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DISTAL HUMERUS FRACTURE ADULT

Introduction

Fracture Nomenclature for Distal Humerus fractures

Hand Surgery Resource’s Diagnostic Guides describe fractures by the anatomical name of the fractured bone and then characterize the fracture by the Acronym:

In addition, anatomically named fractures are often also identified by specific eponyms or other special features.

For the Distal Humerus Fractures, the historical and specifically named fractures do not include any fracture eponyms.

Distal humerus fractures are complex injuries that typically result from trauma to the elbow. These injuries tend to occur in a bimodal age distribution, with the mechanism of injury being high-energy trauma in younger, male patients and low energy falls in elderly patients, particularly those with osteoporosis. Distal humerus fractures are often difficult to manage because they may involve an articular as well as a diaphyseal component. Although conservative treatment was once widely used, it is now only reserved for elderly patients that are unable to undergo surgery, and a surgical approach is recommended for most patients.1-3

Definitions

  • A distal humerus fracture is a disruption of the mechanical integrity of the distal humerus.
  • A distal humerus fracture produces a discontinuity in the distal humeral contours that can be complete or incomplete.
  • A distal humerus fracture is caused by a direct force that exceeds the breaking point of the bone.

Hand Surgery Resource’s Fracture Description and Characterization Acronym

SPORADIC

S – Stability; P – Pattern; O – Open; R – Rotation; A – Angulation; D – Displacement; I – Intra-articular; C – Closed

S - Stability (stable or unstable)

  • Universally accepted definitions of clinical fracture stability are not well defined in the literature.4-6
  • Stable: fracture fragment pattern is generally nondisplaced or minimally displaced. It does not require reduction, and the fracture fragments’ alignment is maintained by with simple splinting. However, most definitions define a stable fracture as one that will maintain anatomical alignment after a simple closed reduction and splinting. Some authors add that stable fractures remain aligned, even when adjacent joints are put to a partial range of motion (ROM).
  • Unstable: will not remain anatomically or nearly anatomically aligned after a successful closed reduction and immobilization. Typical unstable distal humerus fractures have significant deformity with comminution, displacement, angulation, and/or shortening.

P - Pattern2,3

  • Type A: extra-articular fractures of the supracondylar region
  • Type B: partial articular fractures
  • Type C: intra-articular fractures in which the articular surface is completely dissociated from the humeral shaft
    • These three fracture types can be further categorized with the numbers 1, 2, and 3 to indicate increasing degrees of comminution. Type A fractures are most common (39%), followed by type C1 (37%) and type B (24%).

O - Open

  • Open: a wound connects the external environment to the fracture site. The wound provides a pathway for bacteria to reach and infect the fracture site. As a result, there is always a risk for chronic osteomyelitis. Therefore, open fractures of the distal humerus require antibiotics with surgical irrigation and wound debridement.4,7,8

R - Rotation

  • Distal humerus fracture deformity can be caused by rotation of the proximal fracture fragment in relation to the distal fracture fragment.
  • Degree of malrotation of the fracture fragments can be used to describe the fracture deformity.

A - Angulation (fracture fragments in relationship to one another)

  • Angulation is measured in degrees after identifying the direction of the apex of the angulation.
  • Straight: no angular deformity
  • Angulated: bent at the fracture site

D - Displacement (Contour)

  • Displaced: disrupted cortical contours
  • Nondisplaced: ≥1 fracture lines defining one or several fracture fragments; however, the external cortical contours are not significantly disrupted

I - Intra-articular involvement

  • Intra-articular fractures are those that enter a joint with ≥1 of their fracture lines.
  • Distal humerus fractures can have fragment involvement at the radiocapitellar or ulnohumeral joints.
  • If a fracture line enters a joint but does not displace the articular surface of the joint, then it is unlikely that this fracture will predispose to post-traumatic osteoarthritis. If the articular surface is separated or there is a step-off in the articular surface, then the congruity of the joint will be compromised, and the risk of post-traumatic osteoarthritis increases significantly.

C - Closed

  • Closed: no associated wounds; the external environment has no connection to the fracture site or any of the fracture fragments.4-6

Related Anatomy9-13

  • The elbow is a hinge-type synovial joint comprised of the radius, ulna, and humerus, and formed by three articulations: the ulnohumeral joint, radiocapitellar joint, and proximal radioulnar joint (PRUJ).
  • The ulnohumeral joint is the articulation of the olecranon process of the ulna and the medial condyle of the humerus. It allows for flexion and extension of the elbow. It is a hinge joint in which the trochlea serves as the center of the hinge and is supported by medial and lateral columns. The distal humerus has a triangular shape in the coronal plane formed by these columns and is linked by the articular segment.
    • The distal humerus also features three depressions—the coronoid, radial, and olecranon fossae—which accommodate the forearm bones during flexion or extension at the elbow.
  • The radiocapitellar joint is the articulation of the radial head with the capitellum of the humerus. It is essential to elbow longitudinal and valgus stability and has an integral relationship with the lateral collateral ligament (LCL).
  • The key ligaments of the elbow include the LCL (which extends from the lateral epicondyle and blends with the annular ligament of the radius), the MCL (which originates from the medial epicondyle and attaches to the coronoid process and olecranon of the ulna), and the annular ligament (which encircles the radial head and stabilizes the PRUJ and radiocapitellar joint).
  • The key tendons of the elbow include the tendons associated with the biceps, triceps, and extensor carpi radialis longus (ECRL) muscles as well as the common extensor tendon (the shared origin of the extensor carpi radialis brevis (ECRB), extensor digitorum communis (EDC), extensor digiti minimi (EDM) and extensor carpi ulnaris (ECU)), and the common flexor tendon (the shared origin of the pronator teres, flexor carpi radialis (FCR), palmaris longus, flexor digitorum superficialis (FDS), and flexor carpi ulnaris (FCU)).
  • The radius and ulna are also connected by a sheet of thick fibrous tissue called the IOM.

Incidence

  • The estimated incidence of distal humerus fractures is 5.7 per 100,000 persons per year, and this figure appears to be increasing.1,3
  • Distal humerus fractures account for about 30% of elbow fractures and 0.5–7% of all fractures.1,3
  • These injuries have a bimodal age distribution of young men and elderly women.1

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ICD-10 Codes

  • DISTAL HUMERUS FRACTURE - ADULT

    Diagnostic Guide Name

    DISTAL HUMERUS FRACTURE - ADULT

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    DISTAL HUMERUS FRACTURE - ADULT    
    AVULSION FRACTURE MEDIAL CONDYLE    
    - DISPLACED S42.442_S42.441_ 
    - NONDISPLACED S42.445_S42.444_ 
    TRANSCONDYLAR    
    - DISPLACED S42.472_S42.471_ 
    - NONDISPLACED S42.475_S42.474_ 
    AVULSION FRACTURE LATERAL CONDYLE    
    - DISPLACED S42.432_S42.431_ 
    - NONDISPLACED S42.435_S42.434_ 
    SIMPLE SUPRACONDYLAR FRACTURE WITH/WITHOUT INTERCONDYLAR FRACTURE    
    - DISPLACED S42.412_S42.411_ 
    - NONDISPLACED S42.415_S42.414_ 
    COMMINUTED SUPRACONDYLAR FRACTURE WITH/WITHOUT INTERCONDYLAR FRACTURE    
    - DISPLACED S42.422_S42.421_ 
    - NONDISPLACED S42.425_S42.424_ 
    OTHER FRACTURE OF LOWER HUMERUS    
    - DISPLACED S42.492_S42.491_ 
    - NONDISPLACED S42.495_S42.494_ 

    Instructions (ICD 10 CM 2020, U.S. Version)

    THE APPROPRIATE SEVENTH CHARACTER IS TO BE ADDED TO EACH CODE FROM CATEGORY S42
     Closed FracturesOpen Type I or II or OtherOpen Type IIIA, IIIB, or IIIC
    Initial EncounterABC
    Subsequent Routine HealingDEF
    Subsequent Delayed HealingGHJ
    Subsequent NonunionKMN
    Subsequent MalunionPQR
    SequelaSSS

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
Distal Humerus Fracture
  • Closed three part adult Distal Humerus Fracture AP & Lateral views
    Closed three part adult Distal Humerus Fracture AP & Lateral views
Symptoms
History of trauma
Fracture pain
Fracture deformity
Swelling, ecchymosis & tenderness
Abrasion
Typical History

The typical patient is a 20-year-old male who injured his elbow while dirt biking. The boy had been riding his dirt bike on a friend’s halfpipe when he misgauged the bike’s position while doing a trick and landed too far forward on the front wheel, which forced him to fly over the handlebars and land at the base of the halfpipe on his right elbow. The impact resulted in a fracture of the distal humerus, and soon after the injury, the boy was unable to move his elbow, so he was taken to the emergency room.

Positive Tests, Exams or Signs
Work-up Options
Images (X-Ray, MRI, etc.)
Distal Humerus Fracture
  • Closed three part adult Distal Humerus Fracture AP & Lateral views
    Closed three part adult Distal Humerus Fracture AP & Lateral views
  • Closed three part adult Distal Humerus Fracture CT Scan
    Closed three part adult Distal Humerus Fracture CT Scan
Treatment Options
Treatment Goals
  • When treating closed distal humerus fractures, the treating surgeon has 4 basic goals:4,8
    1. An elbow with a normal appearance. The X-ray may not need to be perfect, but the elbow should have no obvious deformity (i.e., the elbow looks normal!)
    2. Avoid elbow stiffness by maintaining a normal functional ROM (i.e., the elbow works!)
    3. The elbow is not painful (i.e., the elbow does not hurt!)
    4. Congruent joint surface with none-to-minimal joint surface irregularities (i.e., the elbow does not develop early post-traumatic arthritis!)
  • One additional goal is mandatory for open fractures:
    1. Fracture care should minimize the risk for infection and osteomyelitis.
Conservative
  • Nonoperative management, which may be used for nondisplaced distal humerus fractures and some patients with comorbidities that may preclude surgical intervention, typically consists of a brief period of immobilization with the elbow in 60° of flexion followed by early gentle range of motion exercises; however, most of these injuries are currently managed surgically due to the generally positive outcomes associated with this approach.2,3
Operative
  • Surgical treatment of distal humerus fractures must always be an individualized therapeutic decision.1,14  However, surgical distal humerus fracture care is most frequently recommended when:
    1. Closed reduction fails or the simple splint immobilization does not maintain the reduction. For these irreducible or unstable fractures, operative treatment is recommended to achieve the 4 treatment goals of fracture care.
    2. There is a significantly displaced distal humerus fracture involving the radiocapitellar or ulnohumeral joint.
    3. Open distal humerus fractures. These injuries require surgical care in the form of irrigation and debridement to prevent chronic infection.
  • Open reduction and internal fixation (ORIF)
    • Generally regarded as the treatment of choice for distal humerus fractures, particularly displaced supracondylar, intercondylar, and/or bicolumnar fractures.
    • The most frequently used direction of fixation is distal to proximal.
    • Fixation devices include:
      • Reconstruction plates
      • Mini-condylar plates
      • Mini-fragment screws
      • Lag screws
      • Variable-pitch countersunk screws
      • Bioabsorbable implants
  • Total elbow arthroplasty
    • Typically, only indicated for bicolumnar fractures in elderly patients with significant articular comminution and osteoporosis, as well as sedentary patients who can comply with post-surgical weight restrictions.
  • Elbow arthrodesis
    • Considered a final resort for patients with painful post-traumatic arthritis, severe bone or soft-tissue loss, chronic persistent infection, concomitant neurologic injury, and failed total elbow arthroplasty.
  • Elbow hemiarthroplasty
    • May be indicated for some younger patients with severely comminuted fractures in which ORIF or conservative treatment are not possible.
Treatment Photos and Diagrams
ORIF of Distal Humerus Fracture
  • ORIF of Distal Humerus Fracture Preliminary Fixation
    ORIF of Distal Humerus Fracture Preliminary Fixation
  • Completed ORIF of Distal Humerus Fracture
    Completed ORIF of Distal Humerus Fracture

Post-treatment Management

  • The care and precautions related to immobilization devices for the distal humerus fracture must be carefully reviewed with the patient. Patients should be educated regarding care and precautions. Patients should know that pain, especially increasing pain, numbness, tingling, skin irritation, splint loosening, or excessive tightness are red flags and should be reported to the surgeon or his team.
  • Pain should be managed with properly fitting splints, reassurance, elevation, ice in the initial post-fracture period, and mild pain medications. Patients should be encouraged to discontinue pain medication as soon as possible. Opioid use should be kept to a minimum.
  • Joints that are splinted for closed stable fractures are usually immobilized.
  • Fractures that require internal fixation can usually be mobilized after 2 to 4 weeks.
  • Therapist-guided, gentle active ROM exercises for the hand, wrist, and shoulder should begin immediately after surgery. Active ROM exercises for the elbow should begin 7–10 days post-surgically if there are no wound issues. Strengthening exercises may begin after there is radiographic evidence that the fracture has healed, which typically occurs around 8–12 weeks after surgery.3,14
Complications
  • Stiffness
  • Aseptic necrosis
  • Avascular necrosis
  • Malunion
  • Loss of elbow ROM
  • Heterotopic ossification
  • Hardware failure
  • Non-union
  • Posttraumatic arthritis
Outcomes
  • Several studies have shown that outcomes are generally much better in elderly patients who are treated surgically compared to those treated non-surgically, with higher rates of nonunion in patients receiving conservative care.3
  • Surgical fixation has been associated satisfactory long-term results, with good or excellent outcomes being reported in up to 86% of patients.13
Key Educational Points
  • Distal humerus fractures were traditionally treated primarily with conservative methods, but this changed in the 1960s when Arbeitsgemeinschaft für Osteosynthesefragen (AO) fracture fixation principles were developed, since this led to notable improvements in outcomes following surgical fixation strategies.3
  • Surgeons consider distal humerus fractures to be challenging injuries to treat due to various anatomic and treatment complexities, poor outcomes, and the risk for complications.15
  • Significant advancements have been made in treating distal humerus fractures, but numerous controversies remain, including the correct operative approach and fixation method, the role of total elbow arthroplasty, and ulnar nerve management.2,15
  • Neurovascular exam should include sensory and motor function assessments of the median, radial, ulnar, anterior interosseous, and posterior interosseous nerves.1
  • Anteroposterior (AP), lateral, and oblique radiographic views of the entire forearm and humerus should be taken. AP radiographs of the distal humerus should be taken with the elbow flexed to 40 degrees.1,3
  • Traction views of the elbow may be helpful for more accurately characterizing fracture fragments.3 Imaging of the wrist and shoulder is often performed to detect concomitant injuries.3
  • Computerized tomography (CT) scanning may be helpful for surgical planning or when there is a shear element of the fracture.1
References

Cited Articles

  1. Crean, TE and Nallamothu, SV. Distal Humerus Fractures. In: StatPearls. Treasure Island (FL): 2021. PMID: 30285369
  2. Nauth, A, McKee, MD, Ristevski, B, et al. Distal humeral fractures in adults. J Bone Joint Surg Am 2011;93(7):686-700. PMID: 21471423
  3. Lauder, A and Richard, MJ. Management of distal humerus fractures. Eur J Orthop Surg Traumatol 2020;30(5):745-762. PMID: 31965305
  4. Cheah, AE and Yao, J. Hand Fractures: Indications, the Tried and True and New Innovations. J Hand Surg Am 2016;41(6):712-22. PMID: 27113910
  5. Nesbitt, KS, Failla, JM and Les, C. Assessment of instability factors in adult distal radius fractures. J Hand Surg Am 2004;29(6):1128-38. PMID: 15576227
  6. Walenkamp, MM, Vos, LM, Strackee, SD, et al. The Unstable Distal Radius Fracture-How Do We Define It? A Systematic Review. J Wrist Surg 2015;4(4):307-16. PMID: 26649263
  7. Ketonis, C, Dwyer, J and Ilyas, AM. Timing of Debridement and Infection Rates in Open Fractures of the Hand: A Systematic Review. Hand (N Y) 2017;12(2):119-126. PMID: 28344521
  8. Meals, C and Meals, R. Hand fractures: a review of current treatment strategies. J Hand Surg Am 2013;38(5):1021-31. PMID: 23618458
  9. Fernandez, DL and Jupiter, JB. Fractures of the Distal Radius: A Practical Approch to Management. Second ed. New York: Springer Science+Business Media New York; 2002.
  10. Zumstein, MA, Hasan, AP, McGuire, DT, et al. Distal radius attachments of the radiocarpal ligaments: an anatomical study. J Wrist Surg 2013;2(4):346-50. PMID: 24436840
  11. Burkhart, KJ, Wegmann, K, Muller, LP, et al. Fractures of the Radial Head. Hand Clin 2015;31(4):533-46. PMID: 26498543
  12. van Riet, RP, van den Bekerom, MPJ, Tongel, AV, et al. Radial head fractures. Shoulder & Elbow 2020;12(3):212–223. PMID: 32565923
  13. Beazley, JC, Baraza, N, Jordan, R, et al. Distal Humeral Fractures-Current Concepts. Open Orthop J 2017;11:1353-1363. PMID: 29290875
  14. Galano, GJ, Ahmad, CS and Levine, WN. Current treatment strategies for bicolumnar distal humerus fractures. J Am Acad Orthop Surg 2010;18(1):20-30. PMID: 20044489
  15. Lee, HJ. Surgical Treatment Strategy for Distal Humerus Intra-articular Fractures. Clin Shoulder Elb 2019;22(2):113-117. PMID: 33330205
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