A distal humerus fracture is a break in the lower end of the humerus, the upper arm bone of the three bones that comprise the elbow joint. The bone can crack slightly or break into many fragments. Broken bone pieces also referred to as a comminuted fracture can line up straight or be far out of place. In some cases, the bone fragments can stick out through the skin, or a wound penetrates down to the bone. This is called an open fracture. Open fractures need immediate attention as there is a higher risk for infection in both wound and bone.
Distal humerus fractures are uncommon accounting for about 2 percent of all adult fractures. Most distal humerus fractures are caused by high-impact situations such as a direct blow during a car accident or falling directly on the elbow. In the elderly, a minor fall may also cause a fracture. Falling on an outstretched arm to brace against the fall drives the ulna, one of the forearm ones, into the distal humerus, causing it to break. Fracturing the distal humerus of the elbow can be very painful and make movement nearly impossible.
- Feeling like your elbow is going to “pop out”
- Open fracture, when the fractured bone sticks out of the skin
A distal humerus fracture is a break in the lower end of the humerus, the upper arm bone of the three bones that comprise the elbow joint.
Most patients will need to be seen at an urgent care or emergency room. Dr. Stowell will ask you about your medical history, general health, and symptoms. He will examine your elbow to determine the extent of your injury. He will check your skin for cuts and lacerations. He will feel around your elbow to determine if there are other areas of tenderness that may indicate elbow dislocation or other injuries. Dr. Stowell will check your pulse at your wrist to ensure good blood flow to your hand and fingers and will check the sensation in your fingers and wrist to determine nerve injury. Although your pain may feel isolated in your elbow, Dr. Stowell may examine your shoulder, upper arm, forearm, wrist, and hand to rule out other injuries. To help diagnose your fracture, Dr. Stowell may order an X-ray.
When you are at the emergency room, the doctor may apply a splint (like a cast) to your elbow and give you a sling to help stabilize your arm. Applying ice will help reduce pain and swelling. Treatment for a distal humerus fracture typically requires surgery. Stable fractures where bone fragments are not out of place may be treated non-surgically. Patients who are also at high risk for surgical complications may need to be treated without surgery.
With nonsurgical treatment, Dr. Stowell will apply a splint to hold the elbow in place during healing. As it heals, Dr. Stowell will order multiple X-rays to see the progress of the bone and ensure that it has not shifted out of place. Splints are typically worn for 6 weeks before you begin any supervised movement.
In most cases, surgery is necessary to restore the anatomy and motion of the elbow. Surgery in distal humerus fractures is usually required if you have a displaced fracture or open fracture. A displaced fracture is where the bones have moved out of place. An open fracture is where pieces of bone have punctured the skin. Open fractures require surgery as soon as possible as there is an increased risk of infection. Patients usually are administered antibiotics intravenously and receive a tetanus shot. During surgery, Dr. Stowell thoroughly cleans the wound and surfaces of the broken bone and repairs the fracture; however, in some cases, open fractures require more than one surgery.
Several types of surgical procedures exist to treat distal humerus fractures including:
- External fixation – Dr. Stowell may apply an external fixator to hold the bones in place until a second surgery is scheduled. During this operation, Dr. Stowell inserts metal pins through the bones. The pins project out of the skin and attach to carbon fiber bars outside the skin. This external fixator acts as a frame to stabilize the elbow and gives damaged skin time to recover before the second surgery is scheduled to fix the fracture.
- Open reduction and internal fixation – This is the most commonly used procedure to treat distal humerus fractures. Dr. Stowell repositions the bone fragments into their normal alignment and then holds them in place with plates and screws attached to the outside of the bone.
- Total elbow replacement (arthroplasty) – In severe cases where the humerus is damaged to the point that it cannot be fixed, a total elbow replacement may be necessary. In this surgery, the broken fragments of the bone are removed and a metal and plastic implant are attached to the humerus; another metal and plastic implant is attached to the ulna, connecting to the two implants to form a hinge. Bone cement may be used to hold the implants in place. Arthroplasty will not allow patients to lift more than 5 pounds with the affected arm for the remainder of the patient’s life. Due to this restraint, this procedure is typically reserved for older patients who do not have to lift heavy objects.
- Arthrodesis (fusion) – Younger patients with a severely damaged humerus may be treated with arthrodesis as opposed to total elbow replacement. Dr. Stowell applies plates and screws to make the humerus and olecranon to fuse as one bone. Patients lose the ability to bend the elbow after this surgery, but will maintain the ability to rotate the hand and regain a strong elbow joint.
During certain surgical procedures, Dr. Stowell may have specific considerations depending on the fracture including:
- Ulnar nerve placement – In most cases, Dr. Stowell may need to gently move the ulnar nerve to to prevent it from being injured during surgery. He would then put it back in place at the end of surgery.
- Bone grafting – If some of your bone has been lost or crushed, the fracture may need a bone graft to fill the gaps. A bone graft can be taken from a donor or from another bone in your own body. Sometimes, artificial material can be used.
- Osteotomy – Dr. Stowell may need to cut the tip of the elbow (olecranon) to better see the bone fragments. After the fracture is fixed, the cut olecranon is put back in place and repaired with plates, screws, pins or wire.
Pain from most fractures can be managed using ice, elevation (holding your arm up above your heart), and taking non-prescription medication. If your pain is severe, Dr. Stowell may suggest prescription-strength medication for a few days.
Recovery from a distal humerus fracture requires diligence whether your treatment was surgical or nonsurgical. Due to long periods of splinting or casting with nonsurgical treatment, your elbow may become very stiff, which will require a longer period of physical therapy. Dr. Stowell and his team of physical therapists will provide you with exercises to help you increase your range of motion, decrease stiffness, and strengthen the muscles around your elbow. You will be advised of restrictions in motions that will prevent further injury to your healing elbow. For elbow replacement patients, you will have permanent restrictions on how you can use your arm.
Complications and Outcomes
Long-term complications may exist for patients who have undergone successful treatment including:
- Stiffness – many patients will not be able to regain full motion in the affected elbow. Although full motion may not be regained, it does not usually affect the overall function of the arm.
- Posttraumatic Arthritis – this is a common type of arthritis that develops after an injury. The cartilage protecting your bone can be damaged even when your bones heal normally. This may lead to pain and stiffness over time. Some patients need further surgery to relieve symptoms of posttraumatic arthritis, but for most patients, the pain is tolerable and there Is no need for further surgery.
- Heterotopic Ossification – is a rare occurrence after surgery resulting in bone growth in the muscle, tendon, and ligament around the elbow. Heterotopic ossification can block movement of the elbow interfering with daily function that may require surgical removal.
Most patients can return to their normal activity within about 6 months. Full healing can take up to 2 years, and recovering arm strength may take longer than expected. Although X-rays may show a healed fracture, many patients still report limitations in movement; however, improvement over time is reported.