Articular Fractures of the Distal Part of the Humerus

Author(s): Ring D, Jupiter J, Gulotta L

Source: J Bone and Joint Surg 85-A: 232-237, 2003


This retrospective review evaluated articular fractures of the distal humerus without significant metaphyseal involvement or isolated capitellar injury.  Twenty-one patients with articular fractures of the distal part of the humerus were identified and reviewed at an average of 40 months post-injury (range, 24-90 months).  A classification scheme was developed based on the radiographs and operative findings with 5 patterns of injury noted.  A type 1 fracture consisted of a single articular fragment that included the capitellum and the lateral portion of the trochlea.  A Type 2 fracture was essentially a Type 1 fracture with an associated fracture of the epicondyle.  A Type 3 fracture was a Type 2 fracture with an impaction of metaphyseal bone behind the capitellum in the distal and posterior aspect of the lateral column. A Type 4 fracture was a Type 3 fracture with a fracture of the posterior aspect of the trochlea.  A Type 5 fracture extended to the medial epicondyle.  There were two male and 19 female patients with an average age of 50 years (range, 20-74 years).  All fractures were closed.  Fifteen patients suffered a fall from a standing height.  The 14 cases that did not involve the medial epicondyle were approached through an extensile lateral exposure and seven patients with a fracture involving the medial epicondyle were approached with an olecranon osteotomy.   Articular fragments were fixed often with Herbert screws and the epicondyles were reattached with 3.5mm reconstruction plates. 

Post-operative mobilization was based on the intra-operative decision of fracture stability with 9 patients initiating range of motion the day after surgery.  Twelve patients required turnbuckle splints at an average of 6 weeks post-operatively due to stiffness.  At final follow up, 4 patients had no pain, 15 patients had mild pain and 2 patients had moderate pain.  The average ulnohumeral motion was 96 degrees, (range, 55-140) with an average of 123 degrees (range, 100-140 degrees) of flexion and average flexion contracture of 27 degrees (range, 0-60 degrees).  All patients had normal rotation of the forearm.  Radiographically there were no signs of arthrosis or osteonecrosis during the follow up period.  The Mayo Elbow Performance Index was excellent in 4 patients, good in 12 and fair in 5. The fair results were related to restricted motion and moderate pain.  Ten patients required a second operation, 6 required a release of an elbow contracture, 2 required ulnar nerve decompression, 1 patient required hardware removal and 1 required revision fixation of the capitellar fragment.

This subset of distal articular fractures of the distal humerus appears most often to be associated with low energy injuries without metaphyseal comminution.  The authors note that a CT scan was often beneficial to enhance the preoperative assessment of the fracture configuration and also to direct operative exposure.  In particular, medial epicondyle involvement necessitated an olecranon osteotomy.  Osteonecrosis was not noted despite the loss of soft-tissue attachments to many of these very distal articular fragments.  Ulnar neuropathy developed in two patients despite the fracture primarily involving the lateral aspect of the distal humerus and was approached through an extended lateral incision.  The development of ulnar neuropathy was associated with increased pain and progressive loss of elbow motion.   Early transposition of the ulnar nerve led to rapid resolution of the symptoms and recovery of elbow function in the 2 patients identified with this problem. The authors also caution that isolated capitellar fractures often can have extension into the trochlea and may involve a more complex distal articular humeral fracture.


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