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Orthopedic Services
Glendale Adventist Medical Center
1509 Wilson Terrace
Glendale, CA 91206
Ph: (818) 409-8000

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Everyone is talking about the need for evidence before making medical decisions about the best course of action. Can you help me find the latest on treatment of a displaced intra-articular fracture of the distal humerus (elbow fracture)? That's what my elderly father has and is facing surgery for. I'd like to do everything I can to make sure he gets the right (best) treatment.

There aren't a lot of studies comparing the two main methods of treating a fracture of this type. But we did find a systematic review of the literature by three surgeons from three countries (United States, England, and New Zealand). The review specifically looked at displaced (separated) intra-articular (inside the joint) fractures of the distal humerus (bottom end of the upper arm bone/upper half of the elbow). This is exactly what you described as the diagnosis for your father. There were only two studies that met the study criteria. The surgeons who carried out this review say right up front that the evidence is insufficient to make a true recommendation for one treatment over the other (internal fixation versus joint replacement). The biggest finding of the study was to point out the need for a large, randomized, controlled trial to investigate this problem more thoroughly. In the meantime, here's what they found from the two studies that were available. Older adults with displaced distal humeral fractures of the elbow regained more elbow/arm function with a joint replacement. And patients who had open reduction and internal fixation (ORIF) were more likely to need a second (revision) surgery. The main advantage of ORIF is that it can be successful leaving the natural anatomy and bone intact. Should the procedure fail to reduce pain, increase motion, and improve function, then it is still possible to have a joint replacement later. The two studies reviewed had several limitations. First, they were small in number. Second, in one study there were six different surgeons involved. The level of experience and expertise was not mentioned but could have been a factor in outcomes. When internal fixation was used with hardware, different types of devices were used (perpendicular plates, parallel plates, screws of different types) that could also affect the results. In the second study, only women were included. In this study, the surgeons paid attention to comorbidities (other health problems present at the same time) that might have influenced the results. Alcoholism, rheumatoid arthritis, chronic obstructive pulmonary disease (COPD), and osteoporosis (brittle bones) were some of the problems reported. The surgeons felt that patients with comorbidities were more likely to have better results with total elbow arthroplasty (TEA). But whether the presence of any comorbidity (or only certain conditions) makes a difference remains unknown. And finally, the period of follow-up for these two studies was only two years so no long-term results were available. The authors' final conclusion was that all of these study limitations reinforce the fact that further studies in this area are needed. That may not be very helpful to you in your current situation trying to help your father. But the information may make the surgeon's decision understandable and/or give you some help in knowing what questions to ask.


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