Issue: August 2010
August 01, 2010
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Distal humerus fracture treatment possible through internal fixation

One physician feels total elbow arthroplasty may be too strong a move.

Issue: August 2010
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Total elbow arthroplasty may be too drastic a move for the treatment of distal humerus fractures despite the complexity of the injury, according to one physician’s findings.

“Aggressive expansion of the indications for TEA to treat distal humerus fractures, particularly in younger patients, may create a new generation of virtually insoluble problems,” said Michael R. Hausman, MD, during a presentation at the 2010 Annual Meeting of the American Academy of Orthopaedic Surgeons.

Hausman said a shift in thinking is required to avoid overuse of total elbow arthroplasty (TEA) for distal humerus fractures. While total elbow replacement may be useful in a small percentage of patients with very distal, highly comminuted fractures in osteopenic, elderly people, most patients could have their native elbows saved with the proper fixation techniques.

“I think the better alternative, particularly for an active patient, would be to fix these correctly and preserve their bone stock,” he said. “Good, durable results can be achieved following these principles, while only limited and unsatisfactory options exist for a failed or infected elbow replacement.”

Older thinking and techniques

Hausman pointed out that the rationale for using elbow replacement is based older reports of higher failure rates of fixation failure using traditional, 90-90 AO-type fixation principles.

Inadequate distal fixation
Inadequate distal fixation results in loss of reduction and nonunion of the lateral condyle.

Successful application of the four-five rule for a distal humerus fracture
Successful application of the “four-five rule” for a distal humerus fracture. Note that all of the distal screws go through the plate and support both condyles, optimizing distal fixation.

Images: Hausman MR

“Newer studies of parallel plating have shown very different outcomes,” Hausman told Orthopedics Today. “There has been such an evolution in hardware and principle that comparison with previous reports of ORIF is not valid.

“While simpler fracture patterns may be adequately fixed with 90-90 techniques, more comminuted fractures are best fixed when all the distal screws go through the plates and have optimal, bi-condylar fixation in the distal fragment thus “re-associating” the articular surfaces to the humerus shaft.

The four/five rule

Exposure is another large concern with complex intra-articular fractures, Hausman noted, and is best handled with an olecranon osteotomy. In most cases, Hausman said he “strongly advocates” finding the ulnar nerve, then the medial and lateral intermuscular septi because they serve as a guide for where to reflect the triceps and also, in the case of proximal approaches, help direct you to the radial nerve and avoid inadvertent injury.

As for plates, Hausman noted that the plate itself was less important than the manner in which it was used.

“There are lots of good plates on the market, and I do not think it makes a difference which you use as long as you follow the four/five rule for complex fracture patterns – and that means four to five screws through the plates traversing the distal articular fragment,” he said.

He added that every screw should go through the plate – engaging a fragment on the opposite side – and any that does not is wasting “a good bite” in the distal bone. All screws should be as long as possible to go all the way across the distal fragments.

“Postoperatively, we are always so concerned with maintaining motion in the elbow, but maybe that is not the top priority with these fractures,” he said. “What we want to do is achieve an anatomic reduction and good fixation, but then we also want to make sure the fracture heals … we should avoid a loss of bone stock, and motion drops down to a secondary priority.” “We have a good, predictable solution for restoring elbow motion, but not for replacing lost bone and articular surface.

Winning the elbow game

The major problem with elbow replacement is that it is “a one-way street,” Hausman said,

“It is really premature and a disservice to aggressively push elbow replacement for these fractures,” he added. “A total elbow is equivalent to being in check in chess … one step away from losing the game.” You need to think carefully before you perform an arthroplasty, because an infected total elbow is a nightmare and there are few good options for that.”

Hausman concluded by reiterating the importance of shifting priorities toward the preservation of bone stock and the optimization of bone union.

Even the notion of the elderly, low-demand patient must be reconsidered, since older people push up with their arms to rise from a chair. – by Robert Press

Reference:

  • Hausman MR. Distal humeral fracture management. Presentation V in the Complex Elbow Injuries: Trauma and Reconstruction – How to Manage and Avoid Complications symposium. Presented at the 2010 Annual Meeting of the American Academy of Orthopaedic Surgeons. March 9-13, 2010. New Orleans.

Perspective

William N. Levine
William N. Levine

Dr. Hausman has raised an important controversy in the management of complex distal humeral fractures with respect to open reduction and internal fixation vs. total elbow arthroplasty. While there has been an increasing number of reports in the literature highlighting the outcomes of total elbow arthroplasty for distal humeral fractures, nearly all surgeons would agree that maintenance of the patient’s own bone with internal fixation is certainly preferable. I agree completely with Dr. Hausman’s assertion, therefore, that we should try and fix most fractures in nearly all patients; especially in patients under the age of 70 years. However, one needs to be cognizant that in elderly patients (age 70 years and older) with osteoporosis and severe comminution, it may be better to perform one reproducible operation well than to have to convert a failed internal fixation to a total elbow replacement down the road. Finally, a recent prospective randomized study from Canada showed that in elderly patients with comminuted distal humerus fractures, total elbow replacement had higher patient outcomes compared to open reduction and internal fixation. Although there was no statistically significant difference in the need for re-operation in the two groups, there was a twofold higher incidence of re-operation in the ORIF group (McKee et al, J Bone Joint Surg (Am). 2009; 91:2010).

– William N. Levine, MD
Professor of Orthopedic Surgery and Chief of Sports Medicine
Columbia at New York-Presbyterian Hospital