Humerus fracture
From Medical-Wiki
Fractures of the distal humerus are the most complicated of all humerus fractures. A distal fracture can impair elbow function. At one time, these fractures were almost all treated through closed reduction—the so called “bag-of-bones” method. The goal of modern day open reduction is restoration of normal anatomy.
The primary reason that distal fractures present a problem is that the distal humerus ends in a supracondylar isthmus that is quite narrow and thus has a paucity of subchondral metaphyseal supporting bone. This means that there can be a "spill over effect,” and any failure of restoration of one joint can cause abnormal wear and tear on adjacent joints.
Fortunately, these fractures are relatively uncommon. They are estimated to make up about 4% of all fractures. The typical etiology for the fractures is a high-energy injury. However, in the pediatric population, particularly in boys aged 5 to 10 years-of-age, 80% of all elbow fractures occur in the supracondylar region.
When taking a history from a patient with a distal humerus fracture, it is important to gain an understanding of the nature of the event that caused the injury. If the patient is elderly and fell, the reasons for the fall and any history of other falls is important relative to the patient’s overall level of function. If the event was a fall from height or an automobile accident, the speed of the automobile or the distance that the patient fell is an indicator of the likelihood of other general trauma. Also, it is important to obtain some understanding of the condition of the injured extremity prior to the injury, i.e. if the elbow already arthritic or if there were any neurologic abnormalities.
The patient should initially be examined with attention to the presence of any other life -threatening injuries. When these have been ruled out, the injured extremity should first be examined for neurovascular integrity. This should be documented and an ongoing documentation should be established. This should include an assessment of the sensory and muscular contributions of the median, ulnar, and radial nerves, as well as the medial and lateral antebrachial cutaneous nerves. Distal pulses should be checked as well as capillary refilling. Duplex Doppler studies or angiography may be used in the case of equivocal findings.
Because in high-energy injuries open wounds often extend into the joint, wounds should be closely inspected. They should be treated with antibiotics and tetanus prophylaxis. The wound should be protected with a loose dressing of povidone-iodine. The elbow should be placed in slight flexion in a well-padded and molded splint. This will offer some pain relief until definitive treatment can be completed. The arm should be re-evaluated for neurovascular integrity on a regular basis. This should include attention to any signs of a compartment syndrome. [1]
When considering treatment options, it is now reasonably well established that open reduction and internal fixation of complex distal humeral fractures will result in favorable results in the majority of patients. However, a satisfactory outcome requires restoration of the structural integrity of the distal humerus, rigid stabilization of the fracture, and an early range of motion program. When these are achieved, excellent results can be expected in up to 75% of patients. An absence of any of the factors greatly increases the chances of a loss in elbow function. [2]
A full, standard elbow series should suffice to define the nature of the fracture. Sometimes a CT scan is of further assistance if there is a question about the involvement of certain structures. Followup films are obviously necessary to establish that proper anatomic relationships have been established. [3]
