Surgical Repair of Elbow Fractures Can Be a Tricky Thing

Fractures of the elbow can involve the upper bone (humerus) or the two lower bones in the forearm (radius and ulna). In this review article, surgeons from Columbia University Medical Center in New York City discuss current ways to treat bicolumnar distal humerus fractures. Evaluation of the injury as well as nonsurgical management and surgical treatment are discussed in detail. Results of treatment and potential complications are included.

A distal humeral fracture is just another way of saying it's the elbow that's involved. The humerus (upper arm bone) obviously can be broken at the top near the shoulder, in the middle along the shaft of the bone, or at the bottom where it joins the elbow. Bicolumnar is a more complex fracture pattern affecting both sides of the elbow. The two sides are medial or inside next to the body and lateral or outside away from the body.

When the humerus breaks across or through both sides, different soft tissues (skin, ligaments, tendons, muscles), nerves, and blood vessels are affected. For example, the radial nerve travels down the lateral (outside) of the elbow and forearm, whereas the ulnar nerve takes the medial (inside) track.

Two groups of patients seem to make up the majority of bicolumnar distal humeral fractures: young athletes involved in high-energy trauma and older adults (mostly women) with osteoporosis (brittle bones). Older folks who lose their balance and fall on an outstretched hand/arm or directly onto the elbow are at risk for elbow fractures of all kinds, especially bicolumnar.

Although this injury doesn't happen very often, those individuals affected by it need careful evaluation and an effective management plan. A visual and hands-on examination is followed by X-rays, CT scans, and any other tests indicated by the results of the clinical evaluation. Once an accurate and complete diagnosis has been made (with all injured parts accounted for), then a management plan can be determined.

So what are the patient's options here? Well -- there aren't many: mostly surgery. The goal of treatment is to restore full function while avoiding long-term problems and complications like nonunion, joint stiffness, nerve injury, or infection. That means each fragment of bone must be dealt with. Conservative (nonoperative) care with bracing or other means of immobilization is only used when it's an older, fragile adult who can't handle surgery. Bracing can be the first choice to avoid surgery when the patient is paralyzed and won't be able to use that arm anyway.

That leads us right down the path to surgery as the main means of managing these fractures. It's a complicated fracture pattern so open-incision rather than arthroscopic surgery is the way to go. Now the surgeon must decide how to open the elbow. The usual approach is from the back (posterior) side of the elbow.

But whether to make the incision from side to side or split it up the middle depends on several factors. For example, has the fracture affected the inside of the joint (intraarticular or is it confined to the outside of the joint (extraarticular)? Having to gain access to the joint changes everything. Making a cut along the back of the elbow usually requires cutting through the triceps muscle. Some surgeons try to spare the triceps by cutting off the end of the bone and going into the joint that way. The muscle isn't cut and the tip of the bone can be reattached once the joint has been repaired.

You can see the surgeon has many decisions to juggle in the process of treating these complex fractures. Next there are considerations around fixation techniques. Fixation refers to how the surgeon holds the bone fragments together once they are all lined up again. Fixation techniques include plates, pins, screws, and wires. When a bicolumnar fracture is present, both columns (medial and lateral) must be stabilized.

Okay, that seems easy enough but guess what? Plates come in a variety of shapes and types. They can be precontoured to fit the curve of the bone or locking in order to increase stability at the site of the fixation. Oh, did we mention the possibility of the hardware being bioabsorbable? That means as the bone knits itself together, the fixation implant slowly dissolves and gets reabsorbed by the body. If a bioabsorbable type isn't used, it may be necessary to complete a second surgery later to remove the hardware when it is no longer needed.

Studies are ongoing looking at how much strength and stiffness each type of plate provides and how much strain each one can take during elbow motion and with load placed on the joint. At the same time, researchers are reporting on the outcomes or results for each type of implant based on final measurements of elbow range-of-motion, strength, and function. Complication rates are also reported to help surgeons decide which one is best for their patients.

Opening the elbow and using fixation to hold and stabilize the bone is referred to as open reduction and internal fixation or ORIF. That takes us through the first wave of surgical decisions. But if the type of fracture can't be managed with ORIF, then the other options include total elbow arthroplasty (TEA) or elbow replacement, arthrodesis or fusion, and hemiarthroplasty or partial elbow replacement.

Older adults with severe fractures of osteoporotic bones may not be able to benefit from ORIF. The brittle, weak bone structure just can't support the weight of the hardware. That's when a partial or complete elbow replacement is considered. This is a nice option for those patients who already have a painful, limited elbow joint due to arthritis. It's best if these patients have low activity demands because they will be restricted to lifting nothing that weighs more than five pounds. Most grandchildren, dogs, cats, and groceries weigh more than that, so it can be a real issue.

When is an elbow fusion the best choice? Well, this is really a last choice effort to save the joint. Once the joint is fused, there's no elbow motion and that can be very nonfunctional when trying to wipe after toileting, lift a cup of coffee to the lips, or perform any number of self-care activities (e.g., brushing the teeth, combing the hair, putting on a pair of eyeglasses, or adjusting a hearing aid). Fusion is only considered when the joint is severely painful and arthritic, there's been considerable loss of bone or soft tissue, and/or an elbow replacement has been tried and failed. Fusion is really the end of the line, so-to-speak.

Finally, no matter what kind of surgical procedure is carried out, the patient now faces a long period of healing, recovery, and rehabilitation. There's a fine line between resting and immobilizing this particular joint in order to foster healing and waiting too long to move it and finding out it stiffened up too much.

A hand therapist (usually a physical or occupational therapist) will consult with the surgeon to set up the right postoperative program for each patient. The patient should expect a minimum of three to four months in rehab. Then the program continues at home with a daily program of exercises to regain elbow motion, strength, and function. Many patients simply don't get full elbow extension. In other words, they cannot straighten the elbow all the way. But the loss of the last five to 10 degrees of elbow extension doesn't usually affect function in any way.

Surgeons can expect to see more of these kinds of complex elbow fractures in the near future. As the graying of America continues, the epidemic of osteoporosis is expected to get worse, not better. Staying abreast of treatment options, when to use each one, and other considerations such as presented in this article will be necessary.

Reference: 

Gregory J. Galano, MD, et al. Current Treatment Strategies for Bicolumnar Distal Humerus Fractures. In Journal of the American Academy of Orthopaedic Surgeons. January 2010. Vol. 18. No. 1. Pp. 20-30.

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