Crouching tiger hidden fracture -

When Xray just ain't enough

(Comminuted intra-articular fracture
distal end humerus)
Goh. B.H.

Department of Orthopaedics and Traumatology

University Malaya Medical Centre
Jalan Lembah Pantai, 59100
Kuala Lumpur

Introduction

A distal humerus fracture is a break in the lower end of the upper arm bone (humerus), one of
the three bones that come together to form the elbow joint. A fracture in this area can be very
painful and make elbow motion difficult or impossible. Most distal humerus fractures are
caused by some type of high-energy event, such as receiving a direct blow to the elbow
during a car collision. In an older person who has weaker bones, however, even a minor fall
may be enough to cause a fracture. Treatment for a distal humerus fracture usually involves
surgery to restore the normal anatomy and motion of the elbow.

The elbow is a synovial joint made up of three articulations

• Ulna-humeral joint: hinge joint
• Radio-capitellar: pivot joint
• Proximal radio-ulnar: gliding joint
The elbow joint bends and straightens like a hinge. It is also important for rotation of the
forearm; that is, the ability to turn your hand palm up (like accepting a gift from a friend) or
palm down (like typing or playing the piano).

It is important that the congruity of the joint be maintained for its full functional purpose of
flexion and extension

Case

We had this patient coming to us, a healthy active 24 years old chinese lady presented post
fall over the right elbow. The patient allegedly had a sports related injury when she fell during
ice skating. She fell backwards and landed directly elbow first, direct impact -broke her fall
with a flexed right elbow.

On examination, her right elbow was swollen, no open wound, mild abrasions. It was tender
on palpation but the range of motion was limited due to pain. The radius and ulna were
palpable with no neurological deficit.

Xray of the elbow was then taken with the position patient was most comfortable with. Xrays
shows a complete displaced fracture of the medial epicondyle - displaced.
The patient was having gross swelling with effusion, and range of motion was very much
reduced. A CT scan of the elbow was done - to look for extended fracture and fracture
configuration. CT scan is as follows:
Diagnosis: Comminuted fracture of distal end humerus (capitulum & trochlea) - intrarticular
without neurovascular compromise.

Patient then under went an elective surgical intervention for screw fixation of the right elbow.

Discussion

The decision to offer operative intervention for distal humerus fractures required
consideration of multiple factors: including fracture type, intra-articular involvement,
fragment displacement, bone quality, joint stability, and soft-tissue quality and coverage.
Hence it is important that the surgeon look into these factors before planning for operation.
However, if there is inadequate imaging during pre-operative planning: important stand points
can be missed, especially failure of understanding the fracture configuration for fixation. In
addition, individual factors, such as patient age, overall health condition, functional extremity
demands, and patient compliance, are all considered. Preoperatively, patients must also
understand the outcome expectations and the importance of rehabilitation post operatively

Conditions in which operative intervention is supported include the following:

 Intra-articular fragment displacement

 Physeal displacement
 Supracondylar comminution and displacement
 Open fractures
 Floating elbow patterns
 Neurovascular injury
 Compartment syndrome
 Multiple traumatic injuries

Main objectives for operative intervention are to restore articular congruity and elbow
stability. Another goal is to decrease the possibility of post-traumatic arthritis and elbow
stiffness.

Contraindications to operative intervention for distal humerus fractures are patient-specific.

Examples:

 Age
 Overall health condition
 Functional demands and expectations
 Overlying soft-tissue quality and bone quality

Finally, the surgeon must be able to make an honest evaluation of his or her ability to
successfully perform open reduction and internal fixation (ORIF) of the fracture pattern.
Hence knowing the fracture configuration is important.

Additional

Although distal humerus fractures remain a challenging reconstructive problem for orthopedic
surgeons, future technology may hold many solutions. With the advent of newer, stronger
biocompatible materials, diverse hardware options allow improved reduction and fixation of
distal humerus fractures. Lower-profile plates and smaller screws allow the surgeon to
maintain the original articular congruity needed to prevent post traumatic arthrosis, which
allows for faster and progressive postoperative rehabilitation.

Conclusion

Knowingly, fracture configuration must be ascertained, prior to operative intervention

decision. What's the option of a blanket rule that all articular fracture requires CT scan before
admission to ward for operative planning. At our national and patient settings, cost and
financial constrain is a huge barrier. Yet when the CT request does play a huge role in
management outcome. Should there be criteria for the CT request on patient to patient basis
or should a blanket rule of all articular fractures proceeding with a CT scan.

Literature review

There is study extracted from the PMC US National Library of Medicine - National Institute
of health (NCBI) Int Orthop. 2006 Apr; 30(2): 110–112, Published online 2006 Feb 23. This
study looks at the role played by the CT scan in decision making in the management of intra-
articular fractures of the calcaneum. 24 patients with intra-articular fractures of the calcaneum
were included. Their initial radiographs and CT films were blinded and assessed by three
independent observers. Based on this they were selected for operative or non-operative
management. The actual management was recorded. The data were then subjected to
statistical analysis to look at the association between the decision from radiograph, that from
the CT scan and the actual management undertaken. Non-parametric tests for related samples
were performed to look at the association between the actual management and the decisions
made by assessing the radiographs and the CT scans. For all three observers, there was no
significant difference between the actual management and decisions made by assessing the
plain radiographs or the CT scan. There was also no significant difference between the
radiograph-based and the CT-based decisions. However, the Cochran Q test showed that there
was significant variation among the three observers for the CT-based assessment. The results,
show that the CT scan should only be done when a definite decision is made to operate on a
patient, based on plain radiographs. Calcaneal fractures which are selected for non-operative
management, based on X rays, should not have a CT scan as a routine as it provides no
valuable additional information affecting the management decision.

They then conclude that a CT scan should be requested only when a decision has been made
to operate on the fracture, based on plain radiographs. This may help to delineate the
fragments in a comminuted fracture and may assist the pre-operative planning of fracture
fixation. A CT scan does not have to be obtained as a routine to assess all intra-articular
fractures of the calcaneum.

Reference

http://orthoinfo.aaos.org/topic.cfm?topic=A00513

Netters concised Orthopaedics Anatomy; Jon C Thompson - second edition (2010)

http://emedicine.medscape.com/article/1239515-treatment

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2532078/

Int Orthop. 2006 Apr; 30(2): 110–112.

Published online 2006 Feb 23. doi:  10.1007/s00264-005-0044-0 PMCID: PMC2532078