Distal Humerus Fracture Trauma Case for FRCS (Tr & Orth) Oral Examination
A 66-year-old man is admitted to the orthopaedic unit after a fall in which he injured his elbow. This is an isolated injury.
1. Describe these radiographs.
These are AP and lateral radiographs of the left elbow showing a displaced, intra-articular and comminuted fracture of the distal humerus.
The radiographs presented here show a displaced, intra-articular, and comminuted fracture of the distal humerus on both the AP and lateral views of the left elbow.
2. Assuming that this is an isolated closed injury in a patient who is medically fit and well with high-functional demands, how would you plan to treat this injury?
For this type of injury in a patient with high-functional demands, my preference would be open reduction and internal fixation using a double plating technique to achieve satisfactory fracture stability and early movement. A thorough history and examination would be conducted, with further imaging (such as a CT scan) if necessary to guide preoperative planning.
Assuming an isolated closed injury in a medically fit patient with high-functional demands, an open reduction and internal fixation using a double plating technique would be preferred to achieve satisfactory fracture stability for early movement. A thorough clinical history and examination would be conducted, and further imaging (such as CT scan) if necessary would be considered to guide preoperative planning.
3. What surgical approach would you use? Which implants would you use and where would you place them?
A posterior surgical approach would be used, with a chevron olecranon osteotomy performed and pre-drilled to allow for fixation at the end of the procedure with a 6.5 mm cannulated cancellous screw and washer. A double plating technique would carry out using anatomic pre-contoured distal humerus locking plates placed in the medial and lateral columns with the parallel plating technique.
A posterior surgical approach would be preferred, with a chevron olecranon osteotomy performed and pre-drilled for surgical fixation with a 6.5 mm cannulated cancellous screw and washer. A double plating technique would be carried out using anatomic pre-contoured distal humerus locking plates placed in the medial and lateral columns with the parallel plating technique for achieving optimal fracture stability.
4. What problems do you anticipate with your treatment choice?
Potential problems include difficulty in fixing the comminuted distal fragment due to osteopenic bone, predisposition to failure of fixation, delayed or non-union causing movement preferentially at the fracture site rather than at the elbow joint. Surgery around the elbow can cause heterotopic ossification and post-traumatic or post-surgical stiffness.
Potential problems associated with the treatment choice of open reduction and internal fixation using a double plating technique include difficulty in fixing the comminuted distal fragment in osteopenic bone, predisposition to failure of fixation, delayed or non-union causing movement preferentially at the fracture site rather than at the elbow joint. In addition, surgery around the elbow can cause heterotopic ossification and post-traumatic or post-surgical stiffness.
5. Are there any other options available if you are unable to fix this fracture?
Alternative treatment options may include non-operative treatment for low-demand patients, total elbow arthroplasty, or distal humerus hemiarthroplasty. A different approach may also be used, such as the para-tricipital approach, to address the fracture directly.
Alternative treatment options may include non-operative treatment for low-demand patients, total elbow arthroplasty, or distal humerus hemiarthroplasty. If total elbow arthroplasty is under consideration, an olecranon osteotomy should not be used. A different surgical approach, such as the para-tricipital approach, may be used to address the fracture directly instead.
6. Can you tell me about any problems with the use of total elbow replacement (TEA) for distal humerus fractures?
Potential issues with the use of total elbow replacement for trauma may include the need for a linked implant, which can contribute to a higher risk of bearing surface wear and implant loosening, as well as lifting restrictions (commonly 5 kg) to limit these risks. Furthermore, younger and more active patients may have poorer satisfaction scores, more complications, and a higher rate of loosening following TEA for trauma than low-demand patients. There is also an increased risk of subsequent prosthetic infection, periprosthetic fracture, loosening, and wear, which may require further surgery, especially for younger patients.
Use of a total elbow replacement (TEA) for trauma can also present complications such as the need for a linked implant, which can contribute to a higher rate of bearing surface wear and implant loosening, as well as lifting restrictions (commonly 5 kg) to reduce risks. In addition, younger and more active trauma patients may have poorer satisfaction scores, more complications, and higher rates of loosening after TEA than low-demand patients. There is also an increased risk of subsequent prosthetic infection, periprosthetic fracture, loosening, and wear, which may require further surgery, particularly in younger patients.
Quiz Results
You scored out of 6.
Review the questions you missed and try again!