Elbow: Supracondylar humerus fractures in adults

Supracondylar fractures in adults are usually intraarticular, in other words the elbow joint is directly involved.

Unless the fracture is not displaced, virtually all intraarticular distal humerus fractures need surgery for a better outcome.

Goals of the surgical treament are as follows:

  1. Reduction, in other words restoration of normal alignment of the elbow joint.
  2. Stable fixation, to allow early motion of the elbow. Fixation must be good enough to allow early motion of the elbow.
  3. Early motion is necessary to prevent stiffness of the elbow. The elbow joint can get stiff easily. Fixation must be stable enough to allow early motion and physical therapy. It is especially important to obtain full flexion at the end of the treatment. Whereas some loss of extension is well tolerated, loss of flexion interferes with the ability to bring one's hand close to the face and is not well tolerated.

How is this surgery done?

In the operating room, after anesthesia is given, the patient is turned on the side, with the injured arm pointing to the ceiling. The incision required is large, in the back of the elbow. In order to be able to see the distal humerus fracture, a transolecranon osteotomy is performed. In other words, an additional break is created in the ulna bone just so that the humerus fracture can be seen.

Once the broken fragments become visible, they are realigned and fixed with temporary wires, clamps, etc. Plates are placed and the whole construct is checked with fluoroscopy xrays. Before closing, the ulna osteotomy must be repaired.

What are the risks of this surgery?

  1. Infection is always a possibility with surgical treatment.
  2. Stiffness is always a risk with elbow fractures.
  3. Posttraumatic arthritis is always a possibility with intraarticular fractures
  4. Delayed union, nonunion, failure of fixation are possible as well.
  5. Nerve injury is possible, as with any other surgery.
  6. Heterotopic ossification is something specific to these fractures and can also result in a stiff elbow.

Glossary

The word comminuted implies fragmentation of the bone into multiple small pieces. In intraarticular fractures, the joint is involved directly by the fracture. Intraarticular fractures have an increased risk of arthritis.
An osteotomy implies surgical cutting of a bone with a saw and chisels. During a transolecranon osteotomy, the part of the ulna that covers the distal humerus is separated in order to allow visualization and handling of the broken distal humerus.

Case study #1: An open highly comminuted distal humerus fracture

This is the very difficult case of a man who sustained an open distal humerus fracture after being hit by a car. He presented with a type 2 open fracture, with heavy contamination with sand and asphalt.

Initial treatment consisted in removing the sand and the mud from the wound and from the bone ends, followed by placement of an external fixator. Parts of the bone that were black with dirt were removed, parts were chiseled until clean.

In the following xrays you can see the external fixator pins in the bone, and the shadows of the carbon-fiber bars connecting them. You may also be able to appreciate the proximal extension of this fracture, which extends to the middle third of the humerus.

A week later, after a series of irrigations, I determined that the wound was clean, without signs of infection. Definitive fixation with plate and screws was performed. Extensile posterior approach to the elbow with transposition of ulnar nerve, transolecranon osteotomy, and meticulous reduction of the articular fragments was performed. Condyles were fixed to each other, and the articular block was treated as a single piece for the rest of the surgery: the metaphyseal comminution was bridge-plaed to the shaft.

In the picture on the left, the fragments are temporarily held together with thin metallic K-wires. In the middle picture, the fracture has been stabilized with definitive plates and screws, the olecranon process is grasped with a towel clip and is about to be reattached to its normal place. In the picture on the right, the olecranon has been reattached with pins and wires, the triceps has been sewn in place, and closure of the skin will complete the operation.

During the surgery, both the radial and the ulnar nerves were identified and protected. The lateral plate was placed under the radial nerve. Utmost respect is given to the soft tissues, and no stripping is performed unless absolutely necessary for the plate placement. This prolongs the surgery, but decreases the chances of bone necrosis and the chances of heterotopic ossification.

Physical therapy with active assisted range of motion was started immediately. A splint was not used, and can be counterproductive. Full motion was allowed and encouraged.

This is the appearance at 1 year.

Infection free, with excellent range of motion.

Case #2: Another case of an open distal humerus intraarticular fracture, with less comminution

This is the case of a snowboarder, very similar to the case described above, yet with a few differences.

  1. Younger patient. The articular surface was split in 2 large pieces (as opposed to 5 in the case above).
  2. Less comminution.
  3. I fixed the olecranon osteotomy with a plate, not with wires.

The young man did undergo serial irrigations, temporary stabilization with an external fixator, followed by definitive surgery with plate and screw fixation.

Here are pictures taken during surgery. In the left picture, note the 2 articular fragments. The triceps and the olecranon have been osteotomized. IN the picture on the right, the fracture of the humerus has been fixed. Note part of the plate. The rest of the surgery consisted of olecranon repair and wound closure.

Stable anatomic fixation was possible, followed by immediate physical therapy.

Full motion, without any limitation was gained in the end.