The best method of managing a fracture of the
distal humerus in a frail low-demand patient with osteoporotic bone remains
controversial. Total elbow arthroplasty (TEA) has been recommended
for patients in whom open reduction and internal fixation (ORIF)
is not possible. Conservative methods of treatment, including the
‘bag of bones’ technique (acceptance of displacement of the bony
fragments and early mobilisation), are now rarely considered as
they are believed to give a poor functional result. We reviewed 40 elderly and low-demand patients (aged 50 to 93
years, 72% women) with a fracture of the distal humerus who had
been treated conservatively at our hospital between March 2008 and
December 2013, and assessed their short- and medium-term functional
outcome. In the short-term, the mean Broberg and Morrey score improved
from 42 points (poor; 23 to 80) at six weeks after injury to 67
points (fair; 40 to 88) by three months. In the medium-term, surviving patients (n = 20) had a mean Oxford
elbow score of 30 points (7 to 48) at four years and a mean Disabilities
of the Arm, Shoulder and Hand score of 38 points (0 to 75): 95%
reported a functional range of elbow flexion. The cumulative rate
of fracture union at one year was 53%. The mortality at five years approached
40%. Conservative management of a fracture of the distal humerus in
a low-demand patient only gives a modest functional result, but
avoids the substantial surgical risks associated with primary ORIF
or TEA. Cite this article:
Compression testing of cadaver specimens showed that excision of the radial head allowed proximal radial displacement. The insertion of a metallic radial head restored normal mechanics, while a silicone rubber implant did not. We reviewed 31 of 36 comminuted fractures of the radial head, 21 associated with dislocation or ulnar fracture, which had been treated by primary replacement with a Vitallium prosthesis. At a mean follow-up of 4.5 years, there was reliable restoration of stability and prevention of proximal radial migration. There had been no dislocations or prosthetic failures, but two implants had been removed for loosening. The prosthesis is recommended for use as a spacer to stabilise the elbow after severe injuries while the soft tissues heal.
Eight cases of unstable fractures caused by sharp heavy weapons such as swords or machetes are presented. A modern approach to these injuries is described against the historical background.
The effects of synovectomy and excision of the radial head in 40 elbows affected by rheumatoid arthritis have been assessed. In contrast with many reports indicating minimal side-effects of this procedure, a common pattern of deterioration from what was often a satisfactory initial result has been demonstrated. A biomechanical theory of one of the factors responsible for failure has been put forward and the importance of conserving or replacing the radial head emphasised.
