Floating Elbow Treatment & Management

Updated: Nov 04, 2021
  • Author: William Oros, MD; Chief Editor: Murali Poduval, MBBS, MS, DNB  more...
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Treatment

Approach Considerations

Indications for treatment of isolated humerus and forearm fractures vary greatly with patient age, location of the fracture, and injury to the soft-tissue envelope. [22, 23] However, the rules change when these fractures occur concomitantly in the same extremity. Reports are relatively few in adults, but available data suggest that patients with multiple fractures in the same upper extremity fare better with anatomic reduction and some type of definitive fixation both for humerus and for forearm fractures.

In children, reduction with percutaneous pinning is the standard of care for the supracondylar humerus fracture component, and management of the forearm component has been shown to be successfully accomplished by means of either closed or percutaneous techniques with similar results. Appropriate soft-tissue management is crucial to aid in fracture healing and may dictate the type of fixation used. [24, 25, 17, 26, 20, 27, 28]

Relatively few contraindications exist for fixation of fractures involved with this injury. Patients who sustain severe irreparable vascular compromise may need to undergo emergency amputation to facilitate patient resuscitation. Patients who are critically ill may require a delay in fixation to allow for recovery from the systemic inflammatory response that accompanies these injuries, but open reduction and internal fixation (ORIF) should still be undertaken when appropriate.

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

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Nonoperative Therapy

Management of these complex injuries has evolved with the understanding of isolated upper-extremity fracture stabilization. Although the goals of therapy 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 the image below). Administer intravenous (IV) antibiotics to patients with open fractures.

Initial management of Monteggia injury consisted o Initial management of Monteggia injury consisted of debridement and irrigation of extensively contaminated ulna fracture and application of external fixator for stability and reduction of radial head dislocation. Humeral fracture was splinted.

The 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.

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Surgical Therapy

Neurologic deficit is a point of controversy, especially in those with a midshaft or distal-shaft humerus fracture. In 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, the location and characteristics of the fracture or fractures, the approach to surgical intervention, and the time when the deficit was discovered (before or after reduction).

The type of fracture management and soft-tissue coverage should be determined 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.

As noted, treatment guidelines for children [29]  differ slightly from those for adults. Studies by Moed et al [26] and Grace et al [24]  showed that immediate internal fixation of both bone forearm fractures in adults with early range of motion (ROM) provided patients 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. The combination of these injuries in the same extremity should be treated 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 [17] 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 (see the image below) or locked intramedullary nailing of the fracture. [30] These techniques allow stable fixation of the fracture site and provide the best chance for union. Rigid fixation of these injuries allows for early ROM of all joints in the affected extremity. This facilitates rehabilitation of concomitant injuries.

Definitive management of fractures was performed w Definitive management of fractures was performed with plate fixation.

In children, supracondylar humerus fractures should be treated with closed (or, if necessary, open) reduction and percutaneous pinning. Little controversy exists about this component of the floating elbow. This option has provided patients with the best opportunity for union of the distal humerus fracture without significant deformity. Acceptable results have been achieved in children with closed reduction of the forearm fracture, with or without percutaneous pinning. [31]

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. Rehabilitation should be tailored to the individual injury pattern, with advancement of activity as fracture union progresses and muscle function returns. [32, 19]

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Complications

Complications of treatment for floating elbow mirror those of treatment for other complex fractures. Significant neurovascular injury may accompany these injuries, ranging from simple isolated nerve palsy to complex brachial plexus lesions with axillary or brachial artery injury or disruption. [33, 18] The cumulative incidence of some type of associated neurovascular injury in children and adults is 25-45%. Loss of ROM 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. It may be wise to delay definitive fixation until the soft tissues are in a condition where appropriate skeletal management can be defined. Malunion and nonunion can result from a number of factors, including persistent infection, inadequate fixation, poor soft-tissue envelope, and poor technique.

Pediatric acute compartment syndrome has been cited as a potential complication in children with floating elbow; however, a systematic review of 11 studies (N = 433) found only a 2% incidence of this complication. [16]

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

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