Splinting for Distal Humerus Fractures
Immediate Recommendation
For nondisplaced or minimally displaced distal humerus fractures in pediatric patients, use a posterior splint (back-slab) rather than a collar and cuff, as it provides superior pain relief in the first 2 weeks after injury. 1
Treatment Algorithm by Fracture Type
Nondisplaced/Minimally Displaced Fractures (Gartland Type I)
- Apply a posterior splint extending from the upper arm to the wrist with the elbow at 90 degrees 1
- This approach provides better pain control compared to collar and cuff immobilization, based on randomized controlled trial evidence showing statistically significant pain relief within the first 2 weeks 1
- Avoid hyperflexion positioning, as this can cause limb-threatening ischemia 1
Displaced Fractures (Gartland Type II and III)
- Closed reduction and percutaneous Kirschner wire pinning is the preferred treatment 1
- Surgical fixation demonstrates superior outcomes with a number needed to treat (NNT) of 20 for preventing cubitus varus and NNT of 7 for Flynn's elbow criteria 1
- Simple casting of displaced fractures is inadequate and carries risk of limb-threatening complications 1
Critical Vascular Assessment
Immediately assess for vascular compromise, as this is the most serious complication that can lead to permanent nerve and muscle dysfunction: 1
- Check wrist pulses and hand perfusion status
- Pale, cold hand with absent pulses requires emergent reduction
- If vascular compromise persists after reduction and pinning, perform open exploration of the antecubital fossa immediately to prevent limb loss 1
- The catastrophic risks of delayed treatment include limb loss, ischemic contracture, and permanent functional deficit 1
Adult Distal Humerus Fractures
For adults with distal humerus fractures, the treatment paradigm differs significantly:
- Most adult distal humerus fractures require operative intervention with dual plate fixation 2
- Nonoperative management with splinting is reserved only for low-demand, medically unwell elderly patients who cannot tolerate surgery 3
- For elderly patients with comminuted intra-articular fractures not amenable to stable fixation, acute total elbow arthroplasty is preferred over attempted splinting 2
Functional Splinting Considerations
When nonoperative management is appropriate for humeral shaft involvement:
- Functional splints are superior to coaptation splints—they are easier to apply, better tolerated by patients, and achieve equivalent fracture reduction 4
- Functional bracing permits greater elbow range of motion (11-126 degrees) compared to traditional U-slab immobilization (50-119 degrees) without affecting fracture healing 5
Duration and Follow-up
- Obtain radiographic follow-up at approximately 3 weeks to confirm adequate healing 6, 7
- The evidence does not support a specific optimal time for pin removal in surgically treated cases 1
- Initiate active finger motion exercises immediately to prevent stiffness, which is the most functionally disabling complication 6, 8
Common Pitfalls to Avoid
- Never immobilize the elbow in hyperflexion—this can cause vascular compromise and compartment syndrome 1
- Do not delay reduction in cases with vascular compromise; the potential benefit of emergent manipulation outweighs transport time to specialized centers 1
- Avoid prolonged immobilization beyond what is necessary for fracture stability, as this increases stiffness risk 7
- Monitor for skin irritation and muscle atrophy, which occur in approximately 14.7% of immobilization cases 6, 8, 7
Technical Objectives for Surgical Cases
When operative fixation is required, stability depends on maximizing distal fragment fixation: 9
- Every screw should pass through a plate and engage the opposite fragment
- Place as many screws as possible in distal fragments with maximum length
- Create fixed-angle constructs by interdigitating screws
- Apply plates to achieve compression at the supracondylar level
- Parallel plating in the sagittal plane provides equal or superior stability compared to 90-degree orientation 9