Humerus Lower End Fracture; Diagnosis, Treatment

Humerus Lower End Fracture/Supracondylar fracture of the humerus is one of the most talked about and often encountered injury (only after clavicle and both bone forearm fracture) in pediatric age group with a male predominance accounting for 16% of all pediatric fractures and 60% of all pediatric elbow fractures, classically occurring as a result of fall on an outstretched hand [rx–rx]. In the pediatric age group, the more common age of presentation is 5-7 years (90% cases). Extension type injury is more common than the flexion type [rx]. It is frequently found in the non-dominant extremity. The flexion type is common in elderly children [rx]. Certain studies have reported up to 30% incidence of open fractures in this subset of the patient [rx].

The vast majority are extension type, resulting from a fall onto an outstretched hand, where the elbow is hyperextended, the olecranon is driven into the olecranon fossa and the anterior humeral cortex fails in tension. The pull of triceps tends to displace the distal fragment posteriorly and proximally. Neurovascular complications are reported in 5–19 % of displaced fractures [rx, rx], due to the close proximity of structures such as the brachial artery and the anterior interosseous nerve. However, most nerve injuries are neurapraxia and recover without further intervention [rx].

Anatomy of Supracondylar Humerus Fracture

Anatomically, the distal humerus has a triangular shape which is built of two columns and a “tie arch”[rx]. The medial column holds at its distal end the nonarticular medial epicondyle with the insertion of the flexor muscles and the medial part of the humeral trochlea. The lateral column holds at its distal end the capitellum and more proximally the lateral epicondyle with the insertion of the extensor muscles (mobile wad). From a lateral perspective, the articular surface of the trochlea and capitellum is projected anteriorly at an angle of 40° to the axis of the humerus, the trochlear axis being externally rotated at an angle of 3°–8° and compared with the longitudinal axis being in 4° to 8° of valgus [rx, rx, rx].

When a fall on the outstretched hand occurs, the olecranon engages on the olecranon fossa and if elbow extension progresses, the olecranon finally acts as a fulcrum on the fossa. Therefore, the bone begins to break at first anteriorly and the fracture progresses posteriorly. If the energy is high, the posterior cortex disrupts, and finally, complete posterior displacement of the distal fragment occurs with the posterior periosteum acting as a hinge. This is the mechanism of extension-type fractures, which represent 97% to 99% of the total.^[rx]

Both supracondylar ridges, condyles, and epicondyles give rise to attachment of various muscles which are responsible for the displacement and rotation of distal fragment. Neurovascular structures lie in proximity to the supracondylar region. The brachial artery which commonly gets involved in supracondylar fracture of humerus lies along the anteromedial aspect of distal humerus just superficial to the brachialis muscle. Major neurological structures of the upper limb (median, radial, and ulnar nerves) are also in close relation with supracondylar region [rx].

Any fracture in the elbow region or upper arm may lead to Volkmann’s ischemic contracture, but it is especially associated with supracondylar fracture of the humerus. Volkmann’s contracture results from acute ischemia and necrosis of the muscle fibers of the flexor group of muscles of the forearm, especially the flexor digitorum profundus and flexor politics long. The muscles become fibrotic and shortened.

Mechanism of Distal Humerus Fracture

Extension type of supracondylar humerus fractures typically results from a fall on to an outstretched hand, usually leading to a forced hyperextension of the elbow. The olecranon acts as a fulcrum which focuses the stress on the distal humerus (supracondylar area), predisposing the distal humerus to fracture. The supracondylar area undergoes remodeling at the age of 6 to 7, making this area thin and prone to fractures. Important arteries and nerves ( median nerve, radial nerve, brachial artery, and ulnar nerve) are located in the supracondylar area and can give rise to complications if these structures are injured. Most vulnerable structure to get damaged is the Median Nerve. ^[rx] Meanwhile, the flexion-type of supracondylar humerus fracture is less common. It occurs by falling on the point of the elbow or falling with the arm twisted behind the back. This causes anterior dislocation of the proximal fragment of the humerus.^[rx]

Types of Supracondylar Humerus Fracture

Classification of Fracture Supracondylar Humerus

Fractures of the supracondylar humerus may be classified in a number of ways as per the following:

•  Displaced or undisplaced fractures of the supracondylar humerus
• Open or closed fractures of the supracondylar humerus.
• Uncomplicated or complicated fractures of the supracondylar humerus (with/without neurological and/or vascular involvement).
• Extension type (95%) or flexion type (5%).
• Modified Gartland’s staging system [rx] is based on the lateral radiograph and widely used for extension type supracondylar fractures to classify further as it can help to guide treatment.

Type I fracture –  Undisplaced.

Type II fractures – Displaced with angulation, but maintain with an intact posterior cortex.

II A fracture – Angulation.

II B fracture – Angulation with rotation.

Type III fracture – Completely displaced and lack meaningful cortical contact, but have a periosteal hinge (either medial/ lateral) intact.

III A fracture – Medial periosteal hinge intact. Distal fragment goes posteromedially.

III B fracture – Lateral periosteal hinge intact. Distal fragment goes posterolaterally.

Type IV fracture – Have no periosteal hinge and are unstable both in flexion and extension i.e., they have multidirectional instability.

Gartland’s classification was modified by Wilkins in 1984,^[rx] subdividing type II fractures into IIA or IIB according to the absence (IIA) or presence (IIB) of malrotation. However, this sub-classification of type II fractures does not show a good intro- and inter-observer reliability.^[rx]

• Type I – Non-displaced fractures (< 2 mm). The AHL still crosses through the center of the capitellum. These fractures are stable because of the integrity of the periosteum.

• Type II – Moderately displaced (> 2 mm). The AHL passes anterior to the center of the capitellum; the posterior periosteum is intact but acts as a hinge.

• Type III – Completely displaced. This type of fracture is more unstable, with extensive soft-tissue and periosteal damage and increased incidence of neurovascular injuries.

Causes of Humerus Lower End Fracture

In correlation to the abovementioned bimodal distribution of age [rx], mainly two fracture mechanisms can be distinguished: low-energy trauma of the elderly with direct impact on the elbow or indirect impact resulting from a fall on the outstretched hand and high energy trauma of the young patient resulting essentially from road traffic or sport accidents [rx].

• Sudden forceful  fall down
• Road traffic accident
• Falls – Falling onto an outstretched hand is one of the most common causes of a broken supracondylar fracture.
• Sports injuries – Many supracondylar Fracture occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
• Motor vehicle crashes – Motor vehicle crashes can cause wrist bones to break, sometimes into many pieces, and often require surgical repair.
• Have osteoporosis – a disease that weakens your bones
• Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
• Walk or do other activities in snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing
• Wave an inadequate – intake of calcium or vitamin D
• Football or soccer – especially on artificial turf

Symptoms of Humerus Lower End Fracture

• Typical signs and symptoms include pain, swelling, bruising, and limited range of motion at the supracondylar fracture reason. Deformity may be present in severe fractures, however, a musculature may cause absence of deformity on inspection.^[rx]
• Numbness over the outside part of the upper arm and deltoid muscle weakness may indicate axillary nerve injury.^[rx]
• Symptoms from poor blood circulation in the arm are uncommon due to collateral circulation in the arm.^[rx]
• Clinical parameters such as the temperature of the limb extremities (warm or cold), capillary refilling time, oxygen saturation of the affected limb, presence of distal pulses (radial and ulnar pulses), assessment of peripheral nerves (radial, median, and ulnar nerves), and any wounds which would indicate open fracture.
• Doppler ultrasonography should be performed to ascertain the blood flow of the affected limb if the distal pulses are not palpable. Anterior interosseous branch of the median nerve most often injured in the postero-lateral displacement of the distal humerus as the proximal fragment is displaced anteromedially.

Comminuted fracture of the elbow. Labeled artwork and corresponding X-ray of extensive comminuted fractures of the distal (elbow) end of the humerus bone in a patient’s left arm. A comminuted fracture is where the bone has broken into several pieces. This is an anterior (frontal) view of the elbow in its extended position, with the fractures being of the lateral and medial condyles. The artwork at right shows the location of the elbow bones in the arm, with the joint in extension. For the surgery carried out, see C021/0785. Screws and metal plates fixed across the condylar fractures held the fragments in place, allowing them to heal in the correct alignment.

Diagnosis of Humerus Lower End Fracture

• Typical signs and symptoms include pain, swelling, bruising, and limited range of motion at the shoulder. Deformity may be present in severe fractures, however, a musculature may cause absence of deformity on inspection.^[rx]
• Numbness over the outside part of the upper arm and deltoid muscle weakness may indicate axillary nerve injury.^[rx]
• Symptoms from poor blood circulation in the arm are uncommon due to collateral circulation in the arm.^[rx]

• There is pain and swelling about the elbow. Bleeding at the fracture results in a large effusion in the elbow joint.
• Depending on the fracture displacement, there may be a deformity. With severe displacement, there may be an anterior dimple from the proximal bone end trapped within the biceps muscle.
• The skin is usually intact. If there is a laceration that communicates with the fracture site, it is an open fracture, which increases infection risk. For fractures with significant displacement, the one end can be trapped within the biceps muscle with resulting tension producing an indentation to the skin, which is called a “pucker sign”.
• The vascular status must be assessed, including the warmth and perfusion of the hand, the time for a capillary refill, and the presence of a palpable radial pulse. Limb vascular status is categorized as “normal,” “pulseless with a (warm, pink) perfused hand,” or “pulseless–pale (nonperfused)” (see “neurovascular complications” below).
• The neurologic status must be assessed including the sensory and motor function of the radial, ulnar, and median nerves (see “neurovascular complications” below). Neurologic deficits are found in 10-20% of patients.^[rx] The most commonly injured nerve is the median nerve (specifically, the anterior interosseous portion of the median nerve). Injuries to the ulnar and radial nerves are less common.

Anterior X-ray

Carrying angle can be evaluated through an AP view of the elbow by looking at the Baumann’s angle.^[rx] There are two definitions of Bowman’s angle:

• The first definition of Baumann’s angle is an angle between a line parallel to the longitudinal axis of the humeral shaft and a line drawn along the lateral epicondyle. The normal range is 70-75 degrees. Every 5 degrees change in Bowman’s angle can lead to 2 degrees change in carrying angle.^[rx]
• Another definition of Baumann’s angle is also known as the humeral-capitellar angle. It is the angle between the line perpendicular to the long axis of the humerus and the growth plate of the lateral condyle. Reported normal values for Baumann’s angle range between 9 and 26°.^[rx] An angle of more than 10° is regarded as acceptable.^[rx]

Lateral X-ray

• On the lateral view of the elbow, there are five radiological features should be looked for: teardrop sign, anterior humeral line, coronoid line, fish-tail sign, and fat pad sign/sail sign (anterior and posterior).^[rx][rx]

Teardrop sign

• Teardrop sign is seen on a normal radiograph but is disturbed in the supracondylar fracture.^[rx]

Anterior humeral line

• It is a line drawn down along the front of the humerus on the lateral view and it should pass through the middle third of the capitulum of the humerus.^[rx] If it passes through the anterior third of the capitulum, it indicates the posterior displacement of the distal fragment.^[rx]

Fat pad sign/sale sign

• A non-displaced fracture can be difficult to identify and a fracture line may not be visible on the X-rays. However, the presence of a joint effusion is helpful in identifying a non-displaced fracture. Bleeding from the fracture expands the joint capsule and is visualized on the lateral view as a darker area anteriorly and posteriorly, and is known as the sail sign.^[rx]

Coronoid line

• A line drawn along the anterior border of the coronoid process of the ulna should touch the anterior part of the lateral condyle of the humerus. If lateral condyle appears posterior to this line, it indicates the posterior displacement of the lateral condyle.^[rx]

Fish-tail sign

• The distal fragment is rotated away from the proximal fragment, thus the sharp ends of the proximal fragment look like a shape of a fish-tail.^[rx]

Compartment syndrome

• Increased interstitial pressure within a closed fascial compartment can lead to compartment syndrome. This increased pressure can result in compromised circulation to the nerves and muscles in that compartment. Elevated tissue pressure obstructs venous outflow from the compartment, which further contributes to the increased pressure and swelling. Ischemia occurs once the pressure rises above arteriolar circulation. Muscle and nerve tissue becomes damaged as soon as 4–6 h after the onset of abnormal pressures.
• The first sign of compartment syndrome is disproportionate pain requiring increasing doses of pain medication [rx]. Other findings include sensory changes such as paresthesias, loss of active movements in the affected compartment, forearm tenderness, palpable tenseness of the muscles of the forearm (or arm), and pain with passive flexion or extension of the fingers.

Treatment of Humerus Lower End Fracture

Non-Pharmacological

• Immobilization –  in either a sling or a Velpeau bandage, with early gentle range of motion exercises. Some fractures may reduce with gravity alone as the patient resumes ambulating, but for some fractures, the closed reduction may improve the deformity and the amount of bony contact.
• In the acute setting – pain control can be difficult for patients. Resting in a supine position allows the arm to extend at the fracture site, and leads to pain and discomfort. Placing the injured extremity in a sling and having the patient rest in an upright or semi-reclining position with some bolsters behind the arm can help to reduce the pain. Patients may also find it more comfortable to sleep sitting in a reclining position when they are at home. Patients and caregivers should be advised that prolonged immobilization can be detrimental to the outcome.
• The Range of Motion Exercises – Due to their limited movement following a proximal humerus fracture, individuals lose their range of shoulder motion and may develop stiffness of the shoulder joint. Your physical therapist will assess your shoulder motion compared to expected normal motion and the motion of shoulder of your noninjured arm, and lead you through a program of motion exercises to restore shoulder function.
• Strengthening Exercises – The muscles of the shoulder and upper back work together to allow for normal upper-body motion. Based on the way the shoulder joint is designed (a ball-and-socket joint, like a golf ball on a golf tee), there are many directions in which the shoulder may move. Therefore, the balanced strength of all the upper body muscles is crucial to make sure that the shoulder joint is protected and efficient with its movements. When there is a fracture to the proximal humerus (near the “ball” segment of the joint), the muscles around the shoulder girdle weaken, as they are not being used normally; this process is called “atrophy.” There are many exercises that can be done to strengthen the muscles around the shoulder so that each muscle is able to properly perform its job. Often, building strength after a fracture can take weeks to months due to atrophy. Your physical therapist will help you develop a strengthening program that is safe and comprehensive.
• Manual Therapy – Physical therapists are trained in manual (hands-on) therapy. When appropriate, based on the stage of healing at your fracture site, your physical therapist will gently move your shoulder joint and surrounding muscles as needed to improve their motion, flexibility, and strength. These techniques can target areas that are difficult to treat on your own.
• Functional Training – Whether you work in a factory, are a mother of a young child, work as a secretary, or are an older adult, the ways in which you perform your normal daily activities are important. Improper movement patterns after a fracture may come back to haunt you, as they may lead to future secondary injuries. Physical therapists are experts in assessing movement quality. Your physical therapist will be able to point out and correct faulty movements, so you are able to regain use of and maintain, a pain-free shoulder.
• Physiotherapy – which can be self-directed or in a formal setting, depending on the patient’s wishes and abilities, should begin no later than two weeks after the injury [rx, rx]. Initially, pendulum exercises will allow for a range of motion without placing weight-bearing stress on the fracture. After the patient is more comfortable, finger crawl exercises along a vertical surface can help with an overhead range of motion.

Medications

Medication can be prescribed to ease the pain.

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema. Antibiotics and tetanus vaccination may be used if the bone breaks through the skin creating an open fracture.^[rx]
• Antidepressants – A drugs that block pain messages from your brain and boost the effects of endorphins (your body’s natural painkillers).
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic or nerve-related pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include  and Ketorolac, Aceclofenac, naproxen
• Calcium & vitamin D3 – to improve bones health and healing fracture.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
• Corticosteroid- to healing the nerve inflammation and clotted blood in the joints.
• Dietary supplement – to remove general weakness & improved health.
• Cough Medication – Specially Cough expectorant syrup to elevate breathing problem or remove the lung congestion.

Surgery

Indications of Surgical Intervention to be Considered in the Following Conditions [rx]

• If close manipulation fails to achieve the reduction.

• If after close reduction fracture is unstable i.e., failure to maintain the reduction.

• If neurological involvement occurs during or after the manipulation of fracture.

• If vascular exploration is required.

• In open fractures.

• All Type II and III fractures requiring elbow flexion of more than 90° to maintain the reduction.

• All Type IV fractures supracondylar humerus.

• Polytrauma with multiple ipsilateral fractures requiring surgical intervention.

Surgical approaches to the distal humerus

• Various surgical approaches to the distal humerus have been described over the past decades. Each fracture needs its appropriate exposure and in cases of intra-articular involvement the exposure of the articular surface. Olecranon osteotomy, the triceps-splitting, triceps-sparing, and triceps-lifting approaches being the most frequently performed approaches in the surgical treatment of distal humerus fractures [rx–rx], we will be giving an overview of the established approaches offering selected indications and an evaluation of the related published data.

Surgical Approaches Used for Treatment of Fractures of the Distal Humerus (Canale & Beaty: Campbell’s Operative Orthopaedics, 11^th edition, Mosby (2007)17.

Complications of Humerus Lower End Fracture

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