You are in: eMedicine Specialties > Orthopedic Surgery > TRAUMA Supracondylar Humerus FracturesArticle Last Updated: May 21, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: Mark A Noffsinger, MD, Clinical Instructor, Department of Orthopedic Surgery, Michigan State College of Human Medicine; Medical Director, Deptartment of Orthopedic Surgery, Bronson Methodist Hospital, Consulting Staff, Kalamazoo Orthopedic Clinic Mark A Noffsinger is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Orthopaedic Medicine, American College of Physician Executives, American Fracture Association, American Medical Association, American Medical Directors Association, Christian Medical & Dental Society, Indiana State Medical Association, International Society on Thrombosis and Haemostasis, Michigan State Medical Society, Mid-America Orthopaedic Association, and Phi Beta Kappa Editors: Jeffrey L Visotsky, MD, Assistant Professor, Department of Clinical Orthopedic Surgery, Northwestern University; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Samuel Agnew, MD, FACS, Associate Professor, Departments of Orthopedic Surgery and Surgery, Chief of Orthopedic Trauma, University of Florida at Jacksonville; Consulting Surgeon, Department of Orthopedic Surgery, McLeod Regional Medical Center; Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital; Mary Ann E Keenan, MD, Professor of Orthopedic Surgery, University of Pennsylvania School of Medicine; Chief, Neuro-Orthopedic Service, Department of Orthopedic Surgery, Hospital of the University of Pennsylvania Author and Editor Disclosure Synonyms and related keywords: distal humerus fractures, bicolumn humerus fractures INTRODUCTIONSection 2 of 12
  Distal humerus fractures in adults are relatively uncommon injuries, representing only approximately 3% of all fractures in adults. In a study from Massachusetts General Hospital of 4536 consecutive fractures in adults seen in the Massachusetts General Hospital emergency department, only 0.31% were supracondylar (bicolumn) fractures of the distal humerus. Although these injuries are relatively rare, most orthopedic surgeons are called upon to evaluate and treat patients with these injuries and, therefore, must be equipped to achieve optimal outcomes. We live in a society with a growing elderly population and a young population in which extreme sports and high-speed motor transportation are popular; therefore, the incidence of these fractures is likely to increase. In young adults, most distal humerus fractures occur from high-energy trauma, sideswipe injuries, motor vehicle accidents, falls from heights, and gunshot wounds. In elderly persons with more osteoporotic bone, most of these injuries occur from falls. Numerous classification schemes have been devised to categorize and discuss supracondylar fractures. In 1936, Reich originally classified supracondylar fractures into T and Y variations. In 1969, Riseborough and Raidin described 4 categories based on degree of displacement, comminution, and rotation. As surgeons became more adept at surgical reduction and internal fixation, the Arbeitsgemeinschaft für osteosynthesefragen–Association for the Study of Internal Fixation (AO-ASIF) group described a classification based on fracture pattern and degree of comminution. AO-ASIF classification
This classification remains somewhat deficient in describing the mechanically important concept of the medial and lateral columns and their fracture involvement. It also is somewhat deficient in describing the level through which the fracture occurs in each column and related important surgical considerations. Because of these limitations, this author believes that the classification of bicolumn fractures of the distal humerus introduced by Mehne and Matta proves useful in planning bicolumn surgical fixation. The classification of Mehne and Matta describes the specific characteristics of bicolumn fractures and allows for better preoperative planning. The classification is as follows:
Although the medial and lateral Lambda fractures are not technically bicolumn fractures, they are included in this classification because they require similar operative fixation techniques (see Image 1). History of the ProcedureSurgical treatment of these fractures has evolved significantly in the last 30 years. In the 1960s and 1970s, most surgeons condemned surgical treatment due to high failure rates with loss of fixation, nonunion, and elbow stiffness. In the 1970s, treatment began to shift from casting and the "bag of bones" technique to surgical intervention with limited internal fixation. Again, results generally were poor due to lack of adequate stabilization for early motion. In the early 1980s, the AO-ASIF group reported good and excellent results in 27 of 39 patients with comminuted fractures of the distal humerus. These by far were the best results reported in the treatment of these difficult fractures at that time. This led to an increased enthusiasm for surgical reduction and fixation. Additional surgical approaches were developed, along with more versatile fixation hardware, leading to improved surgical results. The "bag of bones" treatment was used when bone quality or fracture pattern was not sufficient to gain stable fixation. This led to generally poor and unpredictable results. This has now largely been replaced by total elbow arthroplasty, allowing for improved and more predictable results. FrequencySingle column fractures are relatively rare and account for only 3-5% of distal humerus fractures. Lateral column fractures are more common than medial column fractures. These fractures represent the distal extent of the respective column, including a portion of the articular surface. These are described as high or low, depending on the proximal extent of the fracture line and the extent of joint surface involvement. Milch previously described these as medial or lateral condyle fractures. Bicolumn fractures are far more common distal humerus fractures. In some reports, these account for as many as 70% of distal humerus fractures in adults. These fractures involve disruption of both the medial and lateral columns, thus disrupting the humeral triangle and resulting in disassociation of the articular surface from the humeral shaft. Successful treatment is most challenging in these fractures. EtiologyThe mechanism by which these fractures occur has been a recent topic of debate. Historically, the mechanism has been accepted to be an axial load on the elbow, with the olecranon acting as a wedge splitting the medial and lateral columns of the distal humerus. However, recent mechanical studies performed on cadavers have shown that supracondylar (bicolumn) fractures are more likely produced with the elbow flexed beyond 90° The fracture pattern produced is related to the degree of elbow flexion and the direction and magnitude of the force applied (see Image 1). ClinicalThe clinical presentation is that of a painful swollen elbow that the patient is hesitant to move. The elbow may appear angulated and the upper extremity shortened. Some series report that open wounds are present in as many as 30% of these fractures. Patient history includes a high-energy trauma or significant fall. Evaluate adjacent joints for associated injuries. Neurovascular status must be carefully evaluated and monitored. Due to the close proximity of the neurovascular structures, injury is not uncommon. If a deficiency is noted, carefully evaluate and document when it first became apparent, the degree of involvement, and possible progression. If it first appeared following manipulation or splint placement, consider remanipulation, and, if the deficiency does not resolve, urgently explore to evaluate possible nerve entrapment. Neuropraxias are not uncommon and generally resolve with restoration of normal alignment and lengths. In the author's experience, resolution has occurred up to 18 months postinjury. Radiographic evaluations should include standard anteroposterior (AP) and lateral films. With comminuted bicolumn fractures (AO-ASIF C3), repeat films following initial reduction or with longitudinal traction maintained often prove helpful to further define articular fracture fragments. For complicated fractures, CT scanning also can be helpful for surgical planning. If vascular compromise is evident, obtain emergent arteriograms. If arterial disruption is present, obtain a vascular surgery consultation followed by immediate open reduction and internal fixation to allow for skeletal stability and support of vascular reconstruction. INDICATIONSSection 3 of 12
Indications for surgery are to prevent further injury, restore anatomy, and provide an optimal environment for healing. If these goals are met, the patient will have the best possibility of regaining optimal function. If any surgical treatment of the distal humerus is undertaken, the goal also must be to allow adequate stability to allow for immediate range of motion. Long-term results following surgical treatment of these complex fractures have improved, largely due to improved surgical technique in gaining stability to allow for early motion. Adult's elbows after such an injury are not tolerant of prolonged immobilization, and, if arthrofibrosis occurs, regaining function becomes extremely difficult if not impossible. Therefore, the goal of surgery is to stabilize to mobilize. Fractures in which stable reduction could not be obtained were previously treated with the "bag of bones" technique. In this technique, early range of motion was allowed, without attempted reduction and fixation. This led to generally poor results, with limited motion, pain due to non-congruent joint surfaces and nonunions, and cosmetic deformity. Due to these poor results, this treatment has now for the most part been replaced by total elbow arthroplasty. RELEVANT ANATOMYSection 4 of 12
For the surgeon to properly evaluate, plan, and execute surgical treatment of these fractures, a functional and surgical understanding of the relevant anatomy is necessary. Functionally, the elbow joint behaves as a constrained hinge. The olecranon of the ulnar articulates around the trochlea of the humerus. The trochlea normally is tilted in 4° of valgus in males and 8° of valgus in females, thus creating the carrying angle of the elbow (see Image 1). The trochlea also is externally rotated 3-8° from a line connecting the medial and lateral epicondyles, resulting in external rotation of the arm when the elbow is flexed 90° (see Image 2). A second plane of motion occurs with the elbow joint in supination and the forearm in pronation; this range of motion is allowed by the radial head articulation with the capitellum and ulnar notch. The surgical anatomy closely mirrors the functional anatomy. For stable elbow motion, the trochlea must be restored to its normal position, acting as a tie rod between the medial and lateral columns of the distal humerus. This forms the triangle of the distal humerus, which is crucial for stable elbow function (see Image 3). Both columns must be securely attached to the trochlea. Make every attempt to restore the proper valgus tilt and external rotation of the trochlea to allow for stability, full motion, and a normal carrying angle. The coronoid is important to elbow stability and should be reduced and fixated if displaced. The olecranon fossa, a very thin wafer of bone, does not require restoration if badly comminuted. If the medial and lateral columns can be securely fixated to the trochlea, early motion should be tolerated. The medial column diverges from the humeral shaft at approximately 45°, continues, and ends in the medial epicondyle. As nothing articulates with the anteromedial epicondyle, the entire surface is available for internal fixation hardware. Be careful to protect and transfer the ulnar nerve anteriorly. The lateral column diverges from the humeral shaft at approximately 20° and is largely cortical bone with a broad flat posterior surface, making it ideal for plate placement. At the posterior capitellum, cancellous screws must be used to avoid interrupting the anterior capitellar cartilage. Biomechanical studies have demonstrated the strongest construct of fixation of bicondylar fractures to be a direct medial plate and posterolateral plate with screws directed at 90° angles. This provides the varus and valgus rotational stability to the construct to allow for early range of motion. CONTRAINDICATIONSSection 5 of 12
Contraindications to ORIF surgical treatment include severe osteopenia, making adequate stabilization impossible. An insensate or avascular arm, which cannot be restored, makes any surgical treatment short of amputation futile. This occurs in severe sideswipes, crush, or avulsion-type injuries. As a general rule, attempts should be made to salvage the upper extremity; even a somewhat limited arm, if sensate, is functionally better than an upper extremity prosthesis. Severe contamination or soft tissue injury must be dealt with prior to final stabilization in order to provide an optimal environment for healing and lessen the likelihood of infection. WORKUPSection 6 of 12
Imaging Studies
TREATMENTSection 7 of 12
Surgical therapyOptimally, surgery should be performed in the first 72 hours postinjury. Further delay may be necessary in patients with multiple traumatic injuries or in patients who are unable to undergo anesthesia for other medical reasons. In these cases, splint the limb in as near normal an anatomic position as possible and elevate the limb or keep it in side-arm olecranon traction. Generally, unless an open injury, vascular compromise, or compartment syndrome is present, these fractures do not require emergent late night surgery. These surgeries are best performed with an experienced operating room staff when all functioning optimally. Initial debridement of open wounds or compartment releases must be performed urgently, but even in these cases, the patient can be returned to the operating room during more optimal hours for a second look and possible open reduction and internal fixation. In cases of vascular compromise, bony stability must be provided emergently to support and stabilize the vascular repair. In cases of severe polytrauma, temporary external fixation may be indicated for short-term stabilization. The choice of operative exposure depends on the fracture pattern and surgeon preference. The Chevron olecranon osteotomy, which the author prefers as it allows excellent exposure to the entire distal humerus and elbow joint, is described in this article. It also allows for stable fixation and early range of motion. The author believes that the bony fixation allowed with an olecranon osteotomy allows for safer early range of motion than does a soft tissue repair such as a triceps turndown exposure. Single column fractures or fractures in which access to the articular surfaces is not necessary do not require such an extensive exposure. Preoperative detailsPreoperative planning must include careful review of adequate radiographs. This aids in planning the surgical approach and in selecting proper hardware. If fracture anatomy and fragments are difficult to ascertain, radiographs in longitudinal traction and/or CT scanning can be helpful. General anesthesia most often is necessary to allow for patient comfort and for adequate time for the procedure. On occasion, axillary block can be used if the surgeon is confident that adequate time will be available to complete the procedure. A sterile arm tourniquet also should be available and can be used on the sterile field during the procedure if bleeding makes fragment identification and reduction difficult. The authors prefer supine positioning with the elbow flexed over a sterile towel roll on the patient's chest. This allows excellent posterior exposure, easy wound access for both the surgeon and a first assistant, and a second assistant across the table to assist in retraction. The towel roll also can be used as a fulcrum to assist in obtaining length and in maintaining reduction during internal fixation. The author also believes that the supine position allows better patient physiology and anesthetic access. The author finds the supine position to be especially helpful in patients with multiple traumatic injuries. This position also allows easy access to the iliac crest if bone grafting is necessary. The patient is given prophylactic antibiotics prior to induction of anesthesia. The arm is then prepared and draped in the usual sterile fashion; caution is employed to ensure exposure of the proximal third of the forearm distally and exposure to the axilla proximally. Intraoperative detailsThe arm is elevated and exsanguinated with Esmarch, and the tourniquet is inflated to approximately 250 mm Hg. An incision is made along the proximal 5 cm of the medial ulnar border, curving to the medial side of the olecranon, and returning to midline posteriorly to approximately 15-20 cm above the elbow joint (see Image 4). If abrasions or wounds are present, the skin incision can be altered. The first objective is exposure of the ulnar nerve, which often is not easily palpable due to swelling and displaced landmarks. It usually can be located more easily as it emerges from the triceps fascia just medial to the inner muscular septum. The nerve then is traced distally and released from the cubital tunnel and into the flexor muscle mass; care is taken to avoid the motor branch to the flexor carpi ulnaris. Articular branches need to be sacrificed for later anterior transposition. The nerve then is carefully retracted and protected with a vascular tape (see Image 5). The olecranon is isolated, and a small incision is made in the medial or lateral capsule to pass a probe into the trochlea to palpate the level of the coronoid process. The apex of the Chevron osteotomy cut then is planned 3-5 mm proximal to the coronoid with the apex directed distally. (This also will correlate just proximal to the radio-ulnar articulation.) Because the author uses tension band wires to fixate the osteotomy, he does not predrill. If surgeon preference is to fixate the osteotomy with an intramedullary screw, predrilling will assist later anatomic reduction and screw placement. The cut then is made with an oscillating saw and completed with a sharp osteotome to prevent damage to the articular surfaces. A gauze sponge can be inserted into the joint prior to osteotomy completion to further protect the articular cartilage. The olecranon, with the intact triceps insertion, then is reflected posteriorly and covered with moist sponge, allowing easy access to the entire supracondylar and to joint surfaces (see Image 6). If the fracture extends far proximally, take great care in locating the radial nerve as it exits the spiral groove at the junction of the distal two thirds of the humerus. The next goal is reconstruction of the joint surfaces. This requires careful attention to anatomy and great surgeon patience. Fragments often need to be rotated and intercalated into position in cases of comminution and displacement. Large retinacular reduction forceps are helpful in maintaining medial-to-lateral compression once the fragments of the trochlea are aligned. Carefully placed interfragmentary compression screws can provide excellent stability, provided purchase can be obtained on both medial and lateral fragments. The author prefers to use 4.0 cannulated cancellous screws for this fixation, and if the bone is osteoporotic, they find that washers can be helpful. They've also found it helpful to pass one screw from medial to lateral and one from lateral to medial when possible. When placing these screws, take care to avoid penetrating the trochlear sulcus or olecranon fossa. Also consider the possibility of later plate placement, and place screws so they will not interfere with plate positioning. The next step is to attach the medial and lateral columns to the trochlea. This is accomplished with 3.5-mm reconstruction plates that are of sufficient strength yet can be readily contoured. If possible, the plates are placed directly medial and posterolateral. The bony anatomy lends well to this construct, and this construct is strongest biomechanically. The lateral plate is placed in the most distal position possible, almost abutting the articular cartilage of the capitellum. In this way, the distal screw is directed proximally, avoiding the articular cartilage and providing an interlocking construct. If the thin wafer of bone in the olecranon fossa is comminuted, it need not be reconstructed, provided that both columns can be securely attached to the trochlea, thus restoring the distal humeral triangle. Concern has been raised regarding both plates terminating at the same level proximally, due to the possibility of a significant stress riser being created. Although the authors are unaware of related reported complications, staggering the proximal extent of the plate slightly in order to decrease this potential risk makes sense biomechanically. The olecranon then is replaced in its position and held, and the joint is put through range of motion. Assess motion and stability. If the coronoid is fractured and posterior instability is present, it is reduced most easily and fixated prior to reduction of the olecranon osteotomy. The olecranon then is secured using the surgeon's method of choice, with the goal of adequate stability for early range of motion in mind. The triceps fascia then is closed, and the ulnar nerve is transposed anteriorly, either submuscularly or subcutaneously, depending on the patient's size and surgeon's preference. The tourniquet is released, hemostasis is obtained, and the wound is closed in standard fashion. Postoperative detailsA posterior long-arm splint is applied with the elbow at 60-90° of flexion, depending on the amount of swelling. The arm is elevated above the heart level, and finger and shoulder motion are encouraged. Intravenous antibiotics are continued for 24 hours postoperatively. If the patient is then comfortable on oral analgesics and is independent, discharge from the hospital is allowed. Follow-upThe author sees patients in the clinic 10-14 days postoperatively. At that visit, sutures are removed, and if the wound is stable, the patient is placed in a hinged elbow orthoses, and protected active range of motion is allowed. Passive assisted range of motion is allowed to the point of discomfort, not pain (see Image 7). The importance of early range of motion to final outcome has been well documented. The orthosis is worn until evidence (both clinical and radiographic) of fracture union is present, and then orthosis use is discontinued. This usually occurs 6-12 weeks postoperatively. COMPLICATIONSSection 8 of 12
Complications include infection, occurring in a published rate of 0-6% of cases, including open fractures. The rate of tardy ulnar nerve palsy has been reported to be as high as 15%, but the author believes that this percentage can be lessened using routine anterior transposition of the ulnar nerve when hardware is placed medially. Nonunion of the distal humerus is more common in cases of high-energy trauma or loss of fixation. Most of these patients require reoperation with enhanced fixation to alleviate symptoms. Nonunion of the olecranon osteotomy also has been reported, but this author believes it is rare when the Chevron osteotomy, which allows for greater bony surface and more stable fixation, is utilized. Hardware irritation can occur secondary to plates and screws or fixation of the olecranon osteotomy, and it has been reported in up to 50% of cases in some series. If severe, this condition requires removal of the hardware following union. This appears most commonly due to the hardware used for fixation of the olecranon osteotomy causing tenderness when the elbow rests on a hard surface. Thirty percent of the patients in the author's series later required removal of their tension band wire fixation of the olecranon osteotomy. Loss of fixation necessitates investigation into its cause. Osteoporosis, inadequate placement of hardware, patient noncompliance, and infection all are potential etiologies. Treatment can be initiated based on the cause. If loss of fixation is due to severe osteoporosis or patient noncompliance, further casting to gain union at the expense of motion may be the best alternative. If the patient presents with increased pain, decreased range of motion, and radiographic evidence of hardware breakage or loosening, nonunion can be expected if no intervention occurs. If loss of fixation occurs without infection, total elbow arthroplasty should be considered. OUTCOME AND PROGNOSISSection 9 of 12
Outcomes have improved dramatically over the past 30 years as surgical technique and instrumentation have improved. However, inform these patients early in their evaluation that the elbow will probably never be normal. The goal is to provide a comfortable elbow that functions as near to normally as possible. Most activities of daily living require a flexion range of 30-130° This allows for eating and personal hygiene. Compensating for lack of extension will be easier than compensating for lack of flexion, and compensating for lack of pronation will be easier than compensating for lack of supination. The final motion achieved appears to be related to the degree of initial trauma energy and to successful restoration of stability allowing for early range of motion. High-energy trauma (eg, gunshot wounds, sideswipe injuries, injuries from motor vehicle accidents) results in more soft tissue damage and increased scarring, which is more likely to result in restricted range of motion. Some reports indicate that capsular release performed at the time of initial fixation for these high-energy distal humerus fractures improves the long-term range of motion. Flexion usually returns first, within 2-4 months, and final extension may progress up to 12 months after the injury. Use of dynamic extension splints in gaining final extension has been shown to be of some benefit. Numerous outcome evaluation schemes are available, but generally in low-energy trauma, a successful outcome is a 15-140° arc of motion with full supination and pronation and no pain or minimal pain. In high-energy trauma, these results are more difficult to obtain. Activity-related pain is present in approximately 25% of patients; interestingly, it does not appear to be directly correlated with the amount of initial energy of trauma or with final range of motion (see Image 8). FUTURE AND CONTROVERSIESSection 10 of 12
Treatment of these fractures is likely to continue to evolve. Primary total elbow arthroplasty is increasingly becoming accepted in elderly patients with severe osteopenia and limited functional demand. In limited series, good results have been reported. Fixation hardware, including lower profile bioabsorbable plates and limited dissection application plates, will continue to stimulate interest. Methods of achieving better screw purchase in osteoporotic bone would also be a welcomed advancement. Regardless of future technological advancements, these fractures will continue to provide significant challenges to treating surgeons. If attention is paid to careful evaluation and preoperative planning, stable restoration of anatomy, and early motion, acceptable results can be achieved. MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
Supracondylar Humerus Fractures excerpt Article Last Updated: May 21, 2007 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
