Does an acute minimally displaced fracture of the distal medial humeral metaphysis require immediate reduction?

Management of Acute Minimally Displaced Fracture of the Distal Medial Humeral Metaphysis

Minimally displaced fractures of the distal medial humeral metaphysis do not require immediate reduction and can be managed conservatively with immobilization and early controlled mobilization as pain allows.

Assessment and Classification

• Radiographic evaluation is essential to determine fracture pattern, displacement, and stability 1
• Minimally displaced fractures are defined as those with:
  • Less than 15 degrees angulation
  • Less than 5 mm displacement 2
• CT scan may be needed in complex cases to fully assess fracture pattern 1

Treatment Algorithm

Conservative Management (Recommended First-Line)

For truly minimally displaced fractures:

1. Initial Immobilization:

   • Rigid immobilization with a posterior splint provides better pain relief in the first 2 weeks 1
   • A three-phase rehabilitation protocol should be followed:
     • Initial phase (0-2 weeks): Sling immobilization with pendulum exercises
     • Early mobilization phase (2-6 weeks): Progressive active-assisted range of motion
     • Strengthening phase (6-12 weeks): Progressive resistive exercises 1

2. Follow-up Protocol:

   • Regular radiographic evaluation at 1,3, and 6 weeks to ensure fracture stability
   • Clinical assessment of pain and range of motion at each follow-up 1
   • Watch for signs of displacement during healing

Indications for Surgical Intervention

Surgery is indicated only if:

• Fracture displacement increases during follow-up
• Patient develops significant functional limitations despite adequate conservative management 1
• There is vascular compromise requiring emergent reduction 1

Expected Outcomes

With appropriate conservative management:

• High union rates (100% in studied cases) 2
• Good functional outcomes (median Constant score of 89 points) 2
• Most patients (85%) able to perform all activities of daily living 3

Potential Complications and Management

• Loss of reduction: Regular radiographic monitoring to detect early
• Stiffness: Early controlled mobilization as pain allows
• Pain: Adequate analgesia during initial healing phase
• Rotator cuff issues: May develop in some patients, requiring targeted rehabilitation 3

Special Considerations

• Age significantly affects outcomes - younger patients generally have better results 2
• Bone quality assessment is important, especially in older patients 1
• The American Academy of Orthopaedic Surgeons guidelines suggest that the practitioner's judgment is important in determining treatment approach, especially when considering the risk-benefit ratio of surgical versus non-surgical management 4

Conclusion

Conservative management with appropriate immobilization and early controlled mobilization is the treatment of choice for minimally displaced fractures of the distal medial humeral metaphysis. Surgical intervention should be reserved for cases where displacement increases during follow-up or functional limitations develop despite adequate conservative management.