General Treatment Principles
- Anatomic articular reduction
- Stable internal fixation of the articular surface
- Restoration of articular axial alignment
- Stable internal fixation of the articular segment to the metaphysis and diaphysis
- Early range of elbow motion
Specific Fracture Types
Extra-Articular Supracondylar Fracture
- Results from a fall onto an outstretched hand with or without an abduction or adduction force
- Most are extension patterns with a minority being flexion types.
Treatment
Nonoperative
- Reserved for nondisplaced or minimally displaced fractures as well as for severely comminuted fractures in elderly patients with limited functional ability
- Posterior long arm splint is placed in at least 90 degrees of elbow flexion if swelling and neurovascular status permit, with the forearm in neutral.
- Posterior splint immobilization is continued for 1 to 2 weeks, after which range-of-motion exercises are initiated in a hinged brace. The splint or brace may be discontinued after approximately 6 weeks, when radiographic evidence of healing is present.
- Frequent radiographic evaluation is necessary to detect loss of fracture reduction.
Operative
- Indications
- Displaced fractures
- Vascular injury
- Open fracture
- Inability to maintain acceptable reduction
Patient Positioning- Supine on a radiolucent table with arm over chest
- Quick and easy set up
- Good for multiply injured patients with multiple extremity involvement
- Requires assistant to hold arm during procedure
- Lateral
- Allows good access to posterior arm and elbow without need for additional assistant
- Prone
- Allows good access to posterior arm and elbow without need for additional assistant
Image Positioning- Image intensifier can be placed on same or opposite side of the injured extremity.
Surgical Approaches- All surgical approaches require identification of the ulnar nerve.
- Triceps splitting approach
- Easy to perform
- Enables intact trochlea notch of proximal ulna to act as template to assist fracture reduction
- No need for additional hardware to reattach olecranon
- Can be converted to exposure necessary for total elbow replacement or olecranon osteotomy for increased articular exposure
- Affords limited articular exposure; usually used for extra-articular fractures
- Paratricipital approach
- Easy to perform
- Uses windows on either side of the triceps to assess fracture reduction
- Can be converted to exposure necessary for total elbow replacement or olecranon osteotomy for increased articular exposure
- Has limited articular exposure compared to olecranon osteotomy
- Usually used for extra-articular fractures or if chance of conversion to elbow arthroplasty during surgery
- Triceps reflecting anconeus pedicle (TRAP) approach
- Uses a proximally based triceps–anconeus flap
- Medial portion of flap is created by subperiosteal dissection from the subcutaneous border of the ulna
- Kocher interval is used to raise the anconeus muscle and develop the lateral portion of the flap
- Anconeus flap is elevated and reflected proximally to expose the triceps insertion, which is also released.
- Advantage is preservation of the neurovascular supply to the anconeus.
- Soft tissue repair is required to reattach the extensor mechanism.
- Bryan-Morrey approach
- Involves subperiosteal reflection of the triceps insertion from medial to lateral in continuity with the forearm fascia and anconeus muscle
- Although the triceps tendon insertion is detached, the extensor mechanism maintains its continuity as a single sleeve through its soft tissue attachments.
- Extensor sleeve is repaired using drill holes or osseous anchors.
- Used primarily for arthroplasty
- Campbell (triceps tongue)
- Triceps aponeurosis freed in a tongue-shaped flap proximally to distally, left attached to the olecranon, and retracted distally
- Deep head of triceps divided along midline
- Used for arthroplasty, fractures with complete/high-grade triceps tendon laceration, or patients with chronic elbow dislocation
- Olecranon osteotomy (Fig. 17.3)
- Most extensile approach
- Uses a transverse or apex distal, chevron-type osteotomy of the olecranon which exits in the so-called bare area of the trochlear groove
- Osteotomy is initiated with an oscillating saw and completed with an osteotome.
- Osteotomy requires fixation using a tension band construct, an intramedullary screw/nail or a plate.
Implant Options- Plate fixation
- Plate fixation is used on each column, either in parallel or 90 degrees from one another.
- Use of locked plates has gained in popularity and affords much better metaphyseal fixation than conventional nonlocked plates.
- Parallel plating has been shown to be biomechanically superior to orthogonal plating for distal fractures. Use of parallel plating allows for longer length screws directed from lateral to medial than a posterolateral plate in which screw length is limited by the anterior articular surface.
- Total elbow replacement
- Indicated in elderly patients with a severely comminuted fracture of the distal humerus deemed unreconstructable
- Use of elbow arthroplasty requires a lifelong restriction of 5-lb weight bearing in that arm.
- Medial, triceps-sparing approach should be used, rather than an olecranon osteotomy, for exposure of the elbow joint.
- Range-of-motion exercises should be initiated as soon as the patient is able to tolerate therapy.
Complications
- Volkmann ischemic contracture (rare): This may result from unrecognized compartment syndrome with subsequent neurovascular compromise. A high index of suspicion accompanied by aggressive elevation and serial neurovascular examinations with or without compartment pressure monitoring must be maintained.
- Loss of elbow range of motion: Generally, this is the rule following any fracture about the elbow.
- Loss of extension due to callus formation in the olecranon fossa
- Loss of flexion due to capsular contracture and or heterotopic bone
- Heterotopic bone formation may occur.
Transcondylar Fractures
- Occur primarily in elderly patients with osteopenic bone
Mechanism of Injury
- Mechanisms that produce supracondylar fractures may also result in transcondylar fractures: a fall onto an outstretched hand with or without an abduction or adduction component or a force applied to a flexed elbow.
Treatment
Nonoperative
- Indicated for nondisplaced or minimally displaced fractures or in elderly patients who are debilitated and functioning poorly
- Range-of-motion exercises should be initiated as soon as the patient is able to tolerate therapy.
Operative
- Operative treatment should be undertaken for open fractures, unstable fractures, or displaced fractures.
- Open reduction and plate fixation are the preferred treatment. Precontoured locked plates should be used in order to enhance fixation in this usually osteopenic fracture pattern.
- Total elbow arthroplasty (semiconstrained) may be considered in the elderly patient with good preinjury functional status if fixation cannot be obtained.
Intercondylar Fractures
- The second most common distal humeral fracture (next to extra-articular)
- Comminution is common.
- Fracture fragments are often displaced by unopposed muscle pull at the medial (flexor mass) and lateral (extensor mass) epicondyles, which rotate the articular surfaces.
Mechanism of Injury
- Force is directed against the posterior aspect of an elbow flexed >90 degrees, thus driving the ulna into the trochlea.
Treatment
- Treatment must be individualized according to patient age, bone quality, and degree of comminution.
Nonoperative
- Indicated for nondisplaced fractures, elderly patients with displaced fractures and severe osteopenia and comminution, or patients with significant comorbid conditions precluding operative management. Nonoperative options for displaced fractures include:
- Cast immobilization: This has few advocates; it represents the “worst of both worlds”—inadequate fracture reduction and prolonged immobilization.
- “Bag of bones”: The arm is placed in a collar and cuff with as much flexion as possible after initial reduction is attempted; gravity traction helps effect reduction. The idea is to obtain a painless “pseudarthrosis,” which allows for motion.
Operative
- Open reduction and internal fixation
- Indicated for displaced reconstructible fractures
- Goals of fixation are to restore articular congruity and to secure the supracondylar component.
- Methods of fixation include:
- Interfragmentary screws
- Dual plate fixation: one plate medially and another plate placed posterolaterally, 90 degrees from the medial plate or two plates on either column, 180 degrees from one another
- Total elbow arthroplasty (cemented, semiconstrained): This may be considered in markedly comminuted fractures and with fractures in osteoporotic bone.
- Surgical exposures
- Postoperative care: Early range of motion of the elbow is essential unless fixation is tenuous.
Complications
- Posttraumatic arthritis: This results from articular injury at time of trauma as well as a failure to restore articular congruity.
- Failure of fixation: Postoperative collapse of fixation is related to the degree of comminution, the stability of fixation, and protection of the construct during the postoperative course.
- Loss of motion (extension): This is increased with prolonged periods of immobilization. Range-of-motion exercises should be instituted as soon as the patient is able to tolerate therapy, unless fixation is tenuous.
- Heterotopic bone
- Neurologic injury (up to 15%): The ulnar nerve is most commonly injured during surgical exposure.
- Nonunion of osteotomy: 5% to 15%
- Infection
Condylar Fractures
- Rare in adults and are much more common in the pediatric age group
- Less than 5% of all distal humerus fractures are condylar; lateral fractures are more common than medial.
- Medial condyle fractures: These include the trochlea and medial epicondyle and are less common than medial epicondylar fractures.
- Lateral condyle fractures: These include the capitellum and lateral epicondyle.
Mechanism of Injury
- Abduction or adduction of the forearm with elbow extension
Classification
Milch
Two types are designated for medial and lateral condylar fractures; the key is the lateral trochlear ridge (Fig. 17.4):
- Type I: Lateral trochlear ridge left intact
- Type II: Lateral trochlear ridge part of the condylar fragment (medial or lateral)
- These are less stable.
- They may allow for radioulnar translocation if capsuloligamentous disruption occurs on the contralateral side.
Jupiter
This is low or high, based on proximal extension of fracture line to supracondylar region.
Treatment
- Anatomic restoration of articular congruity is essential to maintain the normal elbow arc of motion and to minimize the risk of posttraumatic arthritis.
Nonoperative
- Indicated for nondisplaced or minimally displaced fractures or for patients with displaced fractures who are not considered candidates for operative treatment
- Consists of posterior splinting with the elbow flexed to 90 degrees and the forearm in supination or pronation for lateral or medial condylar fractures, respectively
Operative
- Indicated for open or displaced fractures
- Consists of screw fixation with or without collateral ligament repair if necessary, with attention to restoration of the rotational axes
- Prognosis depends on:
- The degree of comminution
- The accuracy of reduction
- The stability of internal fixation
- Range-of-motion exercises should be instituted as soon as the patient can tolerate therapy.
Complications
- Lateral condyle fractures: Improper reduction or failure of fixation may result in cubitus valgus and tardy ulnar nerve palsy requiring nerve transposition.
- Medial condyle fractures: Residual incongruity is more problematic owing to involvement of the trochlear groove. These may result in:
- Posttraumatic arthritis, especially with fractures involving the trochlear groove
- Ulnar nerve symptoms with excess callus formation or malunion
- Cubitus varus with inadequate reduction or failure of fixation
Capitellum Fractures
- Represent <1% of all elbow fractures
- They occur in the coronal plane, parallel to the anterior humerus.
- Little or no soft tissue attachments result in a free articular fragment that may displace.
- Anterior displacement of the articular fragment into the coronoid or radial fossae may result in a block to flexion.
Mechanism of Injury
- A fall onto an outstretched hand with the elbow in varying degrees of flexion; force is transmitted through the radial head to the capitellum. Fracture occurs secondary to shear.
- These are occasionally associated with radial head fractures.
Classification (Fig. 17.5)
- Type I: Hahn-Steinthal fragment: large osseous component of capitellum, sometimes with trochlear involvement
- Type II: Kocher-Lorenz fragment: articular cartilage with minimal subchondral bone attached: “uncapping of the condyle”
- Type III: Markedly comminuted (Morrey)
- Type IV: Extension into the trochlea (McKee)
Treatment
Nonoperative
- Primarily used for nondisplaced fractures
- Consists of immobilization in a posterior splint for 3 weeks followed by range of elbow motion
Operative
- Goal is anatomic restoration.
- Open reduction and internal fixation
- This technique is indicated for displaced type I fractures.
- Via a posterolateral or posterior approach, screws may be placed from a posterior to anterior direction; alternatively, headless screws may be placed from anterior to posterior.
- Fixation should be stable enough to allow early range of elbow motion.
- Excision
- Rarely indicated for severely comminuted type I fractures and most type II fractures. Care must be taken in the elderly because these are often type IV fractures, which will lead to elbow instability if excised.
- May be the recommended treatment in chronic missed fractures with limited range of elbow motion
Complications
- Osteonecrosis: This is relatively uncommon.
- Posttraumatic arthritis: The risk is increased with failure to restore articular congruity and excision of the articular fragment.
- Cubitus valgus: This may result after excision of articular fragment or with an associated lateral condylar or radial head fracture. It is associated with tardy ulnar nerve palsy.
- Loss of motion (flexion): This is associated with retained chondral or osseous fragments that may become entrapped in the coronoid or radial fossae.
Trochlea Fractures (Laugier Fracture)
- Isolated fractures are extremely rare.
- Associated with elbow dislocation
Mechanism of Injury
- Tangential shearing force resulting from elbow dislocation
Treatment
- Nondisplaced fractures may be managed with posterior splinting for 3 weeks followed by range-of-motion exercises.
- Displaced fractures should receive open reduction and internal fixation with Kirschner wire or screw fixation.
- Fragments not amenable to internal fixation should be excised.
Complications
- Posttraumatic arthritis may result with retained osseous fragments within the elbow joint or incongruity of the articular surface.
- Restricted range of motion may result from malunion of the trochlear fragment.
Lateral Epicondylar Fractures
- Extremely rare, usually avulsion injuries associated with elbow fracture-dislocations
Mechanism of Injury
- Direct trauma is the mechanism in adults.
- Prepubescent patients may experience avulsion fractures.
Treatment
- Symptomatic immobilization is followed by early range of elbow motion.
Complications
- Nonunion may result in continued symptoms of pain exacerbated by wrist or elbow motion.
Medial Epicondylar Fractures
- More common than lateral epicondylar fractures owing to the relative prominence of the epicondyle on the medial side of the elbow
Mechanism of Injury
- In children and adolescents, the medial epicondyle may be avulsed during a posterior elbow dislocation.
- In adults, it is most commonly the result of direct trauma, although it can occur as an isolated fracture or associated with elbow dislocation.
Treatment
- Nondisplaced or minimally displaced fractures may be managed by short-term immobilization for 10 to 14 days in a posterior splint with the forearm pronated and the wrist and elbow flexed.
- Operative indications
- Fragments within the joint space
- Relative indications include displaced fragments in the presence of ulnar nerve symptoms, elbow instability to valgus stress, wrist flexor weakness, and symptomatic nonunion of the displaced fragment.
- Open reduction and internal fixation versus excision: Excision is indicated for fragments not amenable to internal fixation or are incarcerated within the joint space and are irreducible.
Complications
- Posttraumatic arthritis: This may result from osseous fragments retained within the joint space.
- Weakness of the flexor mass: This may result from nonunion of the fragment or malunion with severe distal displacement.
Fractures of the Supracondylar Process
- The supracondylar process is a congenital osseous or cartilaginous projection that arises from the anteromedial surface of the distal humerus.
- The ligament of Struthers is a fibrous arch connecting the supracondylar process with the medial epicondyle, from which fibers of the pronator teres or the coracobrachialis may arise.
- Through this, arch traverses the median nerve and the brachial artery.
- Fractures are rare, with a reported incidence between 0.6% and 2.7%, but they may result in pain and median nerve or brachial artery compression.
Mechanism of Injury
- Direct trauma to the anterior aspect of the distal humerus
Treatment
- Most of these fractures are amenable to nonoperative treatment with symptomatic immobilization in a posterior elbow splint in relative flexion until pain free, followed by range-of-motion and strengthening exercises.
- Median nerve or brachial artery compression may require surgical exploration and release.
Complications
- Myositis ossificans: The risk is increased with surgical exploration.
- Recurrent spur formation: This may result in recurrent symptoms of neurovascular compression, necessitating surgical exploration and release, with excision of the periosteum and attached muscle fibers to prevent recurrence.