Elbow Fracture Dislocation

Distal Humerus Fractures

Understanding the Elbow Joint

The elbow joint is a complex joint of the upper arm which bends and straightens like a hinge. It is also important for rotation of the forearm; that is, the ability to turn your hand in a palm up (like accepting change from a cashier) or palm down (like typing or playing the piano).

Your elbow joint is a joint made up of three bones

  • The lower end of humerus (arm bone)
  • The upper end of radius (forearm bone on the thumb side)
  • The upper end of ulna (forearm bone on the little finger side)

The distal humerus or the lower end of the humerus forms the upper part of the elbow and is the pivot around which the forearm bends and straightens.

Distal Humerus Fractures

The radial head or the upper end of the radius is a knobby end with a flat upper surface which glides up and down in front of the distal humerus when you bend your arm. The radial head also rotates around a groove in the upper end of ulna when you turn your wrist up or down.

The olecranon or the part of the upper part of ulna "hooks" the lower end of the humerus, creating a hinge for elbow movement. The bony "point" of the olecranon can be easily felt beneath the skin.

The elbow is held together by its bony architecture, as well as ligaments, tendons, and muscles. In addition to this, major blood vessel and nerves supplying the forearm and hand cross the elbow joint.

Elbow Fractures

For simplicity of understanding, the elbow joint can either break at the lower end of the humerus (arm bone) or at the upper end of the forearm bones (radius/ulna) either individually or in combination.

Distal Humerus Fractures of the Elbow

Distal Humerus Fractures of the Elbow

A distal humerus fracture is a break in the lower end of the upper arm bone (humerus) either extending to the surface of the elbow joint or limited to above the joint. A fracture in this area can be very painful and make elbow motion difficult or impossible. Most distal humerus fractures are caused by some type of high-energy event—such as receiving a direct blow to the elbow or during a road traffic accident. In an older person who has weaker bones, however, even a minor fall may be enough to cause a fracture.

Distal humerus fractures are uncommon; they account for just about 2 percent of all adult fractures. They can occur on their own, with no other injuries, but can also be a part of a more complex elbow injury

What are the causes of Distal Humerus Fracture

Distal humerus fractures are most often caused by:

  • Falling directly on the elbow
  • Receiving a direct blow to the elbow from something hard like dashboard or car door during a vehicle collision
  • Falling on an outstretched arm with the elbow held tightly to brace against the fall.
  • Distal humerus fractures are also sometimes caused by weak or insufficient bone. This is most common in older patients whose bones have become weakened by osteoporosis. In these patients, a fracture may occur even after a minor fall.

What are the symptoms & how is a distal humerus fracture diagnosed

A distal humerus fracture may be very painful and can prevent you from moving your elbow. Some of the sypmtoms of distal humerus fractures are

  • Swelling
  • Bruising
  • Tenderness to the touch
  • Stiffness
  • A feeling of instability in the joint, as if your elbow is going to "pop out"
  • In rare cases, the fractured bone may stick out of the skin (open fracture)

Most patients with distal humerus fractures will go to an hospital emergency room for initial treatment. Your doctor will talk with you about your medical history and general health and ask about your symptoms. He or she will then examine your elbow to determine the extent of the injury. During the exam, your doctor will:

  • Check your skin for cuts and lacerations as in severe fractures, bone fragments can break through the skin, increasing the risk of infection.
  • Palpate (feel) all around your elbow to determine if there are any other areas of tenderness. This could indicate other broken bones or injuries, such as a dislocated elbow.
  • Check your pulse at the wrist to ensure that there is good blood flow to your hand and fingers.
  • Check to see that you can move your fingers and wrist, and can feel things with your fingers. In some cases, the ulnar nerve may be injured at the same time the fracture occurs. This can result in weakness and numbness in the ring and small fingers.

Although you may have pain only at the elbow, your doctor may also examine your shoulder, upper arm, forearm, wrist, and hand to ensure that you do not have any other injuries.

Your doctor will order x-rays of your elbow to help diagnose your fracture and also may also order x-rays of your upper arm, forearm, shoulder, wrist, and/or hand to ensure that you do not have any other injuries based on his/her clinical judgement.

What is the initial treatment for distal humerus fracture

In the emergency room, your doctor will apply a splint (like a cast) to your elbow and give you a sling to help keep your elbow in position. This prevents any further movements of the broken fragments and thereby limits the chances of ulnar nerve injury. Immediate treatment may also include medications to relieve pain. Whether or not your fracture requires surgery will then be determined. Some distal humerus fractures can be treated without an operation, but this is rare.

Can a distal humerus fracture be treated non-surgically

distal humerus fracture be treated non-surgically

Nonsurgical treatment may be recommended for stable fractures in which the pieces of bone are not out of place (displaced). It may also be recommended for patients who are at higher risk for surgical complications. For example, patients with severe medical conditions may not be able to tolerate surgery or those with severe weakening of bones due to osteoporosis.

A splint will be applied along with a sling to hold the elbow in place during healing. During the healing process, your doctor will take frequent x-rays to make sure the bone has not shifted out of place. Splints are typically worn for 6 weeks before supervised motion is started. If the fracture shifts out of position during this time, you may need surgery to put the bones back together.

What is the surgical treatment for distal humerus fracture

Surgical treatment is the most common form treatment to treat fractures of the distal humerus unless the patient falls in non operative category for the reasons listed above.

For severe open fractures such as when there is a wound over the elbow which is contaminated, your doctor may apply an external fixator to hold the bones in place until a second surgery can take place. In this operation, the doctor makes small incisions into the skin and inserts metal pins through the bones. The pins project out of the skin and are attached to carbon fiber bars outside the skin. The external fixator acts as a frame to help hold the elbow in a good position until a second surgery can be performed.

More frequently, the distal humerus fracture is treated with open reduction and internal fixation. During the procedure, the bone fragments are first repositioned (reduced) into their normal alignment and then held in place with plates and screws attached to the outside of the bone.

Are there any surgical considerations that I should be aware of

Like any major surgery, there are certain anatomical considerations the surgeon will contemplate upon and brief you about.

  • Ulnar nerve placement - In most cases, your doctor will need to gently move the ulnar nerve out of the surgical field to prevent it from being injured during surgery. At the end of the procedure, the nerve will be put back in place.
  • Bone grafting - If some of the bone has been lost through the wound or is crushed due to the impact of the fall/accident, the fracture may require bone graft to fill the gaps. Bone graft can be taken from another bone in your own body (autograft)—most often the pelvis. In some cases, an artificial material can be used.
  • Osteotomy - Sometimes, the doctor will cut the tip of the elbow (olecranon) to better see the bone fragments. The cut bone is moved out of the way during fracture repair. After the fracture is fixed, the cut olecranon is put back in its original location and repaired with plates and screws, a single screw, or pins and wire.

What are the complications of surgery

There are risks associated with all surgery. If your doctor recommends surgery, he or she thinks that the possible benefits outweigh the risks. However, there is rare risk of complications with elbow fracture surgery.

  • Infection - There is a risk of infection with any surgery. Your doctor will take specific measures to help prevent infection.
  • Damage to nerves and blood vessels - There is a minor risk of damage to nerves and blood vessels around the elbow. Temporary numbness in the hand, or weakness in the hand and wrist may occur. This is caused by stretching of the ulnar nerve during surgery and may take weeks or months to go away. In rare cases, the ulnar nerve may be injured during surgery, and further surgery may be required to help the nerve recover.
  • Nonunion - Sometimes, a fracture does not heal. The fracture may pull apart and the screws, plates, or wires may shift or break. If the fracture fails to heal, further surgery may be needed.

How will my pain be controlled

Prior to surgery, it is common to experience pain due to the injury. This can be controlled with medications. In severe cases, your doctor may suggest giving a nerve block by referring to a anaesthetist colleague. Most fractures hurt moderately for a few days to a couple of weeks after the surgery. Many patients find that using ice after the slab and stitch removal, elevation (holding their arm up above their heart), and simple, non-prescription medications for pain relief are all that are needed to relieve pain. If your pain is severe, your doctor may suggest a prescription-strength medication, such as an opioid, for a few days. It is important to use opioids only as directed by your doctor. As soon as your pain begins to improve, stop taking opioids.


Whether your treatment is surgical or nonsurgical, recovery from a distal humerus fracture requires much work. During rehabilitation, your doctor or a physical therapist will provide you with exercises to help:

  • Improve range of motion
  • Decrease stiffness
  • Strengthen the muscles within the elbow

Rehabilitation in Nonsurgical Treatment

Because nonsurgical treatment can sometimes require long periods of splinting or casting, your elbow may become very stiff. For this reason, you may need a longer period of physical therapy if you are treated conservatively. You will not be allowed to lift, push, or pull anything with your injured arm for a period of time till there is a clinical sign of the fracture uniting.

Rehabilitation in Surgical Treatment

Depending on the complexity of the fracture and the stability of the repair, your elbow may be splinted or casted for a period of time after surgery. Most patients will begin exercises to improve elbow and forearm motion shortly after surgery, sometimes as early as the next day. It is extremely important to perform the exercises as often as directed. The exercises will only make a difference if they are done regularly.

What are the long term complications of distal humerus fractures

Even with successful treatment, some patients with distal humerus fractures may experience long-term complications.

  • Loss of Motion (Stiffness) - Some patients will not be able to regain full motion in the affected elbow, no matter what type of treatment they receive. In most of these cases, the patient cannot fully extend or straighten his or her arm. Fortunately, the loss of a few degrees of straightening does not usually affect the overall function of the arm.
  • Post-traumatic Arthritis - Post-traumatic arthritis is a type of arthritis that develops after an injury. Even when your bones heal normally, the cartilage protecting the bones can be damaged, leading to pain, stiffness and eventually arthritis over time. Post-traumatic arthritis is a relatively common complication of distal humerus fractures.
  • Heterotopic Ossification - A rare problem that may occur after surgery is the growth of bone in the muscles, tendons, and ligaments around the elbow called heterotopic ossification. When this happens, bone forms where it should not be and can block movement of the elbow. This complication is known to be predisposed in those patients who received a massage over the injured elbow initially at the time of injury. However it can occur in those patients who did not receive a massage.
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