Distal Humerus Fractures
What is the distal humerus?
The humerus is the arm bone between your elbow and the shoulder. The distal aspect of the humerus is the lower end of this bone, towards the elbow. The distal humerus, along with the radius and ulna bones of the forearm, are the three bones that make up the elbow joint. Distal humerus fractures are usually caused by a fall onto an outstretched hand or direct fall onto the elbow.
The distal humerus can fracture in multiple locations. Some fractures, such as comminuted fractures (bone breaks into many pieces), are worse and more difficult to treat than others. Open fractures (bone piercing the skin) can also occur and are considered to be very serious given their increased risk of infection. Distal humerus fractures can also be one component of a more complicated elbow injury.
Patients typically present with elbow swelling, bruising, tenderness, and stiffness. Elbow instability (i.e. feeling the joint will dislocate) is also common. In the case of an open fracture, there will be an open wound possibly with the bone sticking out. Range of motion can also be very limited.
There are several large nerves and blood vessels that run close to the distal humerus bone. These nerves and vessels can sometimes be injured following a severe distal humerus fracture. It is therefore very important that you seek medical care IMMEDIATELY should you experience any numbness, tingling, loss of arm/hand function, or coldness of the skin after fracture.
Although rare, compartment syndrome can also develop after a distal humerus fracture. A distal humerus fracture can lead to significant swelling and increases in pressure within the compartments containing muscles, blood vessels, and nerves. This pressure can become so high that it can compress the nerves and blood vessels. Compartment syndrome is considered a SURGICAL EMERGENCY. It is therefore extremely important that you seek medical attention IMMEDIATELY if you experience any of the symptoms of compartment syndrome.
X-rays are usually ordered to further evaluate the fracture pattern. A CT may be ordered if a more detailed view of the fracture is required.
Treatment of distal humerus fractures depends on a variety of factors. A few of the most important factors include the age of the patient, location of the fracture, displacement of the fracture, presence of neurovascular injury, and presence of any additional injuries to the elbow.
Nonoperative management is usually only recommended for completely nondisplaced fractures, or patients who are unable to tolerate surgery. These patients are normally casted for approximately 6 weeks and then instructed to start physical therapy to regain back motion and strength. The elbow joint notoriously stiffens following prolonged periods of immobilization. Physical therapy is therefore a very important component of the rehabilitation process.
Surgical management is usually recommended for displaced fractures and for open or unstable appearing fractures upon presentation. Open fractures are usually taken to the operating room urgently given their increased risk of infection. Patients are usually given antibiotics and the wound/fracture site is thoroughly washed out prior to reducing the fracture to its anatomic position. Fractures are reduced and then fixed in an anatomic position using a variety of methods. Most commonly, the fracture is secured using a combination of plates and screws. Severe fractures in elderly patients sometimes require a total elbow replacement.
Dr. Steven Lee is the Chief of Hand and Upper Extremity at Lenox Hill Hospital, and as such is referred frequently the most challenging and complex cases related to forearm trauma. He is also one of the few orthopedic surgeons in NYC who is comfortable performing total elbow replacements. Learn about scheduling surgery.
Postoperative patients are usually placed into an above elbow splint following surgery. This splint is usually removed one week following surgery and the patient is usually transitioned into an above elbow cast. Patients may wear this cast for 3-5 weeks, depending on the stability of the fracture. Therapy is usually started 4-6 weeks after surgery and can last several months. Patients usually return to normal activities 3-4 months following surgery. Continued subtle improvement can occur for up to a year.
As previously discussed, the elbow joint becomes extremely stiff because of three separate causative reasons. First, the trauma itself causes stiffness. Second, surgery is a form of trauma and also causes stiffness. Finally, immobilization for a prolonged period of time in itself causes stiffness. Strict adherence to physical therapy is therefore extremely important towards regaining back as much range of motion and function as possible. A second surgery to remove scar tissue and other adhesions is sometimes necessary to help regain back additional range of motion. Even when successfully treated, some residual stiffness of the elbow is common.
It is also important to note that arthritis after a surgically corrected distal humerus fracture, even if the surgery goes perfectly, is common. This arthritis, however, would have likely been much more severe and affected the patient at a much earlier age had they not undergone surgical fixation. There may be the need for a total elbow replacement later sore on the top and action due to this arthritis.
Patients can also suffer from something known as heterotopic ossification. Heterotopic ossification is when bone grows into the soft tissues surrounding the fracture site. This is the result of the body laying down a significant amount of new bone in an effort to heal the fracture. This bone growth into the soft tissues can sometimes inhibit movement, requiring an additional surgery to remove this bone and improve range of motion.
Immediate Post-Operative Instructions
Please refer to the following pages for more information:
*It is important to note that all of the information above is not specific to anyone and is subject to change based on many different factors including but not limited to individual patient, diagnosis, and treatment specific variables. It is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopedic advice or assistance should consult Dr. Steven Lee or an orthopedic specialist of your choice.
*Dr. Steven Lee is a board certified orthopedic surgeon and is double fellowship trained in the areas of Hand and Upper Extremity Surgery, and Sports Medicine. He has offices in New York City, Scarsdale, and Westbury Long Island.