Distal humerus Fracture Discussion

Distal humeral fractures in adults may be described by a variety of classification systems. From a prognostic point of view, they fall into four general groups: supracondylar - extraarticular, transcondylar - intraarticular, unicondylar - intraarticular, and bicondylar - intraarticular. Fractures of the distal humerus have been classified by the ASIF group as follows:

A Supracondylar - Extraarticular

A1 Epicondylar Avulsion Fracture

A2 Simple Metaphyseal Fracture

A3 Comminuted Metaphyseal Fracture

B Unicondylar

B1 Sagittal Plane: Lateral condylar, including capitellum

B2 Sagittal Plane: Medial condylar, including trochlea

B3 Frontal Plane

B3.1 Capitellum

B3.2 Medial Condylar - capitellum

C Transcondylar: Bicondylar or Intercondylar

C1 Simple articular, Simple Metaphyseal

C2 Simple articular, Comminuted Metaphyseal

C3 Comminuted Articular

Management of these fractures depends on the global picture as well as the specific fracture pattern. Although the exact choice of treatment is controversial, open reduction and internal fixation is indicated for most intraarticular, unstable or severely comminuted fractures, when possible. Roughly three quarters of patients requiring open reduction for intraarticular fractures have a satisfactory outcome. Typical standards for an acceptable result are at least a 75 degree arc of flexion / extension, only slight pain, and an ability to perform the activities of daily living. The main problem associated with all of these injuries is permanent loss of range of flexion and extension of the elbow. Normal use of the elbow requires an average arc of elbow motion of 100 degrees, from 30 to 130 degrees. Other problems include pain, instability, avascular necrosis, nonunion, visible deformity, weakness and loss of pronation and supination of the forearm. By six years after injury, the majority of patients with intraarticular distal humeral fractures demonstrate radiographic evidence of posttraumatic arthritis. This is even more common following fracture-dislocations. Results following secondary surgery are also frequently disappointing: only one third of patients have a surgery for distal humeral nonunion can be expected to have a satisfactory functional result. Patients' assessment and satisfaction with the final result is difficult to predict, and frequently does not correlate with objective clinical evaluation. Clinical evaluation and patient satisfaction do not correlate well with radiographic findings. Because of this, disability may not be reflected accurately by an impairment rating evaluation. Following injury, many patients are unable to return to their prior occupation and experience long term difficulties with sports and activities of daily living.

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