Journal Reading: Dr. Firdaus Ramli

Journal reading
dr. Firdaus Ramli

Abstract
Introduction
• Fractures of the distal humerus account for 1% of

fractures sustained by adults : two-thirds of those
affected are aged 50 years or older.
• Most distal humeral fractures are routinely treated by

open reduction and internal fixation (ORIF) but this is
controversial in the frail, elderly and low-demand
patient with osteoporotic bone.
• Conservative methods of treating a fracture of the distal
humerus, including the ‘bag of bones’ technique in which
the position of the displaced fragments is accepted and
early movement encouraged, are now rarely considered
as they are thought to give poor functional results.
• This study present its experience of the conservative

management of fractures of the distal humerus in selected
elderly and low-demand patients for whom the inherent
risks of anaesthesia and surgery were substantial.
 The aim of this study was to present the short-
and medium-term functional outcomes of
primary conservative treatment of a fracture of
the distal humerus in elderly and low demand
patients.
Methods
 This study describes the clinical outcomes of a

retrospectively compiled case series of patients
managed using a standard method of
treatment.
 This study reviewed the case notes and

radiographs of all patients aged 50 years or more
with a fracture of the distal humerus which had
been treated conservatively between March
2008 and December 2013 at our hospital.
 In this hospital serves a predominantly urban
population, 50% of whom reside in the most
deprived socioeconomic national quintile, as
measured by the Scottish Index of Multiple
Deprivation.
Fracture classification and radiographic

measurements :
 All anteroposterior (AP) and lateral radiographs
of the elbow joint were reviewed and classified
by one author (SAA) according to the
Arbeitsgemeinshaft für Osteosynthesfragen (AO)
system
Treatment protocol :
 Conservative management of a fracture of the
distal humerus was defined as non operative
treatment or surgical intervention limited to the
early excision of potentially impinging bony
fragments.
Short-term functional data:

 The electronic patient Record (EPR) was
examined to determine the clinical examination
findings at out-patient review within one year of
injury
Medium-term functional data:
 Surviving patients were contacted by telephone and
invited to participate in the study by providing
medium-term functional data.
 Patients were asked to complete the Oxford elbow

score (OES)14 and Disabilities of the Arm, Shoulder and
Hand (QuickDASH)15 questionnaires.
Baseline characteristics :
 A total of 40 patients aged 50 years or more with distal
humeral fractures were treated conservatively, of
whom 29 (72.5%) were women. The mean age of the
cohort was 73.5 years (50 to 93).
Statistical analyses :
 The chi-squared test was used to compare differences
between proportions. Normally distributed continuous
data were presented as the mean, standard deviation
(SD) and range.
Results
 A Charlson comorbidity index of 2 or more was found

in 22 (55.0%) patients and a history of alcohol abuse
noted in 16 (40%). A fall from a standing height
accounted for 37 (92.5%) fractures: the remainder
were the result of a fall down multiple stairs. One
patient sustained an associated fracture of the
ipsilateral olecranon and seven (17.5%) an injury
elsewhere in the same limb. One fracture was open. In
total 28 fractures (70.0%) were displaced, 15 (37.5%)
comminuted and 17 (42.5%) had articular incongruity,
with a mean articular step of 5.2 mm (0 to 17, SD 3.8).
Table I : 19 (47.5%) fractures were AO type A, seven (17.5%) type B and
14 (35.0%) type C.
Short-term functional outcome :
 The first pooled out-patient dataset was recorded at a mean
of 40 days (5 to 78; SD 31.7) post-injury and the second at 115
days (23 to 209; SD 88). After excluding missing information,
adequate data were available for 32 (80%) patients at the first
review and 24 (60%) at subsequent review. There were 21
(53%) patients with flexion-extension data for both the first and
second visit, and 13 (33%) with forearm rotation data.
 Mean extension improved from 60° (20° to 85°; SD 18.8) to 49°

(30° to 80°; SD 18.6), (p < 0.001, paired t-test), mean flexion
from 107° (90° to 140°; SD 8.3) to 120° (95° to 140°; SD 14.6), (p =
0.075, paired t-test), and mean forearm rotation from 112° (45°
to 170°; SD 28.0) to 141° (90° to 175°; SD 18.0), (p = 0.01, paired
t-test). The mean Broberg and Morrey score improved by 25
points during short-term outpatient review: from a “poor” 42.5
points (23 to 80; SD 12.2) to a “fair” 67.1 points (40 to 88; SD
13.5), (p < 0.001, paired t-test).
Union and surgical intervention :
 The early excision of potentially impinging bony
fragments was undertaken as a planned procedure
in five patients at a mean of 20 days (5 to 49; SD
19.8) from injury. One patient died 20 days after
fracturing. Of the remaining 34 patients in whom
bony union could be assessed, 19 (55.9%) progressed
to union and 15 developed nonunion (44.1%). Of
those with united fractures, one patient (5.3%)
underwent TEA after three months for stiffness and
poor function in an already severely eroded
rheumatoid elbow.
Table II shows the cumulative rates of fracture
union, patient mortality, and surgical intervention for the
study cohort.
Medium-term functional outcome :
 A total of 20 patients provided data at a mean of 46
months (5 to 73; SD 20) from injury. Of these, eight had
fractures which had united, eight had a nonunion and
four had an early planned excision of fragments.
 No difference in outcome between men and women

was noted (OES p = 0.314; QuickDASH p = 0.826;
satisfaction p = 0.586). There was no correlation
(Spearman’s rho) between patient age and OES (p =
0.087, p = 0.715), QuickDASH (p = 0.016, p = 0.945) or
satisfaction (p = 0.134, p = 0.562)
There was no difference seen in the distribution of
functional outcome scores (OES, QuickDASH) between
AO fracture types (Table I) or between those patients with
fractures which united and those which did not (Table III).
The medium-term distribution of pain scores provided is
shown in Figure 2. There was no difference in the distribution
of pain scores between patients with united and ununited
fractures in terms of rest pain (p = 0.080, Mann–
Whitney U test), night pain (p = 0.182, Mann–Whitney
U test) or pain on heavy lifting (p = 0.133, Mann–Whitney U test).
Discussion
 The main strength of this study is that is addresses the

short- and medium-term functional results for a method of
treating fractures of the distal humerus that is rarely used
in current practice, but may still be appropriate in certain
groups of patients.
 By comparison, examination of the literature reveals that

patients with a conservatively managed fracture of the
distal humerus tend to have poorer elbow function in the
medium-term than patients with a conservatively
managed displaced fracture of the olecranon (OES
47/48), a simple elbow dislocation (43/48) or a rupture of
the distal tendon of biceps which has been treated
operatively (42/48).
 In keeping with many retrospective reports, our study was
limited by the analysis of available data from the EPR and
patient case notes. In some instances, only 50% of the desired
information was retrievable and this hampered a more detailed
analysis of our functional results by AO fracture type in the short
term.
Conclusion
 the conservative management of a fracture of

the distal humerus in a low demand patient gives
only a modest functional result but avoids the
potential surgical risks associated with ORIF or
TEA.
 The relevant advantages and disadvantages of

both surgical and non-surgical options should be
discussed, before any informed decision is made.
If there is failure to improve, delayed TEA can still
be offered at a later date as an elective
procedure.
THANK YOU

Journal Reading: Dr. Firdaus Ramli

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Journal reading

dr. Firdaus Ramli

• Fractures of the distal humerus account for 1% of

• Most distal humeral fractures are routinely treated by

• This study present its experience of the conservative

 This study describes the clinical outcomes of a

 This study reviewed the case notes and

Fracture classification and radiographic

Short-term functional data:

 Patients were asked to complete the Oxford elbow

 A Charlson comorbidity index of 2 or more was found

 Mean extension improved from 60° (20° to 85°; SD 18.8) to 49°

 No difference in outcome between men and women

 The main strength of this study is that is addresses the

 By comparison, examination of the literature reveals that

 the conservative management of a fracture of

 The relevant advantages and disadvantages of

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