Distal Humerus Fracture, ABOS Oral Boards Preparation

This is a 67-year-old right-hand-dominant woman who slipped on ice and fell directly onto her left elbow. She has a history of rheumatoid arthritis treated with methotrexate and low-dose prednisone. She is an avid gardener and independent in all her activities. She presented with severe left elbow pain and complete inability to move the joint.

On exam, the elbow was markedly swollen with visible deformity and crepitus. The skin was intact but tented over the olecranon. I checked the ulnar nerve, small finger flexion and intrinsic function were normal. Radial and median nerves were intact. Radial pulse was 2+.

AP and lateral radiographs showed a comminuted bicolumnar distal humerus fracture, AO 13-C3, with articular comminution and displacement. The bone quality was osteopenic, consistent with her rheumatoid arthritis and chronic steroid use. I obtained a CT with 3D reconstruction, which confirmed the bicolumnar pattern and helped me understand the articular fragments for pre-operative planning.

This is a challenging fracture. In a 67-year-old with rheumatoid arthritis and osteopenic bone, total elbow arthroplasty is a legitimate alternative to ORIF. I discussed both options with her. TEA would give reliable pain relief and early motion, but it carries a lifetime activity restriction, typically a five-pound limit, and a higher long-term complication rate. ORIF preserves the native joint but demands good bone quality for fixation. Given that she is active, independent, and motivated, and that her bone, while osteopenic, was not severely osteoporotic, she elected for ORIF after understanding the trade-offs.

I performed ORIF through a posterior approach with an olecranon osteotomy for exposure. I used orthogonal dual plating with locking screws and transposed the ulnar nerve anteriorly. The olecranon osteotomy was fixed with a tension band construct.

Post-operatively, she began gentle active elbow motion at five days, early motion is critical after distal humerus fractures to prevent stiffness. At two weeks, wounds were healing well and she had 30 to 100 degrees of motion. At six weeks, X-rays showed early healing. At three months, she had 15 to 130 degrees of motion and was back to light gardening. At six months, the fracture was healed, she had a functional arc of motion, and she was satisfied with her result. I did discuss heterotopic ossification prophylaxis, I prescribed indomethacin for three weeks post-operatively given the severity of the injury.

At final follow-up, she was satisfied and back to gardening independently. Looking back, I spent considerable time debating ORIF versus total elbow arthroplasty preoperatively, and I think that was the right approach, but if the intraoperative articular reconstruction had not come together well, I should have had a lower threshold to convert to TEA. Having a total elbow implant available in the room as a backup is something I now do routinely for comminuted distal humerus fractures in patients over 60. I watched her carefully for ulnar nerve symptoms given the transposition and the hardware, and she remained neurologically intact.