Distal Humerus Fractures: Fractures of the Columns With Articular Involvement

Introduction

Distal humerus fractures represent a very challenging injury. For years, these injuries were universally treated using relatively unstable internal fixation (wires or unstable plate constructs), which led to a substantial rate of poor outcomes secondary to nonunion, stiffness, or posttraumatic arthritis. The outcome of these injuries has been greatly improved by

• 1

  better understanding of these injuries, facilitated by more widespread use of computed tomography (CT) with three-dimensional reconstructions

• 2

  improved internal fixation implants and techniques

• 3

  selected use of elbow arthroplasty

From a practical perspective, there are four major fracture patterns: supraintercondylar fractures, partial articular fractures, shear fractures of the capitellum or a more extensive portion of the articular surface, and low transcondylar fractures. Chapter 44, Chapter 46, Chapter 47, Chapter 92 review low transcondylar fractures, articular shear fractures, and the role of elbow arthroplasty for distal humerus fractures. This chapter reviews internal fixation of distal humerus fractures involving both the columns and the articular surface ( Fig. 45.1 ).

Epidemiology

The rate of distal humerus fractures in the United States has been estimated to be 43 for every 100,000 people, which translates to approximately 130,000 distal humerus fractures every year. The incidence of these injuries is expected to increase over time, especially as the number of elderly individuals continues to grow.

Fractures of the distal humerus have a trimodal epidemiology distribution. In the pediatric age, children tend to sustain supracondylar fractures or partial-articular physeal injuries, described in the section on pediatric trauma. Most high-energy distal humerus fractures are seen in active middle-age adults as a result of motor-vehicle accidents, falls from a height, or, rarely, sport-related injuries. Elderly patients with underlying osteopenia may sustain comminuted distal humerus fractures with falls from a standing height.

Patient Evaluation

Patients presenting to the emergency room or the office with a fracture of the distal humerus involving the columns and the articular surface should be carefully evaluated to identify preexisting elbow pathology and possible associated injuries (both in the same upper extremity and in other locations), as well as to characterize the extent of the elbow injury.

Preexisting elbow pathology (i.e., inflammatory arthritis, previous injuries) may incline the decision-making process toward elbow arthroplasty. The soft tissue envelope should be assessed to identify open fractures and, in the elderly patient, relatively frail skin. It is also important to assess and document the functional status of the median, radial, and ulnar nerves.

Plain anteroposterior and lateral radiographs may be sufficient for the more simple fracture patterns. We have a low threshold to obtain a CT scan with three-dimensional reconstruction when the morphology of the fracture is difficult to understand on plain radiographs, unless it has already been decided to proceed with elbow arthroplasty, as in this case a CT scan provides little help intraoperatively ( Fig. 45.2 ). Traction radiographs obtained with the patient under anesthesia prior to surgery may add useful information to plan the internal fixation strategy.

Management Options

Treatment options for management of complex supraintercondylar fractures of the distal humerus include nonoperative management, internal fixation, and arthroplasty.

Nonoperative management may be selectively considered in low-demand elderly patients whose comorbidities contraindicate surgical intervention. Desloges et al. reported on 32 fractures treated nonoperatively: at most recent follow-up, 19 patients were available (40% were dead or lost to follow-up). Of the remaining 60% of the patients, 70% reported a satisfactory outcome, despite a 20% radiographic nonunion rate.

Even though low-demand elderly patients treated nonoperatively may do well without surgery, most authors agree that distal humerus fractures involving the columns and the articular surface are best treated operatively. Although elbow arthroplasty provides a number of benefits for distal humerus fractures (i.e., bone union is not required, recovery is relatively easier, patients return faster to independent activities of daily living, and both nonunion and posttraumatic arthritis are avoided), implant replacement is associated with a certain rate of mechanical failure, patients need to accommodate restrictions for the rest of their lives, and some complications—such as a deep periprosthetic infection—may be catastrophic. For these reasons, internal fixation is the most common treatment modality used for the management of supraintercondylar fractures of the distal humerus.

Controversy remains regarding the ideal technique for internal fixation of supraintercondylar column fractures. Use of a plate on each column has become the standard of care; luckily, internal fixation techniques using only wires, screws, or one plate have been largely abandoned. For the more simple fractures with no comminution, orthogonal and parallel dual plating probably provide equivalent results. However, for the complex distal humerus fracture, parallel plating is superior. Because many surgeons do not have the opportunity of treating many of these fractures each year, it does not make sense to master two techniques. For those reasons, we recommend mastering the parallel plating technique ( Fig. 45.3 ).

Internal Fixation: Surgical Technique