasty. There have been significant advances in techniques and implants for internal fixation as well as for elbow arthroplasty. In spite of this, complications remain frequent and outcomes, in many cases, suboptimal.

 

Patients present with typical symptoms of a fracture including pain, swelling, and deformity. While most fractures are closed, open injuries are not uncommon in the setting of high energy injuries. Complete nerve injuries are uncommon, however, numbness and weakness in the distribution of the ulnar nerve is not uncommon and should be carefully documented at initial presentation.

AP and lateral radiographs are sufficient to characterize extra-articular fractures; however Computer Tomography, preferably with 3D reconstructions, should be considered to better characterize intra-articular fractures and evaluate coronal shear injuries of the capitellum and trochlea which are often difficult to detect on plain radiographs. A more detailed knowledge of the fracture pattern can be helpful in determining the optimal management, directing the surgical approach, and selecting appropriate implants.

Non-operative Treatment
Non-operative treatment is indicated for low demand patients with severe medical co-morbidities or advanced dementia. A sling with early range of motion, the so-called 'bag of bones' treatment, is utilized in patients who are not a candidate for surgery and have dementia, cachexia or poor quality skin which precludes the use of a splint or cast due to potential problems with skin breakdown. An unstable non-union is the expected result; some patients develop pain while others have little discomfort. Minimally displaced distal humeral fractures in the elderly, who are not candidates for surgery, can be treated with cast immobilization. Some, but not all of these fractures will unite with six to eight weeks of cast immobilization, however, residual stiffness is a frequent and expected result of this treatment approach. Frequent follow-up is required during cast treatment to evaluate fracture alignment and the condition of the skin. A stable elbow with a united fracture, even if stiff, tends to be more useful in elderly patients than an unstable elbow with a nonunion. A flail elbow limits the ability to place the hand in space and to provide the support necessary to ambulate with a walker.

Open Reduction and Internal Fixation
Open reduction and internal fixation is typically employed for most distal humeral fractures. The patient can be positioned in the supine, lateral, or prone position depending on surgeon preference and the availability of assistants. Preoperative antibiotics and a sterile tourniquet are recommended. A posterior elbow incision is made just medial to the tip of the olecranon to protect against flap necrosis, which typically involves the medial side of the elbow. An anterior subcutaneous transposition of the ulnar nerve is recommended. If the fracture is extra-articular or is a simple intra-articular pattern, a paratricipital approach is employed, preserving the triceps insertion on the olecranon. This approach should be strongly considered for patients in wheelchairs and for those who use walkers to ambulate, as it allows for an earlier return to activity. A Bryan-Morrey or triceps splitting approach can be employed for distal humeral fractures where conversion to a total elbow is a possibility. An olecranon osteotomy provides the best exposure for most cases of comminuted intra-condylar distal humeral fractures. The use of pre-contoured plates, to fix the olecranon osteotomy, is more reliable and has a lower incidence of complications compared to tension band fixation.

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Figure 1: Distal Humeral Fracture - ORIF
(A,B) AP and lateral radiographs of a 62-year-old woman with a compound grade II distal humeral fracture. (C,D) Six months following ORIF with parallel plates using a paratricipital approach. Motion was 20 to 140 degrees.

When performing an olecranon osteotomy, visualize the non-articular portion of the ulna by exposing both medially and laterally. Secure a pre-contoured plate to the proximal ulna and then remove it. Perform a transverse or apex distal chevron osteotomy using an oscillating saw, cutting three-quarters of the way to the articular surface. Drill the remaining portion of the olecranon prior to completing the osteotomy with osteotomes. Elevate the triceps with the olecranon tip to gain wide exposure of the distal humerus.

Implants available for internal fixation of distal humeral fractures have evolved in recent years. Pre-contoured plates with or without a locking option are now available, however, evidence has yet to demonstrate improved outcomes with these implants. They are more costly than conventional implants. Medial and lateral column plates can be placed either parallel or in a '90-90' configuration depending on the fracture pattern. In severely comminuted distal humeral fractures, three plates can be employed to improve fixation. The primary advantage of parallel plating is that longer screws can be placed into the lateral column as compared to the use of a posterior plate. To avoid damaging the lateral collateral ligament (LCL), it is important, when applying a lateral plate, to avoid soft tissue stripping in the region of the lateral epicondyle. The distal end of the lateral plate should sit on top of the LCL origin to avoid instability. The lateral plate tends to be the most symptomatic for patients due to prominence along the lateral epicondyle. Since most non-unions occur at the supracondylar level, it is critical to apply compression at the fracture site and to achieve sufficient fixation both proximal and distal to the fracture. Robust plates are employed particularly if there is extension of the fracture proximal to the olecranon fossa. Most pre-contoured plates available today are more rigid than previously employed pelvic reconstruction plates. Three screws should be placed above and below the fracture in each of the medial and lateral plates. The advent of locking plates for the management of distal humeral fractures may improve outcome, however, surgeons should be cautious with their use as many of these plates have fixed angle options which direct screws in orientations which may not be optimal for every fracture. For this reason, a polyaxial locking option is preferable. In the setting of significant supracondylar comminution, humeral shortening should be performed to improve bony contact. This is particularly important in elderly patients and in the setting of compound distal humeral fractures.

Most series report 70-80% good to excellent results with open reduction and internal fixation. The majority of patients achieve a functional arc of motion. The complication rates remain high varying from 10-30% in the literature. These include, but are not limited to, infection, stiffness, painful hardware, non-unions, malunions, and post-traumatic arthritis. Ulnar neuropathy is the commonest complication from treatment of a distal humeral fracture.

Elbow Arthroplasty
The operative management of distal humeral fractures in the elderly is challenging because small distal fragments and poor quality bone lead to an increased incidence of non-union with open reduction and internal fixation. Prolonged anesthesia and a poor soft tissue envelope increase the risk of surgery and postoperative complications. The choice between open reduction and internal fixation and elbow arthroplasty primarily depends on patient factors such as age, expectations, and functional demands as well fracture factors including the pattern, comminution, and extent of osteoporosis.

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Figure 2: Distal Humeral Fracture - Total Elbow Arthroplasty
(A,B) AP and lateral radiographs of an 88-year-old woman following a fall in her seniors apartment. (C,D) Four months post linked total elbow arthroplasty. Her elbow was pain free and motion was 30 to 135 degrees.

Elbow arthroplasty should be considered in the setting of a comminuted distal humeral fracture in an elderly, low demand patient in whom stable fixation and fracture union are unlikely to be achieved. Elbow arthroplasty is also used in older patients with pre-existing rheumatoid and osteo-arthritis. While patient age is less useful than evaluating patient activity and expectations, in general elbow arthroplasty should be considered in females over 65 and males over 70. Elbow arthroplasty is contraindicated if the patient is unable or unwilling to live within the limitations of an elbow arthroplasty which involves no lifting more than 5 kg and no upper extremity sporting activities (e.g. golf). Elbow arthroplasty should not be performed in patients with severe dementia, high grade compound fractures, a history of infection, a poor soft tissue envelope or those with a non functional hand. Fracture characteristics, patient expectations, and co-morbidities are more important than absolute age.

Surgical technique depends on the arthroplasty system selected. The majority of patients are treated with a linked elbow arthroplasty through a paratricipital approach with a concomitant anterior transposition of the ulnar nerve. The distal humeral fragments are removed. Insertion of the humeral component is straightforward, however, access for replacement of the ulnar component can be challenging with the triceps still intact. Careful preparation of the ulnar canal and accurate component positioning are essential for longevity of a total elbow arthroplasty. Due to the severe osteoporosis of patients undergoing a total elbow arthroplasty for a distal humeral fracture, extreme caution must be taken to avoid an intra-operative fracture during component insertion.

A recent randomized clinical trial demonstrated improved short-term outcomes in elderly patients with distal humeral fractures treated with a linked total elbow arthroplasty when compared to open reduction and internal fixation. The objective and subjective outcomes were superior, the surgical duration was shorter, and the complication rates were lower with total elbow arthroplasty. The long-term functional outcome and durability of total elbow arthroplasty in the elderly, however, is not yet known with most of the available literature limited to short-term follow-up. The complication rates for total elbow arthroplasty remain higher than those reported for other joint replacements. Soft tissue healing problems, ulnar neuropathy, intraoperative fractures and infection can occur in the short term, while implant wear and loosening are significant concerns in the long term, particularly in younger more active patients.

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Figure 3: Distal Humeral Fracture - Hemiarthroplasty
(A,B) AP and lateral radiographs of an 83-year-old woman following a fall while gardening. She maintains her own home and is otherwise well. (C) CT scan shows a comminuted articular fracture of the distal humerus. (D,E) Six months post anatomic distal humeral hemiarthroplasty. Her elbow was pain free and motion was 15 to 145 degrees.

The advent of anatomic distal humeral hemiarthroplasty has provided another option for this patient group. The indications for a hemiarthroplasty verses a total elbow arthroplasty have not yet been clarified. They may have a role in younger patients with an unreconstructable comminuted distal humeral fracture where the longevity of a total elbow arthroplasty may be a concern. Although, insertion of the humeral component is straightforward, the challenge is to achieve stability of the elbow by careful preservation or repair of the epicondyles with the associated collateral ligaments. The implant can be inserted using an olecranon osteotomy or a paratricipital approach, with repair of the collateral ligaments and epicondyles to the implant using sutures, tension band wires, or plates as appropriate.

The results of distal humeral hemiarthroplasty are preliminary with small patient cohorts and short-term follow-up. The advent of convertible elbow arthroplasty, where the surgeon can choose between a hemiarthroplasty and linked device intraoperatively with the same system, may be helpful to reduce implant inventory. This option should be particularly helpful to manage instability or ulnar wear following a hemiarthroplasty because the humeral stem does not need to be removed to allow conversion to a linked total elbow arthroplasty.

In summary, open reduction and internal fixation of distal humeral fractures is the treatment of choice in the majority of patients. The increasing incidence of comminuted osteoporotic distal humeral fractures in the elderly will result in greater utilization of elbow arthroplasty for the management of these fractures in the future. While elbow arthroplasty is highly effective in the short-term, these devices should be avoided in younger and higher demand patients as complications such as polyethylene wear and aseptic loosening are challenging to manage for the patient and the surgeon alike.

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