Floating Elbow Treatment & Management

Management of these complex injuries has evolved with the understanding of isolated upper extremity fracture stabilization. While the goals are the same, treatment guidelines for children and adults differ slightly. Regardless of age, initial management should include provisional immobilization of the fractures and appropriate debridement of open fracture wounds (see image below). Administer intravenous (IV) antibiotics to patients with open fractures.

Vascular status of the limb must be assessed carefully. If a disruption is present or suspected, surgical consultation and coordination of management needs for the combined injury should take place.

Neurologic deficit is a point of controversy, especially in those with a mid or distal shaft humerus fracture. When deciding whether to explore a nerve that presents with a deficit, a number of factors should be taken into consideration, including the mechanism of injury, location of fracture or fractures and their personality, approach to surgical intervention, and when the deficit was discovered (before or after reduction).

Determine the type of fracture management and soft-tissue coverage on a case-by-case basis. Some surgeons may elect to span the fractures with an external fixator until other patient care issues can be resolved. Others may elect to stage the procedures or fix both fracture complexes at once. All of these options are acceptable as long as the primary fracture principles are respected.

While the goals are the same, treatment guidelines for children^[25] and adults differ slightly. Studies by Moed et al^[19] and Grace et al^[16] have shown that immediate internal fixation of both bone forearm fractures in adults with early range of motion provide the patient with a stable construct that allows for accelerated rehabilitation and return to function. Operative treatment of isolated humerus fractures in adults has its role in some instances, but for the most part, these injuries do well when treated in a closed manner with functional bracing. Treat the combination of these injuries in the same extremity as a unit and not as separate entities. Rogers et al^[20] reviewed their series of floating elbows and found a high rate of humeral nonunion with closed treatment of the humeral fracture. Lange et al^[18] reviewed their experience with this injury and found that only patients who underwent operative management of the humeral fracture obtained a satisfactory result.

Operative management of the humeral component should consist of either rigid plate fixation (as depicted in the radiograph below) or locked intramedullary nailing of the fracture.^[26] These techniques allow for stable fixation of the fracture site and provide the best chance for union. Rigid fixation of these injuries allows for early range of motion of all joints in the affected extremity. This allows for easier rehabilitation of concomitant injuries. In children, treat supracondylar humerus fractures with closed (open if needed) reduction and percutaneous pinning. Little controversy exists about this component of the floating elbow. This option has provided the patient with the best opportunity for union of the distal humerus fracture without significant deformity. In children, acceptable results have been achieved with closed reduction of the forearm fracture, with or without percutaneous pinning.

The treating surgeon should base the treatment decision on the stability of the fracture reduction and the likelihood of achieving union without angulation. The opportunity for skeletal remodeling also factors into this decision, as well as the type of fixation required. Tailor rehabilitation to the individual injury pattern, with advancement of activity as fracture union progresses and muscle function returns.^{[27, 28]}

Complications of treatment for floating elbow mirror those of other complex fracture treatment problems. Significant neurovascular injury may accompany these injuries. These range from simple isolated nerve palsy to complex brachial plexus lesions with axillary/brachial artery injury/disruption. The cumulative incidence of some type of associated neurovascular injury in children and adults is 25-45%. Loss of range of motion in the elbow and forearm axis is not uncommon, even with anatomic restoration of all fractures.

Infection is a notable complication, especially in those who sustain open fractures and require debridement and immediate internal fixation. A delay in definitive fixation until the soft tissues are in a condition in which appropriate skeletal management can be defined may be wise. Malunion and nonunion can result from a number of factors, including persistent infection, inadequate fixation, poor soft-tissue envelope, and poor technique.

Attention to proper surgical methods and an understanding of the severity of the injury assist the treating surgeon in minimizing these occurrences.

The functional outcomes of these injuries vary in children and adult patients. Pediatric injuries historically have had better results than those of their adult counterparts, largely due to children's ability to remodel skeletal deformity with time. In Stanitski's series of 6 patients,^[1] all had an excellent outcome with respect to range of motion and carrying angle. Papavasiliou reviewed 24 cases and found similar results using the same treatment principles.^[9] Templeton studied 8 subjects with similar clinical presentation and found 7 had good or excellent results and 1 had a poor result (cubitus varus with limited but functional supination/pronation).^[10]

Yokoyama et al reviewed a series of floating elbow injuries in adults.^[2] The surgical management varied from case to case, but each fracture was managed with some type of operative intervention. All patients underwent standardized elbow evaluations, and a review of pertinent complications was included. They had 67% good or excellent results; the final elbow score did not correlate with timing of operation, concomitant neurovascular injury, or open fracture. Nonunions were present in 4 cases. All of these were fractures treated with unlocked intramedullary fixation.

Pierce and Hodorski reviewed 21 cases and only had 28% good results, with residual neurologic dysfunction in more than 50% of their patients. Lange reported on their experience with 7 patients, with 3 good, 1 fair, and 3 poor results.^[18] As advances in fracture fixation and understanding of the basic science of fracture healing have improved with time, so have the results of these devastating injuries.

As methods of fracture care improve, especially in patients with multiple fractures, outcomes of these complex injuries should mirror those efforts. A wide multicenter review of these complex injuries would be helpful in further guiding the understanding of the pathology and treatment options in the floating elbow.