Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

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Intercondylar Elbow Fracture

Basics
Description
  • Intra-articular fracture of the distal humerus, which may occur with a supracondylar fracture
  • Biomechanically and anatomically, the distal humerus forms a triangle composed of a medial column and a lateral column that support the articular surface of the trochlea.
  • The trochlea articulates with the ulna.
  • The capitellum is the part of the humerus that articulates with the radius and is part of the lateral column.
  • Classification:
    • No single classification system is uniformly accepted or used.
    • Many of the newer classification systems simply substitute the word column for condylar because this is believed to be more appropriate, given current understanding of the anatomy.
    • Single-column fractures:
      • Divided into medial or lateral fractures
      • High fractures involve most of the trochlea and are unstable.
    • Milch classification: Based on whether the fracture includes the lateral aspect of the trochlea
      • Type I: Analogous to a low, single-column fracture
      • Type II: Analogous to a high, single-column fracture
    • Bicolumn fractures: A more complex descriptive classification by Jupiter and Mehne is based on the fracture pattern as it traverses the columns and the articular surface.
      • T pattern
      • Y pattern
      • H pattern
      • Lambda pattern
    • Synonyms: Unicondylar fracture; Bicondylar fracture; Intra-articular distal humerus fracture
Epidemiology
  • This fracture occurs in all age groups.
  • In adults, the distal humerus fracture rate is ~5.7 cases per 100,000 in the population with an equal gender distribution.
  • Single-column fractures (unicolumnar, unicondylar) are more common in children than in adults.
  • Lateral column fractures are more common than medial column fractures.
Incidence
  • A single-column fracture is rare (3-4% of fractures of the distal humerus).
  • The reported incidence of bicolumn fractures varies markedly, ranging from 5-62% of all distal humerus fractures.
Prevalence
A bimodal age distribution is noted: Young patients (often male) involved in high-velocity trauma, or elderly osteoporotic patients (often female) with a lesser mechanism.
 
Risk Factors
  • Persons at risk for high-energy trauma
  • Elderly persons: Risks for falls and osteoporosis
Etiology
  • Falls: From a height; on an outstretched arm
  • Automobile versus pedestrian accidents
  • Motor vehicle accidents
  • Direct blows to the elbow
Associated Conditions
  • Neurapraxia
  • Vascular injury
  • Polytrauma
Diagnosis
Signs and Symptoms
  • Severe pain, swelling, and a decreased ability or inability to move the extremity at the elbow
  • Ischemia, dysesthesia, or paresthesia also possible (not common, but important to assess)
Physical Exam
  • These injuries often are associated with substantial energy, and the patient requires a thorough examination.
  • Extremity:
    • Evaluate soft tissues to establish open versus closed fracture status.
    • Marked swelling often is present.
    • Assess the limb for vascular status and signs of ischemia (pallor, capillary refill, peripheral pulses).
  • Neurologic status:
    • Evaluate and clearly document the neurologic status of the extremity in the ulnar, median (and anterior interossei), and radial (and posterior interossei) nerve distributions, including specific muscle testing and 2-point discrimination.
    • Often the patient cannot or will not move, or allow passive movement of, the elbow.
    • If the patient does move it, or allow it to be moved, marked crepitus often is present.
Tests
Imaging
  • Radiography:
    • Plain radiographs include AP and lateral views of the elbow and humerus and forearm views if indicated by examination.
    • Subtle signs, such as posterior or anterior fat pad signs, may be indicative of fracture.
    • Special views, such as the radiocapitellar view, can differentiate other fractures (e.g., radial head or capitellar fractures).
  • CT is useful for operative planning for partial articular fractures or fractures with severe comminution.
Differential Diagnosis
  • Humerus shaft fracture
  • Supracondylar fracture
  • Transcondylar fracture
  • Elbow dislocation
  • Elbow sprain
  • Capitellum fracture
  • Trochlea fracture
  • Olecranon fracture
  • Proximal single or both bones of the forearm fracture or dislocation
  • Radial head fracture or dislocation
  • Monteggia fracture or dislocation
Treatment
General Measures
  • The key to success in all these fractures is stability and early motion.
    • The current trend is to treat most of these injuries surgically.
  • The RICE protocol should be initiated even during evaluation.
  • If operative care is indicated, surgery preferably is performed early (within 2-3 days).
  • If the limb has a diminished or absent pulse, reduction with immobilization or traction should be performed.
    • If this procedure does not improve the status of the limb, angiography or surgical exploration should be performed.
  • The sequence of angiography versus immediate surgery depends on warm ischemia time, other injuries, availability of angiography, and the surgeon’s preference and experience.
  • Single-column fractures:
    • Nondisplaced fractures:
      • Rare and may be treated nonsurgically, but clinical and radiographic vigilance on the part of the physician is required
      • The duration of immobilization should be <2 weeks.
      • Treatment should include gentle passive ROM and placement in a hinged brace with gradually increasing motion.
    • Displaced fractures should be treated surgically.
  • Bicolumn fractures:
    • Treat surgically.
    • In rare cases (severe fracture comminution in an elderly patient or other patient unable to tolerate surgery), treat with immobilization.
Activity
  • Early motion is essential.
  • A period of 10-14 days of immobilization is considered by many to be the maximal acceptable duration.
  • Loaded motion (heavy lifting, repetitive loading) must be avoided until fracture healing has occurred.
Special Therapy
Physical Therapy
  • Early and carefully monitored ROM exercises are necessary to regain a functional arc of motion (100° of flexion).
  • A hinged brace is useful for guiding motion.
Medication
In the acute setting, the patient requires analgesia and postoperative antibiotics.
 
Surgery
  • Surgical therapy for the different types of intercondylar fractures is similar.
    • Most commonly, a posterior approach is used.
    • An olecranon osteotomy is useful for exposure.
  • 3.5-mm reconstruction plates and screws are used for rigid fixation.
    • 2 plates at right angles to each other give maximal strength to the repair.
      • The most common configuration is a plate placed posteriorly on the lateral column and medially on the medial column.
    • Newer plates are precontoured for the bones of the distal humerus.
  • It often is necessary to reconstruct the articular surface with screws before or concomitantly with plating 1 or both columns, to use bone graft, and to transpose the ulnar nerve.
  • Some single-column fractures are far less complex and require simpler constructs, sometimes a single screw or multiple Kirschner wires.
  • Elderly patients with severe comminution and osteoporotic bone can be treated with primary total elbow arthroplasty.
Follow-up
Prognosis
  • Despite the technical challenges, studies with the newer techniques have reported remarkably good results (~75% good to excellent results even with the most complex fractures).
  • For ROM, a good to excellent result is in the range of 15-30° to 120-130°.
Complications
  • Loss of ROM (all patients: usually 10-20° of extension, 10-20° of flexion)
  • Nonunion
  • Malunion
  • Posttraumatic arthritis
  • Loss of fixation
  • Symptomatic hardware
  • Osteonecrosis
  • Neurovascular injury
  • Ulnar neuropathy
  • Infection
  • Heterotopic ossification
Patient Monitoring
The patient must be monitored acutely and postoperatively for neurovascular status and compartment syndrome.
 
Miscellaneous
Codes
ICD9-CM
  • 812.41 Closed supracondylar fracture
  • 812.42 Lateral condyle fracture
  • 812.43 Medial condyle fracture
  • 812.51 Open supracondylar fracture
Patient Teaching
The patient must be informed that he or she will lose ROM at the elbow, and that the functional outcome greatly depends on patient compliance with ROM protocols and strict compliance with lifting and activity restrictions.
 
FAQ
Q: How are intercondylar fractures treated?
A: Most fractures are treated surgically to reduce the joint surface. Rigid fixation allows for early motion, without which elbow stiffness is inevitable.

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