Distal Humerus Fracture

Aka: Distal Humerus Fracture, Medial Epicondyle Fracture, Medial Condyle Fracture, Transcondylar Fracture, Capitellar Fracture, Capitellum Fracture

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II. Epidemiology

  1. Distal Humerus Fractures account for one third of Humerus Fractures and up to 2% of overall Fractures in adults

III. Mechanism

  1. Fall on Outstretched Hand
  2. Direct blow to elbow
    1. Typically a high energy injury in adolescents and young adults
    2. Also occurs in elderly with falls

IV. Symptoms

  1. Elbow Pain and Swelling

V. Exam

  1. See Trauma Evaluation
  2. See Elbow Exam
  3. Avoid evaluating elbow range of motion in known Distal Humerus Fracture
    1. Risk of neurovascular injury
  4. Perform Hand Neurovascular Exam
    1. Radial Nerve Injury at the Elbow is most common associated neurologic injury

VI. Imaging

  1. Precautions
    1. Consider other XRays above and below the Fracture based on exam and mechanism
  2. Elbow XRay
    1. Obtain Anteroposterior (AP) and Lateral Views
    2. Consider traction view
      1. Evaluates for intraarticular Fracture by reducing overlapping bone
  3. Elbow CT
    1. Indicated to prepare for open reduction and internal fixation (ORIF)

VII. Grading: AO/OTA Classification

  1. Extraarticular Fracture (A)
    1. Avulsion Fracture (A1)
      1. Lateral Epicondyle (A1.1)
      2. Medial Epicondule (A1.2)
    2. Simple Fracture (A2)
      1. Spiral Fracture (A2.1)
      2. Oblique Fracture (A2.2)
      3. Transverse Fracture (A2.3)
    3. Wedge Fracture or Multifragmentary Fracture (A3)
      1. Intact Wedge Fracture (A3.1)
      2. Fragmentary Wedge Fracture (A3.2)
      3. MultiFragmentary Fracture (A3.3)
  2. Partial Articular (B)
    1. Lateral Sagittal Fracture (B1)
      1. Simple Transtrochlear Fracture (B1.1)
      2. Capitellar Fracture (B1.2)
        1. Transcapitellar Fracture (B1.2q)
        2. Between capitellum and trochlea (B1.2r)
      3. Fragmentary Transtrochlear Fracture (B1.3)
    2. Medial Sagittal Fracture (B2)
      1. Simple Trochlear Groove Fracture (B2.1)
      2. Simple Medial Trochlear Ridge Fracture (B2.2)
      3. Fragmentary Transtrochlear Fracture (B2.3)
    3. Frontal or Coronal Fracture (B3)
  3. Complete Articular (C)
    1. Simple Articular Fracture and Simple Metaphyseal Fracture (C1)
    2. Simple Articular Fracture and Fragmentary Metaphyseal Fracture (C2)
    3. Multifragmentary Articular Fracture (C3)

VIII. Management

  1. Closed reduction as indicated
    1. Perform under Procedural Sedation, Regional Anesthesia or Hematoma Block
    2. Reevaluate neurovascular exam and imaging after any Fracture reduction or manipulation
  2. Immobilization
    1. Posterior Long Arm Splint
    2. Elbow flexed to 90 degrees
    3. Forearm in neutral position
  3. Emergent Orthopedic Consultation Indications
    1. Neurovascular compromise (e.g. Radial Nerve injury at elbow, brachial artery injury)
    2. Acute Compartment Syndrome
    3. Open Fracture
  4. Orthopedic Close Interval Follow-up (within 3-5 days)
    1. Most cases require surgical management
    2. Open Reduction with Internal Fixation with contoured locking plates (most common)
      1. Typically offers excellent functional outcomes
    3. Total Elbow Arthroplasty or Hemiarthroplasty Indications
      1. Bicolumnar Fracture in the elderly
      2. Significant articular involvement (e.g. C3 Fracture)
      3. Severely comminuted elbow Fractures

IX. Complications

  1. Compartment Syndrome
  2. Radial Nerve Injury at the Elbow
  3. Brachial Artery Injury
  4. Open Fracture

X. Resources

  1. Distal Humerus Fractures (AO Surgery Reference)
    1. https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/distal-humerus
  2. Distal Humerus Fractures (Radiopaedia)
    1. https://radiopaedia.org/articles/aoota-classification-of-distal-humeral-fractures?lang=us

XI. References

  1. Briones and Huang (2021) Crit Dec Emerg Med 35(7): 12-3

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