Fractures of the distal humerus (Elbow) result from a fall on the elbow with the arm in a flexed position. There are two main groups: Those that involve the joint surface (intra-articular fractures) and those that do not involve the joint surface (extra-articular fractures). In addition, the treatment of these fractures in children is different than treatment in adults. In most cases these fractures are unstable and require some type of internal fixation to prevent them from healing in a bad position.
Supra-condylar humerus fractures are common in children and classically occur from falling off the monkey bars. Unlike fractures in adults, these are usually a hyper-extension injury. There is usually an obvious deformity of the arm with rapid swelling. Treatment involves aligning the bones under x-ray (Fluoroscopy) and holding them in place with pins placed through the skin (percutaneous) into the bone. In rare instances, an incision is necessary to visualize the fracture. Most children stay overnight in the hospital and are discharged the next day. The pins are generally removed in clinic after 4 weeks and the cast discontinued altogether after about 6 weeks. Although children tend to have quite a bit of anxiety about having the pins removed, it is essentially painless and does not warrant the risk of additional anesthesia.
Distal humerus fractures in adults usually warrant surgical repair. A small percentage of these fractures can be treated in a long arm cast. However, prolonged elbow immobilization leads to significant and lasting stiffness in the joint. These fractures typically involve the surface of the joint (cartilage). Typically the surface of the joint is smooth allowing the bones to glide past one another with very little friction. If the surface is incongruent because the bones are not aligned, chronic damage to the joint occurs, ultimately leading to arthritis. It is very important to ensure that the surface of the cartilage is repaired as accurately as possible. Surgery is warranted with the joint surface has 2mm of displacement or more.
Surgery involves re-aligning the fracture and holding the repair with plates and screws. The surgery takes approximately 2 hours and most patients stay overnight in the hospital. The most common complications of the surgery are infection (about 2%), stiffness (10%) and nerve injury called neuropraxia (about 2-3%). Neuropraxia is a condition in which the nerve ((ulnar nerve))that runs along the back part of the elbow (funny bone) is irritated and does not work properly after surgery. In most cases this is temporary but can take several months to resolve. After surgical repair, patients are able to begin moving their arm within 2 weeks of the surgery and the risk of long term stiffness is reduced.
Post-operatively, patients wear a splint (soft cast) for a short period of time and then begin a fairly aggressive protocol with physical therapy to regain range of motion in the elbow. Total recovery time can take 6 months and most patients have very good range of motion and strength after the bone heals. The most common long term complications are joint stiffness, heterotopic bone formation and painful retained hardware or pain over the plates. Even with aggressive rehabilitation, most patients have some loss of motion in the involved elbow that is most noticable in extension (straightening the elbow). A dynamic elbow splint applies gentle force to straighten or bend the elbow and patients can adjust the degree and amount of force to their own tolerance. Most insurance plans will allow for a 3 month lease of the splints. For more information about Dynasplints, click on the link below.
In some cases this stiffness can be severe and is caused by ectopic bone formation (bone forming in places where it usually does not occur) along the front capsule of the elbow joint. This is most common with severe injuries or in patients with concomitant closed head injury. In some cases removal of the ectopic bone is necessary but not until 6-8 months after the injury.
Waiting lessens the chances of recurrence. In many instances the plates cause irritation as they sit directly under the skin and next to the nerve that supplies sensation to the ring finger and index finger. The surgery to remove the plates is far less involved than the initial fracture repair and most patients fully recover from the hardware removal in about 4-6 weeks. Plate removal is usually offered around 12 months after the initial surgery.
Elbow Flexion (bending) and Extension (straightening)
This instruction sheet answers a number of questions about what to expect after surgery on your elbow including suggestions about medications, what to do if your splint gets wet and exercises you can begin in the first week after surgery.