Distal Humerus Fracture – Causes, Diagnosis, Treatment

Distal Humerus Fracture

Distal Humerus Fracture/Supracondylar fracture of the humerus is one of the most talked about and often encountered injury (only after clavicle and both bone forearm fracture) in pediatric age group with a male predominance accounting for 16% of all pediatric fractures and 60% of all pediatric elbow fractures, classically occurring as a result of fall on an outstretched hand [–]. In the pediatric age group, the more common age of presentation is 5-7 years (90% cases). Extension type injury is more common than the flexion type []. It is frequently found in the non-dominant extremity. The flexion type is common in elderly children []. Certain studies have reported up to 30% incidence of open fractures in this subset of the patient [].

The vast majority are extension type, resulting from a fall onto an outstretched hand, where the elbow is hyperextended, the olecranon is driven into the olecranon fossa and the anterior humeral cortex fails in tension. The pull of triceps tends to displace the distal fragment posteriorly and proximally. Neurovascular complications are reported in 5–19 % of displaced fractures [, ], due to the close proximity of structures such as the brachial artery and the anterior interosseous nerve. However, most nerve injuries are neurapraxia and recover without further intervention [].

Anatomy of Distal Humerus Fracture

Anatomically, the distal humerus has a triangular shape which is built of two columns and a “tie arch”[]. The medial column holds at its distal end the nonarticular medial epicondyle with the insertion of the flexor muscles and the medial part of the humeral trochlea. The lateral column holds at its distal end the capitellum and more proximally the lateral epicondyle with the insertion of the extensor muscles (mobile wad). From a lateral perspective, the articular surface of the trochlea and capitellum is projected anteriorly at an angle of 40° to the axis of the humerus, the trochlear axis being externally rotated at an angle of 3°–8° and compared with the longitudinal axis being in 4° to 8° of valgus [, , ].

When a fall on the outstretched hand occurs, the olecranon engages on the olecranon fossa and if elbow extension progresses, the olecranon finally acts as a fulcrum on the fossa. Therefore, the bone begins to break at first anteriorly and the fracture progresses posteriorly. If the energy is high, the posterior cortex disrupts, and finally, complete posterior displacement of the distal fragment occurs with the posterior periosteum acting as a hinge. This is the mechanism of extension-type fractures, which represent 97% to 99% of the total.rx

Both supracondylar ridges, condyles, and epicondyles give rise to attachment of various muscles which are responsible for the displacement and rotation of distal fragment. Neurovascular structures lie in proximity to the supracondylar region. The brachial artery which commonly gets involved in supracondylar fracture of humerus lies along the anteromedial aspect of distal humerus just superficial to the brachialis muscle. Major neurological structures of the upper limb (median, radial, and ulnar nerves) are also in close relation with supracondylar region [].

Any fracture in the elbow region or upper arm may lead to Volkmann’s ischemic contracture, but it is especially associated with supracondylar fracture of the humerus. Volkmann’s contracture results from acute ischemia and necrosis of the muscle fibers of the flexor group of muscles of the forearm, especially the flexor digitorum profundus and flexor politics long. The muscles become fibrotic and shortened.

Distal Humerus Fracture

Mechanism of Distal Humerus Fracture

Extension type of supracondylar humerus fractures typically results from a fall on to an outstretched hand, usually leading to a forced hyperextension of the elbow. The olecranon acts as a fulcrum which focuses the stress on the distal humerus (supracondylar area), predisposing the distal humerus to fracture. The supracondylar area undergoes remodeling at the age of 6 to 7, making this area thin and prone to fractures. Important arteries and nerves ( median nerve, radial nerve, brachial artery, and ulnar nerve) are located in the supracondylar area and can give rise to complications if these structures are injured. Most vulnerable structure to get damaged is the Median Nerve. [rx] Meanwhile, the flexion-type of supracondylar humerus fracture is less common. It occurs by falling on the point of the elbow or falling with the arm twisted behind the back. This causes anterior dislocation of the proximal fragment of the humerus.[rx]

Types of Distal Humerus Fracture

Classification of Fracture Supracondylar Humerus

Fractures of the supracondylar humerus may be classified in a number of ways as per the following:

  •  Displaced or undisplaced fractures of the supracondylar humerus
  • Open or closed fractures of the supracondylar humerus.
  • Uncomplicated or complicated fractures of the supracondylar humerus (with/without neurological and/or vascular involvement).
  • Extension type (95%) or flexion type (5%).
  • Modified Gartland’s staging system [] is based on the lateral radiograph and widely used for extension type supracondylar fractures to classify further as it can help to guide treatment.

Type I fracture –  Undisplaced.

Type II fractures – Displaced with angulation, but maintain with an intact posterior cortex.

II A fracture – Angulation.

II B fracture – Angulation with rotation.

Type III fracture – Completely displaced and lack meaningful cortical contact, but have a periosteal hinge (either medial/ lateral) intact.

III A fracture – Medial periosteal hinge intact. Distal fragment goes posteromedially.

III B fracture – Lateral periosteal hinge intact. Distal fragment goes posterolaterally.

Type IV fracture – Have no periosteal hinge and are unstable both in flexion and extension i.e., they have multidirectional instability.

Gartland’s classification was modified by Wilkins in 1984, subdividing type II fractures into IIA or IIB according to the absence (IIA) or presence (IIB) of malrotation. However, this sub-classification of type II fractures does not show a good intro- and inter-observer reliability.

  • Type I – Non-displaced fractures (< 2 mm). The AHL still crosses through the center of the capitellum. These fractures are stable because of the integrity of the periosteum.

  • Type II – Moderately displaced (> 2 mm). The AHL passes anterior to the center of the capitellum; the posterior periosteum is intact but acts as a hinge.

  • Type III – Completely displaced. This type of fracture is more unstable, with extensive soft-tissue and periosteal damage and increased incidence of neurovascular injuries.

Modified Gartland classification of supracondylar humerus fractures [, ]

Fracture type Characteristics Comments
I Minimal displacement Fat pad elevation on radiographs
II Posterior hinge Anterior humeral line anterior to capitellum
III Displaced No cortical contact
IV Displaced in extension and flexion Flexion and extension instability demonstrated radiographically
Medial comminution The collapse of medial column Loss of Baumann angle

Distal Humerus Fracture

Causes of Distal Humerus Fracture

In correlation to the abovementioned bimodal distribution of age [], mainly two fracture mechanisms can be distinguished: low-energy trauma of the elderly with direct impact on the elbow or indirect impact resulting from a fall on the outstretched hand and high energy trauma of the young patient resulting essentially from road traffic or sport accidents [].

  • Sudden forceful  fall down
  • Road traffic accident
  • Falls – Falling onto an outstretched hand is one of the most common causes of a broken supracondylar fracture.
  • Sports injuries – Many supracondylar Fracture occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
  • Motor vehicle crashes – Motor vehicle crashes can cause wrist bones to break, sometimes into many pieces, and often require surgical repair.
  • Have osteoporosis – a disease that weakens your bones
  • Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
  • Walk or do other activities in snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing
  • Wave an inadequate – intake of calcium or vitamin D
  • Football or soccer – especially on artificial turf

Symptoms of Distal Humerus Fracture

  • Typical signs and symptoms include pain, swelling, bruising, and limited range of motion at the supracondylar fracture reason. Deformity may be present in severe fractures, however, a musculature may cause absence of deformity on inspection.[rx]
  • Numbness over the outside part of the upper arm and deltoid muscle weakness may indicate axillary nerve injury.[rx]
  • Symptoms from poor blood circulation in the arm are uncommon due to collateral circulation in the arm.[rx]
  • Clinical parameters such as the temperature of the limb extremities (warm or cold), capillary refilling time, oxygen saturation of the affected limb, presence of distal pulses (radial and ulnar pulses), assessment of peripheral nerves (radial, median, and ulnar nerves), and any wounds which would indicate open fracture.
  • Doppler ultrasonography should be performed to ascertain the blood flow of the affected limb if the distal pulses are not palpable. Anterior interosseous branch of the median nerve most often injured in the postero-lateral displacement of the distal humerus as the proximal fragment is displaced anteromedially.
Supracondylar fracture
Comminuted fracture of the elbow. Labelled artwork and corresponding X-ray of extensive comminuted fractures of the distal (elbow) end of the humerus bone in a patient’s left arm. A comminuted fracture is where the bone has broken into several pieces. This is an anterior (frontal) view of the elbow in its extended position, with the fractures being of the lateral and medial condyles. The artwork at right shows the location of the elbow bones in the arm, with the joint in extension. For the surgery carried out, see C021/0785. Screws and metal plates fixed across the condylar fractures held the fragments in place, allowing them to heal in the correct alignment.

Diagnosis of Distal Humerus Fracture

History

Your doctor in the emergency department may ask the following questions

  • How – How was the fracture created, and, if chronic, why is it still open? (underlying etiology)
  • When – How long has this fracture been present? (e.g., chronic less than 1 month or acute, more than 6 months)
  • What – What anatomy and structure do it involve? (e.g., epidermis, dermis, subcutaneous tissue, fascia, muscle, tendon, bone, arteries, nerves). What comorbidities, economic or social factors do the patient have which might affect their ability to heal the fracture?
  • Where – Where on the body parts is it located? Is it in an area that is difficult to offload, complicated, or keep clean? Is it in an area of high skin tension? Is it near any vital organ and structures such as a major artery?
  • What is your Past – Has your previous medical history of fracture? Are you suffering from any chronic disease, such as hypertension, blood pressure, diabetes mellitus, previous major surgery? What kind of medicine did you take? What is your food habits, geographic location, Alcohol, tea, coffee consumption habit,  anabolic steroid uses for athletes, etc?

Physical

Physical examination is done by your doctor, consisting of palpation of the fracture site, eliciting boney tenderness, edema, swelling. If the fracture is in the dept of a joint, the joint motion, normal movement will aggravate the pain.

  • Inspection – Your doctor also check superficial tissue, skin color, involving or not only the epidermal layer or Partial-thickness affects the epidermis and extend into the dermis, but full-thickness also extends through the dermis and into the adipose tissues or full-thickness extends through the dermis, and adipose exposes muscle, bone, evaluate and measure the depth, length, and width of the fracture. Access surrounding skin tissue, fracture margins for tunneling, rolled, undermining fibrotic changes, and if unattached and evaluate for signs and symptoms of infect warm, pain, delayed healing.
  • Palpation – Physical examination may reveal tenderness to palpation, swelling, edema, tenderness, worm, temperature, open fracture, closed fracture, microtrauma, and ecchymosis at the site of fracture. Condition of the surrounding skin and soft tissue, quality of vascular perfusion and pulses, and the integrity of nerve function.
  • Motor function – Your doctor may ask the patient to move the injured area to assist in assessing muscle, ligament, and tendon function. The ability to move the joint means only that the muscles and tendons work properly, and does not guarantee bone integrity or stability. The concept that “it can’t be fractured because you can move it” is not correct. The jerk test and manual test are also performed to investigate the motor function.
  • Sensory examination – assesses sensations such as light touch, worm, paresthesia, itching, numbness, and pinprick sensations, in its fracture side. Sensory 2-point discrimination
  • Range of motion – A range of motion examination of the fracture associate joint and it’s surrounding joint may be helpful in assessing the muscle, tendon, ligament, cartilage stability. Active assisted, actively resisted exercises are performed around the injured area joint.
  • Blood pressure and pulse check – Blood pressure is the term used to describe the strength of blood with which your blood pushes on the sides of your arteries as it’s pumped around your body. An examination of the circulatory system, feeling for pulses, blood pressure, and assessing how quickly blood returns to the tip of a toe to heart and it is pressed the toe turns white (capillary refill).

Lab Test

Laboratory tests should be done as an adjunct in overall medical status for surgical treatment.

Anterior X-ray

Baumann’s Angle

Carrying angle can be evaluated through an AP view of the elbow by looking at the Baumann’s angle.[rx] There are two definitions of Bowman’s angle:

  • The first definition of Baumann’s angle is an angle between a line parallel to the longitudinal axis of the humeral shaft and a line drawn along the lateral epicondyle. The normal range is 70-75 degrees. Every 5 degrees change in Bowman’s angle can lead to 2 degrees change in carrying angle.[rx]
  • Another definition of Baumann’s angle is also known as the humeral-capitellar angle. It is the angle between the line perpendicular to the long axis of the humerus and the growth plate of the lateral condyle. Reported normal values for Baumann’s angle range between 9 and 26°.[rx] An angle of more than 10° is regarded as acceptable.[rx]

Lateral X-ray

  • On the lateral view of the elbow, there are five radiological features should be looked for: teardrop sign, anterior humeral line, coronoid line, fish-tail sign, and fat pad sign/sail sign (anterior and posterior).[rx][rx]

Teardrop sign

  • Teardrop sign is seen on a normal radiograph but is disturbed in the supracondylar fracture.[rx]

Anterior humeral line

  • It is a line drawn down along the front of the humerus on the lateral view and it should pass through the middle third of the capitulum of the humerus.[rx] If it passes through the anterior third of the capitulum, it indicates the posterior displacement of the distal fragment.[rx]

Fat pad sign/sale sign

  • A non-displaced fracture can be difficult to identify and a fracture line may not be visible on the X-rays. However, the presence of a joint effusion is helpful in identifying a non-displaced fracture. Bleeding from the fracture expands the joint capsule and is visualized on the lateral view as a darker area anteriorly and posteriorly, and is known as the sail sign.[rx]

Coronoid line

  • A line drawn along the anterior border of the coronoid process of the ulna should touch the anterior part of the lateral condyle of the humerus. If lateral condyle appears posterior to this line, it indicates the posterior displacement of the lateral condyle.[rx]

Fish-tail sign

  • The distal fragment is rotated away from the proximal fragment, thus the sharp ends of the proximal fragment look like a shape of a fish-tail.[rx]

Compartment syndrome

  • Increased interstitial pressure within a closed fascial compartment can lead to compartment syndrome. This increased pressure can result in compromised circulation to the nerves and muscles in that compartment. Elevated tissue pressure obstructs venous outflow from the compartment, which further contributes to the increased pressure and swelling. Ischemia occurs once the pressure rises above arteriolar circulation. Muscle and nerve tissue becomes damaged as soon as 4–6 h after the onset of abnormal pressures.
  • The first sign of compartment syndrome is disproportionate pain requiring increasing doses of pain medication []. Other findings include sensory changes such as paresthesias, loss of active movements in the affected compartment, forearm tenderness, palpable tenseness of the muscles of the forearm (or arm), and pain with passive flexion or extension of the fingers.

Treatment of Distal Humerus Fracture

Non-Pharmacological

  • Immobilization –  in either a sling or a Velpeau bandage, with early gentle range of motion exercises. Some fractures may reduce with gravity alone as the patient resumes ambulating, but for some fractures, the closed reduction may improve the deformity and the amount of bony contact.
  • In the acute setting – pain control can be difficult for patients. Resting in a supine position allows the arm to extend at the fracture site, and leads to pain and discomfort. Placing the injured extremity in a sling and having the patient rest in an upright or semi-reclining position with some bolsters behind the arm can help to reduce the pain. Patients may also find it more comfortable to sleep sitting in a reclining position when they are at home. Patients and caregivers should be advised that prolonged immobilization can be detrimental to the outcome.
  • The Range of Motion Exercises – Due to their limited movement following a proximal humerus fracture, individuals lose their range of shoulder motion and may develop stiffness of the shoulder joint. Your physical therapist will assess your shoulder motion compared to expected normal motion and the motion of shoulder of your noninjured arm, and lead you through a program of motion exercises to restore shoulder function.
  • Strengthening Exercises – The muscles of the shoulder and upper back work together to allow for normal upper-body motion. Based on the way the shoulder joint is designed (a ball-and-socket joint, like a golf ball on a golf tee), there are many directions in which the shoulder may move. Therefore, the balanced strength of all the upper body muscles is crucial to make sure that the shoulder joint is protected and efficient with its movements. When there is a fracture to the proximal humerus (near the “ball” segment of the joint), the muscles around the shoulder girdle weaken, as they are not being used normally; this process is called “atrophy.” There are many exercises that can be done to strengthen the muscles around the shoulder so that each muscle is able to properly perform its job. Often, building strength after a fracture can take weeks to months due to atrophy. Your physical therapist will help you develop a strengthening program that is safe and comprehensive.
  • Manual Therapy – Physical therapists are trained in manual (hands-on) therapy. When appropriate, based on the stage of healing at your fracture site, your physical therapist will gently move your shoulder joint and surrounding muscles as needed to improve their motion, flexibility, and strength. These techniques can target areas that are difficult to treat on your own.
  • Functional Training – Whether you work in a factory, are a mother of a young child, work as a secretary, or are an older adult, the ways in which you perform your normal daily activities are important. Improper movement patterns after a fracture may come back to haunt you, as they may lead to future secondary injuries. Physical therapists are experts in assessing movement quality. Your physical therapist will be able to point out and correct faulty movements, so you are able to regain use of and maintain, a pain-free shoulder.
  • Physiotherapy – which can be self-directed or in a formal setting, depending on the patient’s wishes and abilities, should begin no later than two weeks after the injury [, ]. Initially, pendulum exercises will allow for a range of motion without placing weight-bearing stress on the fracture. After the patient is more comfortable, finger crawl exercises along a vertical surface can help with an overhead range of motion.

Do no HARM for 72 hours after injury

  • Heat – Heat applied to fracture and injured side by hot baths, electric heat, saunas, heat packs, etc has the opposite effect on the blood flow. Heat may cause more fluid accumulation in the fracture joints by encouraging blood flow. Heat should be avoided when inflammation is developing in the acute stage. However, after about 72 hours, no further inflammation is likely to develop and heat can be soothing.
  • Alcohol –  stimulates the central nervous system that can increase bleeding and swelling and decrease healing.
  • Running and movement – Running and walking may cause further damage, and causes healing delay.
  • Massage – A massage also may increase bleeding and swelling. However, after 72 hours of your fracture, you can take a simple message, and applying heat may be soothing the pain.

Medication

The following medications may be considered by your doctor to relieve acute and immediate pain, long term treatment

What To Eat and What  to avoid

Eat Nutritiously During Your Recovery

All bones and tissues in the body need certain micronutrients in order to heal properly and in a timely manner. Eating a nutritious and balanced diet that includes lots of minerals and vitamins is proven to help heal broken bones and all types of fractures. Therefore, focus on eating lots of fresh food produce (fruits and veggies), whole grains, cereal, beans, lean meats, seafood, and fish to give your body the building blocks needed to properly repair your fracture. In addition, drink plenty of purified mineral water, milk, and other dairy-based beverages to augment what you eat.

  • Broken bones or fractures bones need ample minerals (calcium, phosphorus, magnesium, boron, selenium, omega-3) and protein to become strong and healthy again.
  • Excellent sources of minerals/protein include dairy products, tofu, beans, broccoli, nuts and seeds, sardines, sea fish, and salmon.
  • Important vitamins that are needed for bone healing include vitamin C (needed to make collagen that your body essential element), vitamin D (crucial for mineral absorption, or machine for mineral absorber from your food), and vitamin K (binds calcium to bones and triggers more quickly collagen formation).
  • Conversely, don’t consume food or drink that is known to impair bone/tissue healing, such as alcoholic beverages, sodas, fried fast food, most fast food items, and foods made with lots of refined sugars and preservatives.

Surgery

Indications of Surgical Intervention to be Considered in the Following Conditions []

  • If close manipulation fails to achieve the reduction.

  • If after close reduction fracture is unstable i.e., failure to maintain the reduction.

  • If neurological involvement occurs during or after the manipulation of fracture.

  • If vascular exploration is required.

  • In open fractures.

  • All Type II and III fractures requiring elbow flexion of more than 90° to maintain the reduction.

  • All Type IV fractures supracondylar humerus.

  • Polytrauma with multiple ipsilateral fractures requiring surgical intervention.

Gartland type I

  • Non-displaced or type I fractures can be managed easily with a long-arm cast or splint [rx]. There is not usually severe swelling or ecchymosis, so elbow flexion up to 80° to 90° and mid-pronation-supination are well tolerated. However, flexion of the elbow within the cast should not pass 90° because it can increase forearm pressures and impede distal vascular flow.,
  • Although secondary displacement rarely occurs, it seems prudent to control secondary displacement with a new radiograph performed at least seven to ten days after injury. Three weeks after the fracture, the cast is removed and progressive joint motion is allowed.

Gartland type II

  • Operative treatment of these fractures has become more popular recently. The limited potential of remodeling of the distal humerus is the strongest argument in favor of surgical management. The distal humerus represents only 20% of the total growth of the bone and the ability to remodel is limited after the age of four years. After the ages of eight to ten years, only 10% of the growth of the humerus remains, so anatomical reduction is thought to be imperative.
  • Closed reduction and casting of these fractures are becoming less popular because of the excessive flexion of the elbow beyond 90° needed to maintain reduction, which increases the risk of compartment syndrome and neurovascular injuries.[,–
  • Regarding conservative treatment with simple immobilization, Moraleda et al described the long-term results of Gartland type II fractures treated with immobilization and no attempt at reduction. The authors described a mild cubitus varus deformity in 26% of cases, pain or instability in 17% of patients, and a mild increase in elbow extension and a mild lack of elbow flexion that was present in almost every patient. However, the authors found that functional results were excellent in most of the patients and were not predictors of bad results.
  • It is thought that Gartland type II fractures with medial column comminution, varus or valgus angulation, or rotation should be treated surgically, even if the fracture is minimally displaced. However, identifying rotation is difficult in plain radiographs.
  • Closed reduction and percutaneous pinning of type II fractures seem to be easy, safe and reliable., The risk of complications is low. In fact, Skaggs et al described no radiographic or clinical loss of reduction and no complications in their series. For these reasons, in our opinion, if any doubt exists about the need for reduction, a closed reduction and percutaneous pinning fixation of a Gartland type II fracture is indicated.

Types III and IV

  • It is widely accepted that type III and type IV fractures should be managed surgically. Nowadays, closed reduction and percutaneous pinning is the gold standard for all displaced fractures. Blount’s method with closed reduction and hyperflexion of the elbow to maintain reduction is no longer used because of the risk of compartment syndrome or neurovascular injury.
  • However, Pham et al have described their results with Blount’s method when treating Gartland type IIB and III supracondylar fractures. The authors described a second displacement in 5% of their cases, a cubitus varus deformity in 2% of their cases, no cases of compartment syndrome and satisfactory results according to Flynn’s criteria in 90% of their cases. The authors concluded that Blount’s method is a reasonable option for treating type IIB and III supracondylar humeral fractures in children. Muccioli et al also described good results with Blount’s technique. Other treatments, such as traction, have only historical interest.–

Surgical approaches to the distal humerus

  • Various surgical approaches to the distal humerus have been described over the past decades. Each fracture needs its appropriate exposure and in cases of intra-articular involvement the exposure of the articular surface. Olecranon osteotomy, the triceps-splitting, triceps-sparing, and triceps-lifting approaches being the most frequently performed approaches in the surgical treatment of distal humerus fractures [–], we will be giving an overview of the established approaches offering selected indications and an evaluation of the related published data.

Olecranon osteotomy

  • Olecranon osteotomy (Chevron osteotomy) is the traditional standard approach to the distal humerus and elbow joint []. A V-shaped olecranon osteotomy is performed, creating a wide exposure of the articular surface of the distal humerus making a reduction and internal fixation of complex fractures feasible [].
  • In literature, complication rates up to nearly 50 % have been highlighted. Zhang et al. showed in their study 14 out of 33 patients with osteotomy-related complications. In detail, one patient presented with non-union, two with delayed-union, and five with implant loosening. Six patients complained about prominent implants. Nine underwent removal of the osteotomy fixation. Six cases needed total implant removal for other reasons [].

Triceps-reflecting (elevating) approach (Bryan-Morrey)

  • Avoiding the abovementioned complications of the olecranon osteotomy, Bryan and Morrey established in 1982 the triceps-reflecting approach. The approach is basically posterior, the triceps mechanism is reflected from medial to lateral from the olecranon and the ulnar periosteum and at the end of the procedure is being resutured transosseous.
  • This approach allows the surgeon a widespread view of the joint without olecranon osteotomy and is used for arthroplasty and internal fixation of intraarticular fractures [].

Triceps-sparing approach

  • After a posterior midline incision, a window on the lateral side of the triceps is created by elevating it off the posterior border of the intermuscular septum and posterior humerus. The radial nerve is being identified and mobilized for its protection.
  • Not detaching the triceps from its insertion, the view of the distal articular surface is relatively impaired. The indication is open reduction internal fixation (ORIF) in extra-articular or simple articular fractures [].

Triceps-lifting approach

  • After posterior incision, the ulnar nerve is exposed, mobilized, and protected. The triceps muscle is detached and lifted in a “V” shape. Then, the muscle is split up to the condyles enabling the surgeon a wide view of the articular surface [, ]. This approach has been evaluated and established for intraarticular fractures (AO type B3 and C) [].

Triceps-splitting approach

  • After a posterior median incision, an interval between the long and lateral heads of the triceps is established. The medial head comes into view and a split along its muscle fibers is performed. The split is prolonged over the olecranon subperiosteally while preserving the connection between the flexor carpi ulnaris and anconeus muscle. This approach has been well-established in the treatment of distal diaphyseal fractures and intraarticular fractures (AO type C) [].

Triceps flexor carpi ulnaris approach

  • This approach is a modification of the triceps-reflecting approach. It involves reflection of the triceps periosteal portion off the ulna from lateral to medial incising the anconeus to develop the view to the distal humerus articular surface. Few data have been published about this approach. Deakin et al. reported about 12 patients with the good clinical and radiological outcome. Due to the small number of cases, no significant benefits concerning the protection of the ulnar nerve or recovery of the extensor mechanism could be shown compared to olecranon osteotomy. The approach has been described to be used for extra- and intra-articular fractures [].

Approaches for partially articular fractures

  • For selected partial articular fractures of the distal humerus, the usage of minimally invasive approaches has proven itself sufficient for successful fracture reduction and fixation. For type B1 fractures a lateral approach has been shown to be feasible and safe, exposing the lateral epicondyle by developing the interval between the triceps, the brachioradialis, and the extensor carpi radialis longus. [].
  • For AO type B2 fractures, after mobilization of the ulnar nerve and release of the medial intermuscular septum, the flexor carpi ulnaris, and pronator teres are pulled anteriorly to display the joint capsule, thus enabling fracture reduction after incision of the capsule [].

Plating options in distal humerus fractures

  • Open reduction and internal fixation have become the treatment of choice for fractures of the distal humerus [–]. Achieving rigid internal fixation and anatomical reconstruction is essential for allowing early ROM exercise, adequate bone healing, and avoiding future cartilage degeneration [].
  • Biomechanical studies could demonstrate the advantages of double plating over single plating in proximal and intraarticular fractures of the distal humerus, providing the necessary stability and rigidity [, –]. The standard fixation that has been used by most surgeons is double plating with the two planes perpendicular to each other [, , ].

Total elbow arthroplasty and hemiarthroplasty of the elbow

  • The introduction of locking compression plates improved the outcome of internal fixation in distal humerus fractures significantly, especially in patients with minor bone quality [].
  • Nevertheless, in the elderly patient an increasing risk of failure of osteosynthesis like loss of reduction, non-union and screw cut out is still expected [] and reconstruction and fixation of comminuted fractures remain to be highly challenging with high rates of complications [].

Surgical Approaches Used for Treatment of Fractures of the Distal Humerus (Canale & Beaty: Campbell’s Operative Orthopaedics, 11th edition, Mosby (2007)17.

Surgical Approach Indications Contraindications Advantages Disadvantages
Olecranon osteotomy Open reduction and internal fixation (ORIF) for fractures involving columns and articular surface Total elbow replacement (TER) Good access to posterior articular surfaces for reconstruction Nonunion and failure of fixation of the osteotomy
Poor anterior access to capitellum
Triceps-splitting ORIF/TER for fractures involving columns and articular surface Previous olecranon osteotomy approach
Patients at increased risk for healing problems		 Avoids complications associated with olecranon osteotomy Poor access to the articular surface for internal fixation
Risk of triceps detachment
Triceps-reflecting Fractures requiring TER ORIF
Previous olecranon osteotomy approach
Patients at risk for healing problems		 Avoids complications associated with olecranon osteotomy Risk of triceps detachment
Triceps-detaching ORIF/TER for fractures involving columns and articular surface Previous olecranon osteotomy approach
Patients at risk for healing problems		 Avoids complications associated with olecranon osteotomy Poor access to articular surfaces for internal fixation
Risk of tricep

Complications of Distal Humerus Fracture

Vascular Insufficiency

  • The absence of the radial pulse is reported in 6 to 20 percent of all supracondylar fractures [,]. Vascular injury evident by the involvement of the brachial artery is most commonly associated with Type II and III supracondylar fractures, frequently encountered in postero-laterally displaced fractures [,].
  • Patients without significant improvement in pulse after orthopedic care, warrant emergent vascular exploration, especially if there is intractable pain, the persistence of pain or increasing pain despite fracture site stabilization which is suggestive of ischemia [,–].

Neurologic Deficit

  • The frequency of neurologic deficit reported after supracondylar fractures in children is 10 to 20 percent and increases in some series of children with Type III supracondylar fractures to as high as 49 percent [,,–].
  • The median nerve and its anterior interosseous nerve branch is at risk and gets most commonly involved in the postero-lateral displacement of the distal fracture fragment, whereas radial nerve is most commonly involved with a posteromedial displacement of the distal fracture fragment. Ulnar nerve injuries are commonly associated with flexion type supracondylar fractures [,,].

Forearm Compartment Syndrome Resulting in Volkmann’s Ischemic Contracture

  • Vascular injury and primary swelling from the injury can lead to the development of compartment syndrome within 12 to 24 hours []. If compartment syndrome is not treated timely, the associated ischemia may progress to infarction and subsequent development of Volkmann’s ischemic contracture: fixed flexion of the elbow, pronation of the forearm, flexion at the wrist, and joint extension of the metacarpal-phalangeal joint [].

Malunion

  • One of the frequent long term complications of supracondylar fracture is angular deformities, of which cubitus varus or “gunstock” deformity is very common. The distal humerus physis, in contrast to the proximal humeral physis, contributes only 15 to 20 percent to the overall longitudinal growth of the humerus [].
  • This suggests very limited remodeling in the correction of fracture angulation in children with supracondylar fractures. Modern surgical techniques (e.g., closed reduction with percutaneous pinning) have reduced this frequency of cubitus varus from 58 percent to approximately 3 percent in children treated for supracondylar fractures [].
  • Posttraumatic cubitus varus deformity has important problems, which are associated with tardy ulnar nerve palsy [], tardy Postero-Lateral Rotatory Instability (PLRI) [], and secondary distal humeral fractures [].