eMedicine Specialties > Orthopedic Surgery > Hand & Upper Extremity

Distal Humerus Fractures: Workup

Author: Edward Yian, MD, Consulting Staff, Department of Orthopedic Surgery, Southern California Permanente Group Orange County
Coauthor(s): Madhav Karunakar, MD, Consulting Surgeon, Section of Orthopedic Surgery, Department of Surgery, University of Michigan Medical Center
Contributor Information and Disclosures

Updated: Jul 26, 2007

Workup

Laboratory Studies

  • Preoperative laboratory studies should be patient specific. They should be performed to medically clear the patient for an operative procedure if one is justified.
    • Studies should include coagulation studies and hemoglobin level. If the patient's medical condition is in question, then a medical team consultation may be appropriate.
    • While blood loss can be minimized with the intraoperative use of a tourniquet, typing and screening can be performed if the patient is unable to tolerate blood loss.

Imaging Studies

  • The fracture personality, including the bone quality, fracture pattern, level of comminution, articular involvement, displacement, and associated injuries, must be understood completely before treatment is attempted.5 Multiplane radiographs, including anteroposterior (AP) and lateral views, are appropriate.
  • AP radiographs should be obtained with the elbow flexed approximately 40° and with the radiographic beam directed perpendicular to the distal humeral surface. This allows disengagement of the olecranon from its fossa and permits a better view of the distal humerus. In the pediatric population, the Baumann angle—defined as the angle between the lateral condylar physeal line and the axis of the humerus—is often measured using AP radiographs. It must be compared to the contralateral side. In addition, displacement of the anterior, posterior, or supinator fat pad can suggest a fracture. The posterior fat pad is the most sensitive for pathology. Skaggs and colleagues demonstrated a 76% incidence of occult elbow fracture with a positive posterior fat pad sign.6 A medial epicondylar fracture should be suspected if a fragment is visible within the joint and the epicondyle is not visible.

    • Oblique radiographs can aid in assessing multiplane involvement of the fracture lines and comminution.
    • Many times, traction views allow for better visualization of the fracture lines and fragments. Mobile fluoroscopy can be helpful as well, especially in cases associated with seemingly minor fractures and instability.
    • Other radiographic views of the elbow can be obtained to exclude associated injuries. A radial head-capitellar view is a semilateral view of the elbow with the beam aimed 45° toward the ipsilateral shoulder joint. With the thumb of the hand pointed upward, the radial head can be magnified without any overlap of the proximal ulna. The coronoid view can be obtained to define the coronoid process. The radiographic beam is directed at the lateral elbow and pointed 45° away from the ipsilateral shoulder.
  • A computed tomography (CT) scan can be obtained of the distal humerus to further analyze the fracture pattern.

    • Thin-cut coronal and axial cuts at 1 mm intervals should be obtained.
    • Three-dimensional reconstructions can be obtained but rarely contribute much to the overall assessment of the fracture.
    • The integrity of the central column, as well as comminution and preexisting arthritic changes within the joint surfaces, should be observed.
    • Often, CT scans reveal details that cannot be viewed on simple radiographs.
    • A study suggests that additional CT scanning can improve intraobserver reliability but does not improve interobserver agreement, indicating that interpretation is a reflection of training, knowledge, and experience.5
  • If questions regarding vascular status arise, duplex Doppler ultrasonography or angiography can be performed. Ultrasonography has also been shown to be helpful in differentiating stable from unstable pediatric lateral condylar fractures. Vocke-Hell and colleagues showed effective use of ultrasonography in determining which nonossified fractures involved the joint surface and required operative intervention.7

Staging

No perfect classification system has been developed for distal humerus fractures that allows accurate direction for treatment considerations and prognostic outcome. The many classifications that have been proposed often overlap.

Mehne and Jupiter separate fractures based on column involvement and whether the fractures are intra-articular, intracapsular, or extracapsular.8,9 Their classification system incorporates features of many previously described fracture types. For single column involvement, the Milch classification is often used. It classifies fracture patterns as having medial or lateral condylar involvement and further characterizes them as either low (type I) or high (type II), depending on how proximally the fracture started before traveling obliquely across the trochlea. These fractures usually occur from an abduction or adduction force. Kuhn and colleagues described a divergent bicolumn fracture pattern that can occur with an axial force from the olecranon in patients with fenestrated olecranon/coronoid fossae.10

  • Capitellar and trochlear fractures are seen infrequently, occur in the coronal plane, and can be classified into one of the following subtypes:
    • Type I - These are isolated capitellar fractures involving a large portion of cancellous bone; they are known as Hahn-Steinthal fractures.
    • Type II - These are fractures involving the anterior cartilage, with a thin-sheared layer of subchondral bone; they are known as Kocher-Lorenz fractures.
    • Type III fractures - These are comminuted osteochondral fractures.
    • Type IV fractures - Classified by McKee and associates, these involve the capitellum and one half of the trochlea; they often result in the double-arc sign observed on lateral radiographs.
  • For bicolumn variants, the classification system introduced by Mehne and Matta takes into consideration the height of the fracture through each column.
    • Y and T fractures begin in the center of the trochlea, secondary to trochlear impaction into the olecranon-trochlear ridge, causing propagation of the fracture vertically and across each column. If a fracture involves both columns at a distal level, it may enter the olecranon and coronoid fossae and produce comminuted articular fragments too small to reconstruct.
    • H-type fractures may produce a free-floating trochlear fragment, with the medial column fractured in 2 places. This can increase the risk of avascular necrosis of the articular fragment. The system does not identify comminution or fragment displacement.
  • Many continue to use the simple classification proposed by Riseborough and Radin.3 It differentiates fractures on the basis of displacement and rotation. The use of this classification system is limited because it does not account for the large variety of fracture patterns. Riseborough and Radin's classification is as follows:
    • Type I - Fractures involving minimally displaced articular fragments
    • Type II - Fractures involving displaced fragments that are not rotated
    • Type III - Fractures involving displaced and rotated fragments
    • Type IV - Fractures involving comminuted fracture fragments
  • The AO-ASIF classification is the most commonly used system for clinical research and treatment. The Orthopaedic Trauma Association and the International Society for Fracture Repair expanded the AO-ASIF classification to provide a more detailed system for reproducibility. It contains 38 different fractures of the distal humerus and separates the patterns into groups and subgroups based on the specific fracture propagation and involvement. Subgroups are based on the fracture comminution and orientation. For example, a unicondylar fracture or tangential fracture of a single condyle would be a group B fracture, while a bicondylar fracture with extensive comminution of the condyles and columns would be a group C3 fracture. The group classification is as follows:
    • Group A - Extra-articular fractures
    • Group B - Partially articular fractures
    • Group C - Entirely intra-articular fractures
  • The most common classification system used for pediatric supracondylar humerus fractures is the Gartland classification, which is based on the degree of displacement. Skaggs and colleagues found a high interobserver reliability with this classification system and an overall k value of 0.74.11 The Gartland classification system is as follows:
    • Type I - Nondisplaced fractures
    • Type II - Minimally displaced fractures with an intact posterior cortex
    • Type III - Completely displaced fractures with complete cortical disruption
  • Pediatric supracondylar humerus fractures can also be classified as extension-type and flexion-type fractures, depending on the angulation of the distal fragment.
  • Lateral condylar physeal fractures can be differentiated based on either anatomic location of the fracture or the amount of displacement. The Milch classification is as follows:
    • Type I (Salter-Harris type IV) - Describes the fracture extending lateral to the trochlea through the capitulotrochlear groove
    • Type II (Salter-Harris type II) - Describes the fracture line penetrating to the trochlea, producing elbow instability
  • Medial condylar physeal fractures also are classified according to the Milch classification, as follows:
    • Type I - Salter-Harris type II fracture
    • Type II - Salter-Harris type IV fracture
  • Fracture separation of the distal humeral epiphysis also has been described. (In some cases, separation of the epiphysis with an attached portion of the metaphysis may occur.) DeLee and colleagues classified this type of fracture into the following 3 groups12 :
    • Group A - These fractures involve patients aged 1 year or younger with Salter-Harris type I physeal injuries.
    • Group B - These fractures involve children aged 1-3 years in whom ossification of the lateral condyle epiphysis is evident.
    • Group C - These fractures occur in children aged 3-7 years and produce a metaphyseal flag with the distal fragment.

More on Distal Humerus Fractures

Overview: Distal Humerus Fractures
Workup: Distal Humerus Fractures
Treatment: Distal Humerus Fractures
Follow-up: Distal Humerus Fractures
Multimedia: Distal Humerus Fractures
References
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References

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Further Reading

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Keywords

elbow fractures, supracondylar humerus fractures, elbow injuries, distal humerus injuries, elbow joint fractures, single condylar fractures, epicondylar fractures, coronal shear fractures of the articular surface, distal humeral fractures, distal humeral injuries

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Contributor Information and Disclosures

Author

Edward Yian, MD, Consulting Staff, Department of Orthopedic Surgery, Southern California Permanente Group Orange County
Edward Yian, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

Madhav Karunakar, MD, Consulting Surgeon, Section of Orthopedic Surgery, Department of Surgery, University of Michigan Medical Center
Madhav Karunakar, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons and AO Foundation
Disclosure: Nothing to disclose.

Medical Editor

Peter M Murray, MD, Associate Professor of Orthopedic Surgery, Mayo Clinic College of Medicine; Director of Education, Mayo Foundation for Medical Education and Research; Consultant, Department of Orthopedic Surgery, Mayo Clinic, Jacksonville; Consulting Staff, Nemours Children's Clinic and Wolfson's Children's Hospital
Peter M Murray, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for Hand Surgery, American Orthopaedic Association, American Society for Surgery of the Hand, American Society of Reconstructive Microsurgery, Florida Medical Association, Orthopaedic Research Society, and Society of Military Orthopedic Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Thomas R Hunt III, MD, John D Sherrill Professor of Surgery, Director, Division of Orthopedic Surgery, Surgeon in Chief, UAB Upper Extremity Fellowship, UAB Highlands Hospital, University of Alabama at Birmingham School of Medicine
Thomas R Hunt III, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for Hand Surgery, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, American Society for Surgery of the Hand, AO Foundation, and Mid-America Orthopaedic Association
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD, Consulting Surgeon, Broward Hand Center, Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine
Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society
Disclosure: Nothing to disclose.

 
 
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