Fractures of the distal humerus frequently are comminuted and intraarticular.31 Loss of elbow function is tolerated poorly, because the inability to reach the face, head, or perineal areas is a major functional impairment.4 The principles of open reduction and internal fixation (ORIF) to permit early motion are well-established, and the goal of full, unrestricted motion is important. These principles have improved the results of treatment, but nonunion and malunion occur in 20–25% of patients and may be unreconstructable.5,9–11,20,29
Traditional teaching with plates applied in two perpendicular planes, 90° to each other, as is recommended by the AO/ASIF group, currently is used by most surgeons.8,15,31,32 The AO precepts of rigid internal fixation and early rehabilitation are usually, although not always, achievable in the youthful population, but geriatric patients with osteopenic bone require different strategies from the traditional treatment philosophies and techniques. Inadequate internal fixation combined with early mobilization may lead to nonunion and loss of bone stock. Several strategies have evolved for treating this condition, including two-stage revision ORIF followed by immobilization and subsequent joint release and total elbow arthroplasty.7,25,26,28
Modification of traditional treatment techniques may improve outcomes by avoiding loss of fixation and failure leading to successful initial treatment of these difficult fractures. The development of newer plating systems and techniques based on principles that maximize fixation in the distal fragments and compression at the supracondylar level,29 the use of massive, tricortical bone grafts to replace comminuted segments of the medial and lateral columns,18,27 and modification of olecranon osteotomy fixation, represent significant steps in obtaining stable initial fixation in the presence of osteoporosis.
The success of elbow contracture release3,16 also has affected our treatment philosophy: if adequate stability is not achieved despite using the aforementioned techniques, a short period of immobilization is instituted followed by early soft tissue release. Use of these treatment strategies has resulted in a more predictable outcome in our experience.
Internal Fixation in Osteoporotic Bone
In general, elderly patients are served best by rapid definitive fracture care, aimed at early restoration of function. This is achieved by anatomic restoration of the articular surface, stable fixation, and early motion. Because bone mineral density (BMD) correlates linearly with the holding power of screws, osteoporotic bone often lacks the strength to hold plates and screws securely.
The primary mode of failure of internal fixation in osteoporotic bone results from bone failure rather than implant breakage because standard internal fixation devices tend to be primarily designed for use in healthy bone.8
In the diaphysis, osteoporosis is associated with a reduction in cortical thickness and an increasing width of the medullary canal. The main morphologic and mechanical change of cancellous bone is rarefaction of the trabeculae, which only is partially and only initially compensated for by their relative thickening.16 Screw purchase in advanced osteopenia relies essentially on the thin shell of peripheral cortical bone and not on the cancellous trabeculae.
Therefore, there exists a need for specific adjustments in implant use and surgical techniques tailored to the specific requirements of osteoporotic bone. Because the impaired anchorage of the implant jeopardizes osteosynthesis of osteoporotic bone, solutions are directed toward increasing the stability of the compound system by transferring more load to the bone thereby relatively unloading the implant. Additionally, there exists a need to enhance biologic fixation. This is achieved by minimal exposure and indirect reduction, with careful balance between mechanical stability and the preservation of bone viability, and by the routine use of autogenous bone graft.
The basic principles of internal fixation in osteoporotic bone (impaction, wide buttressing, long splintage, bone augmentation, and substitution) should be adhered to rigidly. When combined with specific techniques and implants developed for the distal humerus, ORIF should be seen as the gold standard treatment of these injuries, unless the patient has a chronic, irreversible condition that limits independence.
Internal Fixation of Osteoporotic Distal Humerus Fractures
In younger adults, distal humeral fractures are the result of high-energy trauma. In elderly patients with demineralized bone, these fractures may be the result of lower-energy injuries.13 Nonetheless, the close proximity of the fractured distal humerus to neurovascular structures mandates a careful neurovascular examination. Standard AP, lateral, and capitocondylar radiographs of the elbow usually are sufficient to characterize the fracture, although CT scanning may assist preoperative planning in comminuted fractures. Most fractures in elderly patients are intraarticular with bicolumnar involvement.
Distal Humeral Plating and Autogenous Bone Graft
Although plate and screw fixation is biomechanically stronger than pin fixation, all techniques, including triple plating, are significantly less stiff than the intact distal humerus, especially in the sagittal plane.8
Traditionally the strongest construct has been considered a medial ⅓ tubular plate combined with a posterolateral 3.5 DCP plate (Fig 1). The widely accepted concept that plates must be applied in two perpendicular planes, 90° to each other8,14,31,32 has been challenged by the introduction of new plating systems specifically designed to address the reported unsatisfactory results in 20–25% of patients treated using more traditional techniques.5,9–11,20,29 The rate of delayed unions and nonunions of fractures of the distal part of the humerus has been reported to be between 2% and 10%,1,9,14,17,19,21,24,30,33,34 and failure of internal fixation at the distal humerus level usually results from nonunion at the supracondylar level, whereas the intercondylar region generally unites.29,31 The lateral column particularly is susceptible to failure, because fixation of the capitellar fragment to the proximal shaft often depends on one or two unicortical screws with poor bony fixation. Bicortical fixation cannot be achieved with a posterior plate without violating the articular surface. Because the distal articular fragments generally unite, the problem is, therefore, improving fixation of the articular surface to the shaft and proximal fragment.29
Newer contoured plates applied to the medial and lateral surfaces of the distal humerus, such as the Mayo Congruent Elbow Plate system (Acumed, Portland, OR), use a fixation strategy that concentrates on maximizing stability between the distal fragments and the shaft of the humerus at the metaphyseal level, and represent a significant step in the advancement of the armamentarium available in the treatment of fractures of the distal humerus in osteoporotic bone (Fig 2).
The technique has been reported accurately in the literature.29 To achieve reliable union between the distal fragment and the shaft, fixation of the distal fragment should be maximized and all fixation in the distal fragment should contribute to stability between the distal fragment and the shaft. It relies on the execution of seven technical objectives (each of which contributes to maximizing the stability between the articular segment and the shaft).
Concerning screws in the major distal fragment (articular segment): each screw should go through a plate; each screw should engage a fragment on the opposite side that also is fixed to a plate; as many screws as possible should be placed in the distal fragments; each screw should be as long as possible; each screw should engage as many articular fragments as possible.
Concerning the plates used for fixation: plates should be applied such that compression is achieved at the supracondylar level for both columns; and plates used must be strong enough and stiff enough to resist breaking or bending before union occurs at the supracondylar level.
Additionally, diaphyseal bone stock must be restored and supplemented with autogenous bone graft, if necessary, to maintain column height and width.
Nonanatomic Supracondylar Reconstruction
Severely comminuted supracondylar and intercondylar fractures of the elbow can be treated with removal of the comminuted supracondylar fragments and use of tricortical bone grafts from the iliac bone to obtain stable fixation.1
This technique is applicable for fractures categorized as type C3–3 in the AO/ASIF classification, which is defined as T or Y bicondylar fracture with severe intercondylar and supracondylar comminution. In these cases, the fragments often are small, osteoporotic, and lack periosteal attachments.
The operation involves temporary stabilization of the articular surfaces and reconstruction of medial and/or lateral columns with tricortical bone blocks. The distal parts of the graft may need to be trimmed to recreate the coronoid and olecranon fossae. Once again, the use of contoured medial and lateral plates that capture each of the transcondylar screws in the plate improves fixation. The technique only has been described sporadically in the literature18,27 but is a viable salvage procedure and may be helpful in avoiding the need to do a total elbow arthroplasty.
Although minimal shortening may be tolerated,29 any significant loss of length will compromise the olecranon and coronoid fossae and restrict motion.
Furthermore, malunion may complicate subsequent elbow release surgery because resection of bone to recreate the fossae may excessively thin the columns, resulting in early or late stress fractures. Therefore, replacement of comminuted or deficient columnar bone stock with stout, tricortical iliac crest grafts to avoid excessive shortening is preferable. Additional benefits compared with simple shortening are that it avoids loss of supracondylar fossae, avoids the need for the secondary creation of supracondylar fossae to achieve a functional range of flexion and extension, and avoids the risk of stress fracture sometimes seen after these secondary procedures.
Salvage of Failed ORIF
Because of the technical difficulty of achieving anatomic reduction and sufficiently stable fixation to achieve union, failure after ORIF is not uncommon.5,9–11,20,29 Total elbow arthroplasty may be used for salvage, but the failure rate is substantial and, perhaps, not acceptable in the active geriatric patient (Fig 3). Revision ORIF may be the best option. Most failures occur because of inadequate fixation of the distal, articular fragments to the proximal fragments.29,31 As mentioned, fixation with the traditional 90/90 plating technique is marginal, particularly in the lateral column and capitellum where fixation may be dependent on one or two unicortical screws into the soft, cancellous bone of the capitellum.
Revision with newer plating systems that incorporate the solidly fixed transcondylar screws into the plate may provide adequate fixation, even in apparently hopeless situations. Liberal use of bone grafts also is required. Tricortical grafts are used to replace the lost bone stock in the columns. These block grafts usually can be captured with screws through the plate. Corticocancellous strip onlay grafts also may be used and can be wired onto the columns.
In such cases, immediate ROM exercises usually are not feasible and a two-stage procedure is preferred. The elbow is immobilized in a long arm cast or external fixator for approximately 6–12 weeks or until definitively healed. Exercises then are begun, but an elbow release is frequently, although not always, necessary. An extreme example is seen in Figure 4 where chronic windshield wipering of the distal fragment scooped out the bone, leaving only cartilage and subchondral bone. In this case, wires passed through a cannulated screw were used to tie the articular surface to the proximal fragment across large, tricortical grafts. The elbow was immobilized with an external fixator to optimize the chance of union, after which an elbow release restored a satisfactory ROM.
An articulated external fixator should not be used, because any deviation from the exact axis of motion will significantly load the distal humerus and cause failure. Such devices are designed to stabilize an unstable elbow articulation, such as a fracture with dislocation, not a complex distal humerus fracture. Also, the surgeon should not be discouraged by a highly comminuted and damaged articular surface, because good results are possible even in severe cases, as long as major articular fragments are not missing.
Opinions vary on treatment of the ulnar nerve, with some surgeons advocating anterior transposition.31 Unless otherwise indicated by scarring or preexisting ulnar neuropathy, we prefer to leave the nerve in situ and close the underlying fascia to protect the nerve from hardware. This simplifies release surgery, especially arthroscopic release which, although technically challenging, can be done with hardware in place. Plates and screws are not removed during release surgery unless they specifically impede motion, because removal weakens the bone and predisposes to fracture.
Specific Techniques for Olecranon Osteotomy
Adequate fixation of distal humeral fractures requires good exposure of the articular surface. Although some advocate triceps splitting or reflecting approaches, full exposure of the distal articular surface for treatment of comminuted fractures requires an olecranon osteotomy.2,5,10,12,23 This approach originally was advocated by Cassebaum2 as a way of enhancing observation of the joint surface. Once again, technique modification and attention to detail can avoid problems and prevent nonunion, which is reported at 10–30%.9 Large (3-mm) Steinmann pins are inserted under fluoroscopic control to engage the anterior cortex. Large pins should be used because olecronon fixation principally is intramedullary and thin wires can bend with elbow flexion and extension (Fig 5).
A chevron osteotomy offers better geometry for stable fixation and is our preferred technique. The osteotomy is done with a small, sharp Lambotte osteotome (Lorenz, Jacksonville, FL) and is completed by cracking the anterior cortex. Thick osteotomes should not be used because anatomic reduction will not be achieved and the fragments will be overcompressed. Similarly, higher nonunion rates occur with a saw. Cracking the anterior cortex ensures good interdigitation and an anatomic reduction, with preplacement of the pins, which are extracted partially for the osteotomy to speed fixation at the end of the case. In very osteopenic bone, a third pin directed from anterior into the posterior cortex may be used and a second circlage wire can be added.
We routinely use iliac crest graft, obtained by percutaneous harvest using a bone trephine, on the distal humerus fracture and the olecronon osteotomy. A thin paste of morselized graft is applied along the cortical surfaces to increase the chance of rapid union.
Rehabilitation is another important aspect of treatment in geriatric patients. Although the goal of surgery remains stable anatomic alignment allowing immediate active mobilization, the postoperative treatment needs to be individualized to the stability of the final construct. Only patients with fractures that are judged intraoperatively to have sufficient stability after fixation are allowed early postoperative motion. If the stability of the fixation remains in question, it probably is better to immobilize the elbow until the fracture is healed adequately and do an elbow capsulectomy if the elbow becomes stiff. The predictable results of contracture release surgery provide a newer ordering of priorities that stress fracture union over motion. The alternative, motion without stability, risks losing alignment or allows movement leading to delayed union or nonunion, which are more difficult problems to treat than a stiff elbow.3,7,12,16,22,23
Elbow contractures are a common complication of trauma. There is much experience in dealing operatively with established elbow contractures either by open or arthroscopic release. The surgical release of elbow contractures is rewarding with a high incidence of success and a reasonable risk of complications.3,16,22
The Role of Elbow Replacement
The indications for semiconstrained total joint replacement for acute fractures of the distal humerus are limited to a restricted group of patients older than 60–65 years with an extensively comminuted fracture that is not amenable to adequate and stable osteosynthesis.6 The strict selection criteria are emphasized by the fact that at the Mayo Clinic only 22 acute distal humerus fractures (10 patients with associated RA) were treated by total joint replacement during a 10-year period.25 Such patients must have low physical demands and subsequent athletics are precluded.
Fractures involving the distal end of the humerus are among the most difficult to treat effectively.8,15,31,32 The high ratio of cortical to cancellous bone and the complex distal humeral architecture complicate fixation even in young patients. Lack of strong cancellous bone, multiple, small distal articular fragments and complex joint surfaces precluding bicortical fixation make adequate fixation of these fractures an arduous, often unachievable task. The presence of significant osteoporosis requires the modification of standard surgical techniques and rehabilitation protocols.
Fractures of the distal humerus are difficult to study because of their relative rarity. There is substantial variability among case studies regarding the length of followup, number of patients, and outcome data. Additionally they include a wide variety of types of fractures, operative techniques, and implants used.1,5,10,14,20,34 Nonetheless, there is a a subset of patients in whom the bone may be too osteoporotic for traditional fixation techniques.
The implementation of the surgical techniques discussed in the text has often allowed us to achieve adequate fixation even in the face of severe osteoporosis and comminution. The presence of significant osteoporosis, however, still may preclude an aggressive postoperative rehabilitation program. Increasing experience with treatment of the stiff elbow has resulted in reasonable outcomes despite prolonged immobilization after tenuous internal fixation of distal humerus fractures. For fractures that are intraoperatively judged not to be stable enough to commence early motion, immobilization to permit healing followed by staged elbow release, if necessary, minimizes the risk of nonunion, and results in a more predictable functional outcome.
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