Distal humeral fractures treatment and rehabilitation Distal humeral fractures treatment and rehabilitation – Distal humeral anatomy – Fracture classification – Mechanism of injury – Fixation methods – Rehabilitation protocols – Frequently asked questions Distal humeral anatomy Mechanism of injury Intraarticular fractures Articular surface fractures – Mainly direct external violence to the elbow joint – Differences in contact points and angles of contact resulting in different internal and external condyles Extraarticular fractures – the elbow joint is in a slightly flexed or extended position during a fall, the palm of the hand hits the ground first, and the violence is transmitted from the ground upward through the forearm to the humeral condyle, pushing the humeral condyle posteriorly. The top-down body gravity pushes the humeral stem forward and causes an extension fracture. When the fracture is severely displaced, the brachial artery and nerves are easily damaged. – In a fall, the elbow is in flexion, the tip of the elbow hits the ground first, and the violence is directed from below the back of the elbow – Distal Humerus Anatomy – Fracture Classification – Mechanism of Injury – Fixation – Rehabilitation Program – Anatomy of the distal humerus – Mechanism of injury – Intraarticular fractures – Fractures of the articular surface – Mainly direct external violence to the elbow joint – Different contact points and angles of contact resulting in different fractures of the internal and external condyles - Anatomy of the distal humerus – Fracture classification – Mechanism of injury – Fixation – Rehabilitation programs – Frequently asked questions Anatomy of the distal humerus – Mechanism of injury Intraarticular Fractures of the articular surface – mainly direct external violence to the elbow joint – different contact points and angles of contact resulting in different fractures of the internal and external condyles – pushing the humeral condyle anteriorly and superiorly, resulting in a flexion fracture, rarely complicated by vascular and neurological injury. Supracondylar fractures of the humerus- Extra-articular fractures of the joint surface and joint capsule- Common in children- 90% extension, flexion, and comminution fractures in adults- Swelling with fracture displacement predisposes to osteofascial compartment syndrome- Often associated with vascular nerve injury – often secondary to elbow inversion deformity – mostly non-surgical treatment of medial humeral epicondyle fractures – extra-articular capsule fractures outside the articular surface – starting point of forearm flexors and pronators – easy formation of medial soft tissue due to tearing of the capsule and pronators Intercondylar fracture of the humerus – Fracture of the articular surface – When the elbow is flexed during a fall, the posterior elbow lands directly on the ground and the eminence of the hawk enters between the two condyles, causing a split fracture – There are Y and T types The fracture is often associated with large tears of the joint capsule and soft tissues, making it very easy to stiffen the joint and challenging to rehabilitate. Mobility (shoulder and elbow mobility and carry angle) – Muscle strength in the vicinity of the joint – Maintaining the patient’s basic self-care Expected time for fracture recovery – 8 to 12 weeks – When an open fracture or incision and internal fixation is performed, fracture healing is delayed Rehabilitation interventions required Time to healing – 12 to 24 weeks Different fracture fixation treatment modalities – Cast or posterior splint splinting – Percutaneous pinning with cast or splint Open reduction and internal flxation Internal fixation – External fixation – Skeletal traction Cast or posterior splint plaster splinting – for undisplaced fractures or stable fractures after reduction – preservation of the carry angle – suspension with a cervical wrist strap at 90° median flexion of the elbow – undisplaced fractures for 3 weeks after fixation with guided rom Exercise for 4-6 weeks – post-reduction fixation with 4-6 weeks of braking and x-ray review of bone fracture formation before starting rehabilitation Percutaneous pinning with cast or splint splinting – used more in children than adults with fractures – For non-articular fractures of the distal humerus – 4-6 weeks of pinning – Open reduction and internal fixation after pin removal and imaging to confirm a solid fracture – Provide stress masking – One-stage healing of fracture – For intra-articular surface fractures and extra-articular surface fractures that are unstable after reduction – Ulnar nerve transposition if the implant is fixed in the ulnar nerve groove External fixation – Skeletal traction – when good repositioning cannot be achieved – to obtain normal bone length and alignment before surgery – fixation above the cephalad position – after traction Loss of joint mobility after fracture – incomplete repositioning – ossifying myositis (early prom?) – scarring Age – older people prone to joint stiffness – arthritis makes internal fixation less stable – Traumatic arthritis poor healing – abnormal angular recovery prone to nerve damage Joint dislocation or ligament damage – humeral talus fracture = dislocation – often combined with ligament and capsule damage Open fracture – soft tissue takes longer to recover – Rehabilitation takes longer. Delayed or non-healing after cutting of ulnar hawk bone – Tension band or screw fixation – Tension band provides compressive stress – Avoid screw fixation alone Combined injury Nerve injury – Ulnar nerve injury is most common – Surgery must be handled with care – Immediate exploration for post-operative neurological symptoms Vascular injury – Brachial artery injuries are common in supracondylar and bicondylar fractures – Ischemic atrophy secondary to post-operative rehabilitation for two weeks – Watch for pain, swelling, sensory abnormalities, finger movement – Swelling at 4 days postoperatively requires removal of splint – Prevention of osteo-fascial compartment syndrome – Avoidance of weight bearing – Active movement of fingers and metacarpophalangeal joints – Shoulder pendulum movement, avoiding internal and external shoulder rotation – Finger Flexion-extension-adduction-adduction muscle strength exercises- Suspension of the upper extremity- The healthy hand is responsible for daily living. Avoid PROM to prevent ossifying myositis within two weeks of plaster splinting/knuckle fixation- Avoid elbow movement- Active finger movement, shoulder pendulum, avoid internal and external rotation of the shoulder Incisional repositioning internal fixation- Active movement of each joint after 3-5 days (firm fixation) – Exercise with posterior brace and posterior cast for protection- avoid internal and external shoulder rotation- immobilization if bone quality is poor, but prone to joint stiffness 2-3 weeks- note pain, swelling, sensory abnormalities, finger movement- persistent swelling prone to Compressive nerve swelling – Active finger and metacarpophalangeal joint movement – Shoulder pendulum movement to avoid internal and external shoulder rotation – Increase centripetal massage if fingers are swollen – Increase finger strength exercises – Avoid weight bearing – Avoid PROM to prevent ossifying myositis 2-3 weeks plaster splinting/knuckle pinning-. If stable fracture, elbow tolerates Arom (2-3 weeks) – If repositioned fracture, practice greater than 90° flexion under posterior elbow protection – Avoid shoulder and forearm rotation – Absolute braking required for supracondylar fractures in extension type Incisional internal fixation – Increase AROM to avoid joint stiffness- avoid PROM to prevent ossifying myositis 4-6 weeks- check elbow rom and joint stiffness- isometric movement of forearm, shoulder pendulum movement- avoid internal and external rotation of shoulder- increase grip strength exercises – Instruct patient to continue exercises at home – Avoid weight bearing – Avoid PROM to prevent ossifying myositis 4-6 weeks plaster splinting = kyphosis pin fixation – X-rays show firm fracture reduction, start supervised ROM exercises – Removal of kyphotic pins and wearing a brace in addition to exercises Dissection and internal fixation. Active movement of each joint (firmly fixed) – Heat therapy before exercise to improve joint stiffness – Increase flexion and extension exercises to avoid joint stiffness 8-12 weeks – Check elbow rom and joint stiffness – Start partial weight-bearing, full weight-bearing after 3 months – PROM combined with AROM – PROM is less likely to cause ossifying myositis – Heat therapy can be added for joint stiffness – ADL functional exercises – When X-ray shows fracture healing, remove brace After fracture Residual problems – Loss of ROM is common in both articular and non-articular surface fractures. Causes include capsular contracture and ossifying myositis – Extension restriction is more likely to be missed than flexion restriction – Both capsular contracture and ossifying myositis require re-surgical release for resection. Osteochondritis is not reoperated until it has matured for about a year – It is often difficult to achieve good ROM after limitation of joint motion – Proper postoperative rehabilitation is the best way to prevent these problems.