The overall incidence of distal humeral fractures in adults is 0.5% of all fractures. The nature of the injury is commonly severe and is often associated with injury to surrounding soft tissue and nerves. Before we discuss the fractures, we have a look at the anatomy of distal part of humerus.
Anatomy of Distal Humerus
Humerus bone widens distally in the coronal plane
to a maximum between the medial and lateral epicondyles and narrows from proximal to distal in the sagittal dimension before its distal most articular segment expands and juts anteriorly.
This forms kind of lateral and medial column which diverge diverging medial and lateral columns. At their most distal point, they are joined by the “tie arch,” consisting of the articular segment—the trochlea and the capitellum.
The capitellum itself is the most distal portion of the lateral column and the trochlea is intermediate between it and the distal end of the medial column.
The fracture typically occurs when there is a force applied to upper limb when the joint is flexed more than 90 degrees.
Clinical Presentation
Patients with a distal humeral fracture present with pain and swelling of the distal arm and elbow. Displaced fractures may cause a deformity and painful attempted movements.
The patient should be given an above elbow splint after thorough examination of limb including neurovascular examination and xrays.
Radiography
A good quality anteroposterior and lateral projection surfice for the purpose of diagnosis making. These xrays should be obtained while maintaining gentle longitudinal traction with inclusion of the elbow joint on the film.
Xrays without traction are not that useful { as xrays in splints} for accurate diagnosis, for classifying the fracture, and for formal preoperative planning
If there is an additional injury present, investigations might be needed accordingly. For example, arteriogram for arterial injury.
Fracture classification
Ao/OTA classificationn is the most widely used classification used .
- A-type
Fracture is nonarticular. - B Type
A fracture of the B type is partially articular. A part of the articular segment remains in continuity with the shaft - C Type
Fractures are articular, but have no articular fragments remaining in continuity with the shaft
Type C is further divided into subtypes 1
- C1: T or Y fractures
- C2: Articular fracture is simple, but the nonarticular supracondylar area is segmental or comminuted
- C3: Articular segment is segmental or comminuted.
Treatment
Displaced distal humeral fractures are managed by open reduction and stable internal fixation. The aim is to achieve anatomis reduction of the fragments and to facilitate a painless elbow motion and maximize the likelihood of full functional restoration.
However there could be circumstances where patient is not suitable to get operative treatment. For exmple debilitated patients, patients with other ailments that make them a poor canditdate for anaesthesia, problem with local sites such as degloving injuries
Such cases need to be treated non operatively.
Method
Most common method of treatment includes passing a transolecronon pin through proximal ulna for traction on to the fracture and once fracture becomes sticky, a cast/functional cast/cast brace or hinged brace may be applied.
Mobilization is begun as dictated and subsequently advanced as determined by patient comfort.
Another method, used in case of comminuted fractures includes the placement of the arm in a collar and cuff with as much flexion as possible. The elbow is left hanging free, allowing gravity to exert a ligamentotaxic effect. Hand and finger motion and shoulder pendulum exercises are begin after 10th day. Gradual elbow motion is started as guided by patient comfort. By 6 weeks, the collar and cuff are discontinued and more intensive exercises are begun.
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