What is the appropriate care plan for an adult patient with a distal humerus fracture and no significant past medical history?

Distal Humerus Fracture Care Plan

For an adult patient with a distal humerus fracture and no significant comorbidities, surgical fixation with dual-plate osteosynthesis is the treatment of choice to restore stable humeral columns and enable early elbow motion, with total elbow arthroplasty reserved for elderly patients with comminuted fractures not amenable to stable fixation. 1, 2

Initial Assessment and Imaging

• Obtain orthogonal radiographs (AP and lateral views) as the initial diagnostic study 1
• Add a traction view radiograph to better visualize fracture displacement and articular involvement 1
• Order CT scan with three-dimensional reconstruction for preoperative planning, particularly for complex fracture patterns 1
• Assess neurovascular status, paying particular attention to ulnar nerve function 1

Treatment Algorithm Based on Patient Age and Fracture Pattern

For Younger, Active Adults (Age <65 years)

Surgical osteosynthesis is the definitive treatment 1, 2

• Perform open reduction and internal fixation (ORIF) with dual-plate fixation 2
• Place one strong plate on each column (medial and lateral) 2
• Orient plates either at 90° (orthogonal) or 180° (parallel) to each other 1, 2
• This approach allows anatomic reduction, rigid internal fixation, and early elbow motion 1

For Elderly Patients (Age ≥65 years)

Decision depends on fracture complexity and bone quality 3, 4

• If fracture is amenable to stable fixation with good bone quality: proceed with dual-plate ORIF 2, 4
• If fracture is displaced, comminuted, intra-articular with poor bone quality: perform acute total elbow arthroplasty 2, 4
• Consider patient's functional demands, including whether they use upper extremity for weight-bearing with walker or rising from chair 4
• Have arthroplasty implants available in operating room in case trochlear fracture cannot be adequately plated 3

Surgical Approach Considerations

• Select approach based on fracture pattern, articular involvement, and need for ulnar nerve management 5
• Ensure chosen approach allows conversion to arthroplasty if intraoperative assessment reveals fracture not amenable to stable fixation 3
• Balance maximum exposure needed with minimum soft tissue disruption 5

Special Fracture Patterns

Displaced coronal shear fractures of the distal humeral articular surface require operative fixation via a lateral approach 2

Nonoperative Management (Rare Indication)

• Reserve for lower-demand, medically unwell, elderly patients who cannot tolerate surgery 1
• Provide appropriate pain control to facilitate early mobilization 6
• Initiate early range-of-motion exercises after brief immobilization (1-2 weeks maximum) to prevent elbow stiffness 7

Critical Pitfalls to Avoid

• Do not attempt nonoperative management in active adults, as distal humerus fractures require anatomic reduction for functional outcomes 1, 2
• Avoid prolonged immobilization beyond 2 weeks, as elbow stiffness causes major disability 7
• Do not proceed with ORIF in elderly patients with severe comminution and poor bone quality when stable fixation cannot be achieved 2, 4
• Ensure adequate preoperative planning with CT imaging to avoid intraoperative surprises 1

Postoperative Goals

Achieve at least 100° and preferably 120° of flexion-extension at the elbow 3

• Begin early range-of-motion exercises once surgical stability allows 1
• Provide adequate analgesia to enable participation in rehabilitation 6

Secondary Fracture Prevention (If Age ≥50 Years)

• Systematically evaluate for osteoporosis risk with DEXA scan, vitamin D, calcium, and parathyroid hormone levels 8
• Initiate pharmacological treatment with bisphosphonates or alternative anti-osteoporotic medication based on results 8
• Implement Fracture Liaison Service model for coordinated secondary prevention 8