Distal humerus fractures can be among the most challenging periarticular fractures to treat, and geriatric patients are no exception. Their poor bone quality means low-energy mechanisms produce multifragmentary injuries, often with complex articular comminution. Elderly patients may also be reliant on their upper extremity as a weight-bearing limb when using a walker or rising to stand. This creates additional demands on surgical implants in an area of complex anatomy with limited surfaces for internal fixation. Nonoperative treatment is still an option in the most low-demand patients such as those with advanced dementia. If chosen, the goal of surgical treatment is to recreate a stable, painless elbow with a functional range of motion (ROM) to preserve independence for daily activities and mobilization. The main surgical treatment options available are open reduction and internal fixation (ORIF) and total elbow arthroplasty (TEA). Although shoulder arthroplasty is increasingly used for proximal humerus fractures in this population, total elbow arthroplasty is more limited. Our goal was to present our experience with distal humerus fractures in an elderly population regarding specific injury patterns, patient factors, and technical tricks.
A thorough history should be obtained from the patient and caregivers to determine the presence of underlying medical comorbidities, cognitive impairment, preinjury function, and independence with activities of daily living. This is an important first step specific to this injury that cannot be overemphasized. Setting expectations early is particularly important in those who need their upper extremity for mobilization because neither arthroplasty nor surgical fixation can reliably allow immediate weight-bearing. A preoperative computed tomography (CT) scan may be obtained. Specifically, it may be helpful to scrutinize for subtle articular comminution and condylar cancellous bone impaction. In our experience, articular injuries are often more complex than they first appear on plain radiographs, and impaction through cancellous metaphyseal bone is common and is underestimated on plain radiographs. Three-dimensional reconstruction technology is particularly helpful to examine the collateral ligament origins for fracture involvement that may lead to instability if ignored and for examining fracture surfaces for planning surgical approach and reduction strategy. An optimal surgical plan can then be developed, including positioning, approach, and reduction sequence.
After a standard posterior approach, exposure can be tailored based on the fracture characteristics and plan. In cases of articular comminution, the paratricipital exposure with an olecranon osteotomy or a triceps-reflecting anconeus pedicle flap provides the greatest exposure of the joint surface.1–3 Raising the anconeus on its neurovascular pedicle as part of the osteotomy has several advantages, including visualization of the bare spot of the greater sigmoid notch for accurate osteotomy and improved exposure of the lateral articular surface. It is also theorized to reduce the incidence of osteotomy nonunion by preserving the anconeus' proximal neurovascular supply. Some surgeons have concerns with olecranon osteotomy in elderly patients because it can make reconstruction with TEA more challenging should surgical fixation fail. Although little studied, there are series of patients achieving reasonable outcomes with osseous union or stable fibrous union of the olecranon after TEA.4 Olecranon osteotomy is indispensable for anatomical reduction in complex articular injuries. This supersedes concerns over the impact on reconstruction should fixation fail. However, this does mean a surgeon should commit to either surgical fixation or elbow arthroplasty before an olecranon osteotomy and, if fixing, every effort should be made to do it right the first time.
Goals of surgical fixation are to restore limb length, alignment, and rotation with anatomical articular reduction and create a stable construct sufficient to allow early motion. Provisional reductions can be aided with both smooth and fully threaded Steinmann pins, minifragment (2.0, 2.4, and 2.7 mm) plates and screws, and modified Weber (“point-to-point”) clamps with straightened tines that can be placed through unicortical drill holes. Small, free chondrocancellous fragments can be secured either with countersunk minifragment screws or small-diameter (∼1.1 mm) fully threaded Steinmann pins that can then be cut flush with the cancellous bone surface. If bone loss is present, metaphyseal shortening or bone graft/substitute can be used to maintain condylar width and length.
Once provisionally reduced, either orthogonal or parallel plating techniques using rigid plates with locking options are suggested. Choice of plating technique primarily depends on condylar fragment size, comminution, and how distal the fracture lines extend. Distal fixation can use metaphyseal, locking or cortical screws depending on the patient's bone quality and intercondylar comminution. An essential detail is to not let provisional fixation affect a rigid definitive fixation construct that closely adheres to the O'Driscoll principles.5 The importance of closely adhering to these basic principles cannot be overemphasized, especially in patients with poor bone quality. Screws in the distal fragment should (1) be placed through a plate, (2) engage fragments on the opposite side, (3) be as long as possible, (4) interdigitate, and (5) be as numerous as possible. Placing multiple, independent, large-diameter screws or wires near the articular surface during provisional reduction may obstruct opportunities to place as many screws as long as possible through rigid plates in the periarticular bone.
ORTHOGONAL VERSUS PARALLEL PLATE FIXATION
Biomechanical and clinical studies have compared parallel and orthogonal plating with minimal differences in torsional load to failure and minimal functional difference.6–8 Typically, a parallel plate construct means anatomically precontoured rigid plates along the medial and lateral supracondylar ridges, whereas an orthogonal plate construct uses posterolateral precontoured implants. Depending on the situation, either may be advantageous. A parallel plate construct allows for maximizing distal articular fixation because every distal screw placed through the plate has an opportunity to be long and engage the contralateral condyle. This is clearly preferred in patients with very comminuted, complex articular injuries because of the biomechanical demands placed on fixation. However, the osteology of the distal humerus makes plating on the narrow lateral supracondylar ridge challenging. The common extensor origins must be elevated from bone. This may increase local soft tissue injury or threaten the origin of the lateral ulnar collateral ligament if not performed carefully. Application of a posterolateral plate may be easier, with the added benefits of more distal plate placement and more fixation options in the capitellum fragment, although these screws are typically short in the range of 20–24 mm and unicortical. Most fractures can usually be reasonably treated with either option. A good rule of thumb may be parallel plating for low supracondylar fractures, fractures with bone loss, and in severely osteopenic bone. Patients with more complex diaphyseal or metaphyseal injuries and less complex articular injuries may be safely treated with orthogonal plate constructs. Some manufacturers have posterolateral plates with lateral “tabs” that allow long screws to be placed to engage the trochlea and medial condyle which may extend their range for use (Fig. 1).
ILLUSTRATIVE CASE FOR ORTHOGONAL PLATE FIXATION
A 71-year-old man fell from standing sustaining a left open distal humerus fracture. Radiographs demonstrate a “C-type” injury with comminuted metadiaphyseal and articular segments (Fig. 1A). There are relatively large medial and lateral condylar segments, but scrutiny of the 3D CT scan demonstrates the central articular comminution and trochlear impaction that may be missed on plain film radiographs (Fig. 1B). Basic principles for open fracture management preceded definitive fixation, which used an orthogonal plate construct with a “tab” option in the posterolateral plate for additional articular fixation (Figs. 1C, D). Several reduction techniques are illustrated here in the order they were performed. Minifragment fixation, independent cortical lag screws, and modified clamps through pilot drill holes maintain a provisional reduction for a “C” to “B” strategy (Fig. 2A). The affected trochlea is reduced (Fig. 2B). Central articular comminution is cleaned on the back table, replaced, and held with 1.1-mm fully threaded Steinmann pins cut flush with the bone surface before intercondylar compression with large Weber clamps (Figs. 2C, D). At his 12-week postoperative visit, his ROM was 5–120 degrees with radiographically progressing healing.
ILLUSTRATIVE CASE OF PARALLEL PLATE FIXATION
A 77-year-old woman fell 3 steps sustaining multiple traumatic injuries including a “U-shaped” sacral fracture, intra-articular right distal radius fracture, and right distal humerus fracture. Radiographs demonstrate osteopenia with a complex articular injury with multiple chondrocancellous pieces and intercalary comminution (Fig. 3A). Reduction using metaphyseal cortical reads shows the central articular defect (Fig. 3B). Select articular fragments sizeable enough for reconstruction are replaced before parallel plate fixation (Figs. 3C, D). Note the sparing use of temporary fixation to allow ample opportunity for all distal screws to be placed through plates and be as long as possible. Her postoperative course demonstrates the difficulties with mobilizing this population because she was kept to bed or chair for 6 weeks postsurgically despite fixation of all her skeletal injuries. At 6-month follow-up, she had radiographic and clinical healing of all injuries and ambulates without the need for assistive aid. Her elbow healed with heterotopic bone formation with elbow flexion from 20 to 120 degrees with a pronation–supination arc of 120 degrees.
Patients with a higher functional demand are not well served with TEA because of lifelong activity restrictions. Similarly, patients with severe cognitive impairment may not be able to comply with these restrictions despite their low functional demands and may be best treated nonsurgically. Benefits of acute arthroplasty include immediate stable fixation and preservation of the elbow extensor mechanism. A prospective, randomized study performed by McKee et al demonstrates improved functional outcomes at 2 years with TEA compared with ORIF.9 Several level III studies have also shown improved functional outcomes after TEA for distal humerus fractures in patients older than 65 years.9–12 TEA can be performed as index surgery or as delayed reconstruction after failed nonsurgical treatment or ORIF. Delayed TEA does have increased risks for complication in comparison with primary TEA.13 Long-term survivability data show that, in carefully selected elderly patients, a well-performed TEA reliably creates a well-functioning and durable elbow. The best available data show 76%–92% survivorship at 10 years in carefully selected patients.14,15
Elbow hemiarthroplasty (HA) may be cautiously considered. It should be noted that this is an off-label use, and there are no available implants that are FDA-approved in the United States. Patients must have no pathology of the proximal ulna or radial head. It can be performed through a paratricipital exposure or with an olecranon osteotomy. The medial and lateral epicondyles and collateral ligaments must either be intact or repairable for varus and valgus stability. This can be performed by plate and screw constructs, independent screws, anchors, or sutures passed through drill tunnels. Proposed benefits of a HA over a TEA include less activity restriction, preservation of bone stock, and improved implant survivorship because of lower loosening rates. This makes it potentially a reasonable option for more functional or active patients with the rare nonreconstructible distal humerus. Although there are some short-term studies demonstrating acceptable range of motion and functional outcome, long-term and randomized studies are limited.16 There are questions still to be answered regarding the stability, durability, and accelerated cartilage wear of the radiocapitellar and ulnohumeral joints.
ILLUSTRATIVE CASE OF HEMIARTHROPLASTY
A 60-year-old woman with a history of osteogenesis imperfecta fell from standing sustaining a right distal humerus fracture. Radiographs demonstrate a complex articular injury including coronal plane capitellar and trochlear shear fractures (Figs. 4A–C). A computed tomography scan demonstrated extreme subchondral osteopenia with minimal supporting bone for surgical fixation. For hemiarthroplasty, any available cortical reads are used to set condylar length. Here, the lateral column is reduced and held with unicortical fixation that does not impede placement of the humeral implant (Fig. 5A). A pair of large bone-holding forceps can help provide proximal control during trochlear cut, broaching, and trialing (Fig. 5B). After the final implant was cemented into place, the medial epicondyle is then reduced and fixed. Carefully placed cerclage wires or cables can augment proximal fixation (Figs. 5C, D). At 6-month follow-up, she had functional elbow ROM with healed epicondyles and olecranon osteotomy, without a sign of implant loosening.
ILLUSTRATIVE CASE OF TOTAL ELBOW ARTHROPLASTY
A 76-year-old low-demand woman with a history of chronic elbow instability fell from standing. Radiographs demonstrate underlying deformity believed to be due to childhood injury (Figs. 6A, B). She failed initial attempts for nonsurgical treatment, and TEA was performed through a triceps-on approach. At her 2-year follow-up, she had painless ROM from 15 to 105 degrees with stable implants (Figs. 6C, D).
- Careful patient selection is paramount. The most low-demand patients may be treated nonsurgically. The most high-demand patients may not be well served with TEA.
- If using ORIF, use strategic distal provisional fixation that will not block the implants needed for stability of your definitive fixation construct. Fixation should follow the O'Driscoll principles with either orthogonal or parallel plating using rigid plates with locking options.
- Hemiarthroplasty and TEA can be carefully considered in select elderly patients.
The primary goal of treatment in the elderly patient with a distal humerus fracture is to recreate a stable, painless elbow with a functional range of motion to allow independence and use of the extremity for mobilization. Comparative studies between ORIF and TEA confirm that TEA is a viable option. However, treatment should be tailored to each patient's needs based on their age and function. Future studies should be directed toward the safety of immediate weight-bearing after surgery with both surgical fixation and TEA. Hemiarthroplasty may be considered as an underused option in the physiologically young or more active elderly population.
The authors acknowledge Dr Kaveh Sajadi for contributing cases for this manuscript.
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