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Staged Management of Distal Humerus Fractures

By William Edward Sanders, MD

Distal humerus fractures involving the elbow joint have been voted the most disliked upper extremity injury. The concept of rigid internal fixation that will allow early range of motion is very difficult to obtain in many situations, and impossible in some. I have treated three patients in a staged method because of special situations, and believe that this variation has promise. One patient had significant bone loss in the membranous area with intra-articular fracture line, and two patients had uncontrolled mania (and could not be trusted to cooperate with protected range of motion).

STAGE I:

  • Wound care and preservation of blood supply to the fragments. Because this technique does not require further dissection, blood supply is preserved as much as possible.
  • Reduction and fixation of fragments using all available methods. Rigid internal fixation is not required, and therefore K-wires, absorbable K-wires, suture, and tissue glue, as well as screws and plating, can be utilized.
  • A long locking plate is applied to the distal humerus and the ulna with the elbow at approximately 90°. The locking plate feature allows fixation to the distal humerus without compression of the triceps muscle.
  • Reconstruction of the soft tissue envelope if needed.

STAGE II:

  • Protect the elbow and fracture with a removable splint.
  • Allow approximately 6 months for the soft tissue to mature and the bone to declare itself as far as infection, avascular necrosis, and nonunion.
  • Any needed intermediate intervention can be provided at any time (such as bone grafting).

STAGE III:

  • At approximately 6 months, a final decision can be made regarding further treatment, from plate removal and capsular stripping to total elbow replacement.
  • Through the same posterior incision used for application of the locking plate, it is removed. Other fixation that is not needed can also be removed.
  • Capsular stripping and release is actually an easy procedure. The elbow joint is concentric, so ligament release is not required. Through a lateral incision anterior to the lateral collateral ligament, the anterior capsule is stripped (from within the elbow joint). Posterior to the ligament and anconeus the posterior capsule is stripped along the dotted bluelines using a periosteum elevator.
  • Medially, a periosteum curved rib elevator allows release where visualization is limited.
  • A gentle manipulation is carried out, and physical therapy to regain maximum range of motion postoperatively is used.

Advantages:

  • Pronation and supination exercises are allowed.
  • This is a variant of the bridge plate fixation for distal radius fractures.
  • Shorter initial operative time and diminished pain after surgery.
  • No therapy is needed usually during the first six months.
  • Only the initial operation is emergent, the others can be scheduled electively.

ACKNOWLEDGMENTS:

  1. Drawings adapted from Grant’s Atlas of Anatomy, 5th edition, 1962.
  2. Drawings adapted from Hollinshead’s Anatomy for Surgeons, 2nd edition, Volume 3, 1969.
  3. Also from images available on the Internet that do not have citations.

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