Distal humerus fracture
What is distal humerus fracture?
Distal humerus fracture is a discontinuation or breaks in the lower end of the humerus (arm bone) near the elbow joint. The elbow joint comprises of three bones, humerus (upper arm), radius and ulna (forearm bones). It is usually caused by high energy collision or a direct blow to the elbow in a car accident or football tackle in an adult or by a low energy injury in elderly people who have weak bones or fall on an outstretched hand in children.
Distal humerus fracture accounts for 2 % of all fractures and 30 % of the fractures of the humerus. It is the third most common fracture in the humerus bone. It is mostly seen in young males of age 3- 11 years or in elderly females. 60 % of the cases of elbow injuries seen in the paediatrician population are supracondylar fractures (a type of distal humerus fracture). These fractures are sometimes associated with other injuries of the elbow like elbow dislocation, floating elbow, terrible triad injury or Volkmann contracture.
What are the symptoms of distal humerus fracture?
Its symptoms are pain, swelling, bruising and tenderness in the affected area. This fracture is so painful that you may feel elbow motion impossible or difficult. There may be a feeling of the instability of the joint with popping out sensation. In rare cases, the fractured bone can come out of the skin (in open fractures). If there is associated injury to blood vessel (brachial artery), no pulses are felt distally and the hand will appear pale and cold. In some patients because of associated nerve injury, they feel numbness, tingling and loss of function in hand.
How is it diagnosed?
Your orthopaedic surgeon will take a medical history and examine your affected arm. He will ask you for an X-ray as it can provide information regarding the type of fracture (simple or complex fractures) and associated injuries. He can ask you for an MRI or CT scan to get more information about the injury (injury to ligament, blood vessels and nerve) and to plan for surgery.
What happens if nothing is done?
If distal humerus fracture is left untreated, it may cause wobbly and unstable elbow, stiffness and deformity in the elbow due to non-union or mal-union of the broken bone fragments. It may also lead to post-traumatic arthritis.
How is it treated?
The fractures in the distal part of the humerus (arm bone) require immediate emergency medical intervention. You are taken to an emergency room; you are treated conservatively or surgically. The conservative treatment is indicated in a few cases only. It involves rest, cast immobilisation, application of ice, medications, and physiotherapy.
Surgery is indicated in
- Displaced fractures
- Unstable fractures
- Open fractures
- Supracondylar fractures
- Floating elbow
- Intra-articular fractures
- Associated ligament injuries
- Associated nerve injury
- Associated injury to blood vessels
What are the non-operative treatments?
Non-operative treatment has a limited role in these injuries and is only adopted in the cases where fractures are stable i.e. not displaced from their position or where surgery is contraindicated in elderly people. It includes-
- Rest- the arm is rested in the splint, cast or sling or brace for 6 weeks to keep the broken bone fragments in position and prevent new injury to the arm.
- Ice packs- ice packs can be applied on the affected part for two to three times in a day for 20-30 minutes to relieve pain and swelling.
- Medication- paracetamol and codeine are given as painkillers to manage pain. Anti-inflammatory drugs such as aspirin, ibuprofen, etc can be given few days to control pain and swelling.
- Physiotherapy- physical therapy is necessary to regain the lost strength and range of motion and prevent stiffness in the joint. It is started with gentle exercises of the elbow after immobilization in a sling. It is followed by strenuous and strengthening exercises of the elbow. It should be done under the supervision of your surgeon and physiotherapist.
What does the operation involve?
Most of the distal humerus fractures require surgical management especially in cases where bone fragments are displaced or have punctured the skin. The main goal of the surgery is stabilization of the joint and early restoration of the range of motion. Surgery usually involves open reduction and internal fixation with plates/screws/pins/wires and in some cases external fixation,
- Depending on the complexity of the fracture, the surgery is conducted as a day case or an inpatient under general anaesthesia. The skin is cut in the affected site to realign the bone fragments. The number of cuts on the skin depends upon the surgery technique adopted.
- In children with most fractures could be reduced by manipulation and fracture fixed with wires (stainless steel) and cast or cast alone if the fracture is stable after reduction.
- In adults the bone fragments are repositioned together with pins, plates, or screws. In some cases, with multiple fracture fragments, bone substitutes are used to accelerate healing and to bridge the gap. Bone grafts can also be used to fill the gaps.
- The cuts on the skin are then stitched with absorbable sutures. The operation takes one to two hours and majority of the patients are discharged on the same day.
What happens after surgery?
- The local anaesthetic wears off 4-10 hrs after surgery, patients are encouraged to start taking painkillers before the pain starts i.e. on return home and for at least 48 hours from there. This way most of our patients report little or any pain.
- Before discharge, your physiotherapist will teach you gentle exercises of fingers, wrist, elbow and pendulum exercises for the shoulder. This is necessary to prevent stiffness and to maintain the strength of the muscles.
- The bulky bandage could be removed in 48hrs and dressings over the wound kept clean and dry for 2 weeks
- The patient is reviewed at 2 weeks and referred for physiotherapy.
- The fracture union is confirmed by x-rays at regular intervals, usually 6 weeks, 12 weeks and 6 months. However, in selected cases x-rays are taken in first few weeks to assess displacement/union.
- The wound should be massaged (typically after 2 weeks) using the moisturizing cream by the patient 3 times a day for 3 months once the wound is well healed. This reduces the scar sensitivity and scar-related complications and helps the scar to mature.
- The physical therapy in distal humeral fractures begins with gentle exercises as tolerated by the patient after surgery and is progressed to strengthening exercises around 8 weeks. This depends on the X-ray reports and clinical union of fracture as guided by your surgeon. The duration may increase or decrease based on the personality of fracture, quality of bone and method of fixation.
Are there any risks?
- Elbow stiffness
- Delayed union
- Ulnar or Median or Radial nerve injury
- Vascular injury (uncommon, brachial artery)
- Frozen shoulder
- Myositis ossificans
- Anaesthetic complications
- Hardware failure
- Posttraumatic arthritis
What are the results of the operation?
The outcome of the surgery is good with minimal serious complications (<5%). The outcome following this surgery depends on grade and severity of the injury, associated injuries, treatment involved and adherence to physiotherapy. However is more predictable in the author’s experience.
When can I return to driving and work?
You can get back to work in 2-4 weeks if you have a desk job, however might take upto 3 months if your job involves physical work. Regarding return to contact sports, it usually takes 3-6 months and depends on the severity of injury. You should be able to resume driving in 4-6 weeks. The above time line could vary based on the severity of injury and the treatment modality. Your physician will be able to advise you.
- 30 year old gentleman sustained complex elbow fracture;
- The fracture was fixed with plates and screws.
- 50 year old gentleman sustained complex open elbow fracture;
- The fracture was fixed with plates and screws and was later removed as the implants were prominent underneath the skin