Fracture Elbow

Fraktur Distal Humeri

The majority of distal humerus fractures occur in one of two ways, low energy falls or high
energy trauma. The most common cause is a simple fall in the forward direction. The history should
determine the mechanism of injury, the energy level, and the time since injury. In patients with high
energy injuries, vigilance is required in identifying systemic injures and associated fractures. The pain
from polytrauma and other concurrent issues such as inebriation and drug uses may make
identification of all injuries difficult.

Elderly patients, who comprise the majority of patients with distal humerus fractures, should be
evaluated for the precipitants of the characteristic fall as they may have undiagnosed cardiac
arrhythmias, cerebrovascular disease, polypharmacy, or alcohol dependence. Special attention is
directed toward identifying comorbidities and reversible illnesses that may impact upon the
treatment recommendations and perioperative risk. Mental status, the ability to cooperate with
rehabilitation, ambulatory status, and the requirement of walking aides should be assessed.

Standard anteroposterior and lateral radiographs of the elbow are usually sufficient for
diagnosis, classification, and surgical templating. However, initial radiographs obtained in plaster or
a splint may obscure the fracture pattern and should be repeated.

Clasiffication using OA

 Type A – extra-articular supracondylar fracture

 Type B – intra-articular unicondylar fracture (one condyle sheared off)
 Type C – bicondylar fracture with varying degree of comminution
Nonoperative Treatment of Distal Humerus Fractures (Extra-Articular and Complete Articular
Fractures)

Nonoperative management of distal humerus fractures in young patients is rarely

recommended and it is generally reserved for patients deemed medically unfit to undergo surgery.
Patients with nondisplaced fractures may also be managed with a trial of nonoperative
management. These patients should be followed for the first 3 to 4 weeks with weekly serial
radiographs to ensure displacement or angulation does not occur. Other circumstances are elderly
patients with unrepairable distal humerus fractures where arthroplasty is the most reasonable
option; however, it is contraindicated because of soft tissue compromise, such as skin loss
Nonoperative management techniques include above-elbow casting, olecranon traction, and
collar and cuff treatment, the so called “bag of bones” method. The traction method involves the
placement of a transolecranon traction pin that is attached to weights through a pulley system.103
Traction is applied for 3 to 4 weeks, until there is sufficient early callous to allow cast bracing. The
major disadvantages of this method are the complications associated with prolonged bed rest.
Patients who are typically treated nonoperatively, the frail elderly, have significant medical
comorbidities that put them at high risk of bed rest-related complications, such as deep venous
thrombosis, pulmonary embolism, and decubitus ulcers. The technique is largely of historical
significance and has little use in modern distal humerus fracture care
Collar and cuff treatment had been used for centuries before it was first reported in modern medical
literature in 1937 by Eastwood. He described a closed reduction followed by application of a collar
and cuff with the elbow between 90 and 120 degrees of flexion. The elbow is hung freely to allow
gravity-assisted reduction via a ligamentotaxis-type effect. Shoulder motion and active elbow flexion
are initiated at 2 weeks and progressed

Operative Treatment

Distal humerus fractures are generally complex injuries with associated fragmentation, bony
instability, osteopenia, and soft tissue injury. The risk of functional impairment is relatively high
when these injuries are managed nonoperatively. Contemporary literature would support improved
patient outcomes and lower complication rates when these injuries are managed with surgery. ORIF
of these injuries is considered gold standard. However, ORIF may not be attainable in elderly
patients with osteopenia, comminution, and articular fragmentation or in patients with pre-existing
conditions of the elbow such as rheumatoid arthritis (RA). In such cases where rigid internal fixation
cannot be achieved to allow early range of motion, elbow arthroplasty has been shown to be a
reliable treatment option with good patient outcomes.
 Surgical fixation of distal humerus fractures requires preoperative planning, specialized
implants, instruments, and surgical expertise. Medically fit and stabilized patients with
noncompromised soft tissues may be best managed with early surgery within 48 to 72 hours. Early
surgery may lead to decreased complications such as HO and stiffness. Polytrauma patients who are
unstable or those with identified modifiable risk factors should be medically optimized preoperativel
Fracture Radial Head
Radial head fractures are the most common fractures of the elbow with an estimated
incidence of 2.5 to 2.9 per 10,000 people per year. Most radial head fractures occur as the result of
low-energy mechanisms such as a trip and fall on an outstretched hand. Sporting activities as well as
motor vehicle collisions cause higher energy fractures typically with greater displacement and a
higher incidence of concomitant injuries. Mechanisms of fracture vary but include three common
patterns:

1. A valgus load causes impaction of the radial head into the capitellum, commonly with rupture of
the MCL.
2. Posterolateral rotatory subluxation of the radial head with respect to the capitellum causes a
partial articular shear fracture of the anterior portion of the radial head often with rupture of
the LCL.
3. An axial forearm load causes impaction of the radial head into the capitellum with more severe
trauma producing a fracture of the coronoid or rupture of the interosseous membrane and distal
radioulnar joint ligaments; the so-called Essex–Lopresti injury

Nonoperative Treatment of Radial Head Fractures

Patients with undisplaced or minimally displaced radial head fractures without a block to forearm
rotation should be treated nonsurgically. Radial head fractures treated nonoperatively are
immobilized for 2 or 3 days for comfort and then active motion is encouraged with the use of a sling
or collar and cuff between exercises.
Operative Treatment of Radial Head Fractures

those who have concomitant injuries which require surgical intervention such as unstable
fracture-dislocations, or those with retained intra-articular loose bodies are best treated surgically.
Treatment options include radial head fragment excision, radial head excision, open reduction and
internal fixation, and radial head arthroplasty.

CORONOID FRACTURES
Isolated fractures of the coronoid are uncommon with the majority having associated
fractures of the radial head or proximal ulna, collateral ligament injuries, or concomitant
dislocations. Classification using d bristol
 Terrible triad injuries consist of a fracture of the radial head and coronoid and an elbow
dislocation. These injuries may be challenging to treat and suboptimal clinical outcomes have been
commonly described in the past. Terrible triad injuries are thought to occur by posterolateral
rotatory displacement of the ulna, resulting in elbow subluxation or dislocation. A detailed
neurovascular examination must be performed before and after reduction of a dislocated elbow.
Soft tissue status and the condition of the skin should be carefully assessed.

Nonoperative Treatment of Terrible Triad Injuries

Terrible triad injuries of the elbow are usually treated surgically due to residual instability
precluding a congruous reduction and early motion. If the radial head and coronoid fractures are
small and the elbow is congruously reduced following a closed reduction, nonoperative treatment
should be considered. A closed manipulative reduction of the elbow is usually performed in the
emergency room or the operating room.

Operative Treatment of Terrible Triad Injuries

The majority of patients with terrible triad injuries require surgical management to achieve a
stable congruous reduction of the elbow allowing early motion. Residual subluxation of the elbow
following a closed reduction or residual instability precluding early motion is an indication for
surgery. Displaced radial head fractures blocking motion or incarcerated fracture fragments in the
articulation are also indications for surgery
PROXIMAL ULNA FRACTURES

Mechanisms of Injury for Posterior Ulna Fractures Proximal ulna fractures may result from
either direct or indirect elbow trauma. Olecranon fractures typically result from a direct blow to the
olecranon. More complex fracturedislocation patterns may be the result of a more indirect
injury such as a fall onto the outstretched hand. Transolecranon fracture-dislocations are typically
the result of higher energy trauma such as a fall from a height, assaults, or motor vehicle collisions.
Although posterior Monteggia lesions may also result from high-energy trauma, they are typically
lower energy injuries that occur in more osteopenic bone and result from a ground-level fall.
Although typically isolated upper extremity injuries, 20% of proximal ulna fractures are
associated with polytrauma, and a complete examination of the patient for systemic injuries is
important. The affected extremity should be evaluated for shoulder, forearm, wrist, or hand injuries.
The arm should be examined for open wounds and abrasions that typically occur over the dorsal
surface of the proximal ulna. There is typically swelling about the elbow with fluid accumulation in
the olecranon bursa.
Anteroposterior, lateral, and radiocapitellar radiographs of the elbow are performed. In the
case of a fracture-dislocation, radiographs should be performed after a closed reduction in order to
better delineate the fracture components. A traction view is useful in these cases, especially if the
elbow is unstable after closed reduction. Ct scan can be useful, but it is rarely needed.

The elbow may have obvious deformity in the case of a fracture-dislocation. Examination of
distal neurologic status with close attention to ulnar, median, and posterior interosseous nerve
function is performed. Evaluation of vascular status and forearm compartments is necessary
Classification of Proximal Ulna Fractures
Olecranon Fractures

The Mayo classification divides olecranon fractures into three groups based on fracture
displacement and elbow stability. This classification helps direct treatment with Type I generally
being amenable to nonoperative management while Type II and III fractures generally require
operative treatment

Olecranon Fracture-Dislocations

Anterior fracture-dislocations of the olecranon have been termed “transolecranon fracture-

dislocations”.These fractures are also represented by the Mayo Type III classification. An important
feature of these injuries is that the proximal radioulnar joint is relatively preserved.

Posterior fracture-dislocations are typically posterior Monteggia lesion. These fractures

encompass a unique set of injuries including posterior angulation of the proximal ulna, a radial head
fracture, a coronoid fracture, and collateral ligament injuries. When this pattern is recognized,
careful evaluation of radiographs should be carried out to define associated injuries. Traction films,
fluoroscopy, and/or CT scanning are often useful. The coronoid fracture pattern is variable and may
include a large anterior fragment, a small tip fragment, or both.

Mayo classification for olecranon fracture

PROXIMAL ULNA FRACTURE TREATMENT OPTIONS

Nonoperative Treatment of Proximal Ulna Fracture

Since these injuries involve an articular surface, the majority of proximal ulna fractures are
treated operatively. However, a nondisplaced fracture or a minimally displaced fracture that remains
reduced with the elbow flexed may be treated nonoperatively. Patients with significant medical
comorbidities that are poor surgical candidates may be treated nonoperatively even with displaced
fractures as long as there is no skin compromise or elbow instability.
 the elbow is splinted for 2 to 3 weeks and then gentle active-assisted flexion is started
avoiding active extension against gravity or resistance for the first 6 weeks after injury. At 6 weeks,
the patient can begin active motion against gravity with resistive exercises started at 3 month.

Operative Treatment of Proximal Ulna Fractures

The majority of proximal ulna fractures are treated surgically. Most fractures with
displacement and those associated with dislocations or elbow instability as well as open fractures
should be managed operatively. Simple olecranon fractures without comminution or instability may
be managed with tension-band wiring, plating, or an intramedullary rod. Comminuted fractures or
those associated with elbow instability should be managed with plate fixation. In osteoporotic bone
with significant comminution that precludes stable internal fixation, excision with triceps
advancement may be used if the excised fragment comprises less than 75% of the olecranon, but
this technique should be reserved for elderly, low-demand patients if possible.
Daftar Pustaka
1. Court-Brown CM, Aitken SA, Forward D, O'Toole III RV. The Epidemiology of Fractures. In:
Bucholz RW, Court-Brown CM, Heckman JD, Tornetta III P. Rockwood and Green's Fractures
in Adults. 7th edition. Philadelphia: Lippincott Williams & Wilkins; 2010.
2. Egol KA, Koval KJ, Zuckerman JD. Handbook of Fractures. Fifth Ed. New York: Wolters Kluwer;
2015
3. Apley, G.A and Solomon, L. Apley’s System of Orthopaedics and Fractures. 9th ed. London:
Hodder Arnold. 2010