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BROKEN ELBOW
(DISTAL HUMERUS FRACTURE)


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What is a Distal Humerus fracture?

The humerus is your arm bone, and your elbow is where the arm bone joins the forearm bones.  A distal humerus fracture is break at the end of the arm bone, as the arm forms the elbow. The elbow joint is often understood has having two sides (or columns) because the arm bone (humerus) intersects with two forearm bones: 1) the radius on the outside of the forearm, and 2) the ulna on the inside of the forearm.  Therefore, distal humerus fractures (which are essentially a type of elbow fracture) are described as uni- (one) or bi (two) -column injuries.

Single column injuries are classified as Milch Fractures and are mostly seen in kids.

Both column injuries are more common in adults, and there are many names to describe them. The fracture usually occurs when someone falls directly onto their elbow, with their elbow bent at 90 degrees, which causes the force of the fall to go directly up the arm, breaking the arm bone.

How is a Distal Humerus fracture diagnosed?

The diagnosis of a distal humerus fracture is made by first listening to the history of a person's injury and their symptoms.  People report elbow and arm pain, with elbow swelling and the inability to bend their elbow.  Doctors will get X-rays of the arm and elbow to diagnose the injury. These are usually complex fractures with many broken fragments.  Its often difficult to see exactly how the bone is broken on x-ray because there are so many pieces (this type of fracture initially got the name “bag of bones”, that was a medical term, yikes).  A CT scan (which is many x-rays taken at three different angles to give a detailed picture of the elbow) is often used by surgeons to get a better view of the fracture and determine exactly what parts of the bone is broken for surgical planning.  Some of the newer CT scanners can show 3D models of the broken elbow. 

How is a Distal Humerus fracture treated?

This type of fracture almost always requires surgery. 

Anytime the fracture line extends into a joint (like the elbow in this case), it causes the cartilage to move out of alignment.  If the cartilage surface of the joint becomes uneven by only 2 mm or more, surgery is required to realign the joint surface and minimize the risk of early arthritis ("post-traumatic arthritis").  From a surgical prospective, the elbow is difficult to repair, because its hard to safely get access to the joint.  The front of the elbow is covered by the major arteries and nerves so usually too risky to perform surgery here. Surgery is therefore performed through a incision along the back of the elbow, where you find the triceps muscle. This muscle is moved out of the way to allow the surgeon direct visualization of the elbow joint.  The fracture is repaired with metal plates and screws, which hold the fragments of bone is the correct position while your body heals.  The screws and metal plates hold everything together so people can start using the arm for modest daily activities just one week after surgery (the keyword is “Modest”: people cannot hit the weight room and start carrying heavy things until the bone has had significantly more time to heal). One purpose of fixing the fracture with surgery is to reestablish the normal architecture of the elbow so that it can move without developing early arthritis. Another purpose of fixing the fracture is to give the broken bone stability so that you can start moving the elbow, which reduces the risk of long term stiffness, which is a big concern with elbow injuries

What is the long term outcome?  

Unfortunately these are bad injuries. Elbow stiffness and arthritis are the biggest concerns after this type of injury because they are very common. After surgery most people regain about 75% of their elbow motion. People usually have trouble fully straightening their arm (often you have a 30° limitation).  Overall, as high as 1 in 4 people have poor outcomes (this gives an idea about how severe these fractures are).  Poor outcomes refers to either very limited elbow motion or continued elbow pain after it heals.

Although most orthopedic injuries do very well, there is a more guarded prognosis with this injury. And the greater degree of damage to the bone that supports the elbow cartilage, the more cartilage is destroyed, and the high chance of continued pain and post-traumatic arthritis.