Distal Humerus Fractures Workup
- Author: Edward Yian, MD; Chief Editor: Harris Gellman, MD more...
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. Whereas 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.
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. Multiplane radiographs, including anteroposterior (AP) and lateral views, are appropriate. (See the images below.)
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 et al demonstrated a 76% incidence of occult elbow fracture with a positive posterior fat pad sign. 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.
Computed tomography (CT) of the distal humerus can be performed 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 suggested that additional CT could improve intraobserver reliability but did not improve interobserver agreement, indicating that interpretation is a reflection of training, knowledge, and experience. Another study found that although adding CT to radiography did not improve interobserver reliability, it did change fracture classification and treatment planning.
Other imaging modalities
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 et al showed effective use of ultrasonography in determining which nonossified fractures involved the joint surface and required operative intervention.
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.[17, 18] 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 et al described a divergent bicolumn fracture pattern that can occur with an axial force from the olecranon in patients with fenestrated olecranon/coronoid fossae.
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 et al, 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, as follows:
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 two 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. 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 Arbeitsgemeinschaft für Osteosynthesefragen (AO)-Association for the Study of Internal Fixation (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.
In this system, 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 classification system most commonly used for pediatric supracondylar humerus fractures is the Gartland classification, which is based on the degree of displacement. Skaggs et al found a high interobserver reliability with this classification system and an overall κ value of 0.74. 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 on the basis of either the 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 et al classified this type of fracture into the following three groups :
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
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