Arch Orthop Trauma Surg (2006) 126: 188–191

DOI 10.1007/s00402-006-0116-7

CASE REPORT

Carl Haasper Æ Michael Jagodzinski Æ Christian Krettek

Johannes Zeichen

Hinged external fixation and closed reduction for distal humerus fracture

Received: 14 April 2005 / Published online: 2 March 2006

Ó Springer-Verlag 2006

Abstract Elbow fractures are relatively rare in extremity with diabetes mandate a stepwise protocol to minimize
injuries. Functional deficits often comprise the outcome. the potential complications of delayed fracture healing
We report of a 77-year-old diabetic lady with a distal and wound complications. Hinged external fixation of
humerus fracture. She was treated with external fixation the elbow has been used with success for elective
and closed reduction. Special emphasis was directed to treatment of elbow dislocations [16], degenerative dis-
early motion exercises. Follow-up after 1 year demon- eases or contractures [2, 12]. This technique might be
strated a range of motion of 0-30-130° for extension and indicated in some distal humerus fractures although
flexion of the elbow joint. No neurovascular deficits there are no reports in the literature until the present
were seen. The use of a hinged device was successful in day after early application of such a device in acute
re-establishing a good function. Although there are no treatment. Hence, we report of a case using a tech-
earlier reports using this technique in acute treatment, nique that primarily leads up to good functional
we consider this strategy as an alternative option in results.
carefully selected cases.

Keywords Elbow Æ Joint spanning Æ Articulated Æ Case report

Injury
A 77-year-old diabetic female was presented to the
emergency room with pain in the left elbow after
Introduction stumbling over a curb. She showed tenderness over the
radial side with crepitation. There were no neurovas-
Although fractures of the elbow are quite rare cular deficits seen. Radiographic investigations indi-
compared with the total incidence of extremity injuries cated a distal humerus fracture of the radial and ulnar
(2–6% of all extremity fractures [1, 15, 18]), the condyle (Type C3.3 [8], Fig. 1). Due to the co-mor-
proximity of neurovascular structures requires careful bidity of diabetes it was decided to treat her with
attention. In elderly women, fracture incidence of the closed reduction and application of a hinged external
distal humerus from the Finnish National Hospital fixation.
Discharge Register is quoted at approximately 200 per The device we used was the Compass hinge (Smith
100,000 women [10]. Outcomes are as yet often com- and Nephew, Memphis, TE, USA) which is applicable
promised by functional deficits, especially following with Ilizarov instrumentation. Under plexus anaesthe-
prolonged immobilization. Fractures in elderly patients sia, the elbow’s centre of rotation joint was determined
using a pin under fluoroscopic control. This pin was
inserted to position the hinges of the external fixation
with the proximal and distal rings attached to the
humerus and the ulna. Two Ilizarov half-rings were
C. Haasper (&) Æ M. Jagodzinski Æ C. Krettek Æ J. Zeichen fixed with Steinmann’s nails drilled into the bones.
Trauma Department, Hanover Medical School (MHH), After distraction and radiological control of concentric
Carl-Neuberg-Strasse 1, reduction the fixation was temporally locked in 20° of
30625 Hannover, Germany flexion.
E-mail: haasper.carl@mh-hannover.de
Tel.: +49-511-5322050
Physiotherapy was initiated the next day with active
Fax: +49-511-5325877 and passive range of motion exercises. Prior to discharge
URL: www.mhh-unfallchirurgie.de she was able to reach 0-30-90° range of motion and
 189

Fig. 1 A 77-year-old diabetic female struggled over a curb and The lateral radiograph (b) shows a double arc including parts of the
injured the left elbow. The anteroposterior radiograph (a) shows trochlea and the capitellum. To enhance the three-dimensional
displaced articular fragments from the capitellum and the trochlea. understanding a CT reformation (c) was performed

physiotherapy was continued on an outpatient basis.

Radiological results were documented (Fig. 2). Discussion
Seven weeks after application the hinge was removed
under local anaesthesia (Figs. 3, 4). Four months after Distal humerus fractures in elderly diabetic patients
trauma the patient was free of pain. The left elbow are a challenging task. The therapeutical recommen-
showed normal alignment and was neurovascular intact. dations, also in the elderly, are relatively homoge-
There were no signs of infection. The range of motion neous: primary open reduction and internal fixation
was 0-30-110° and the joint was stable on examination. should be carried out aiming for an early postopera-
There were no side-to-side difference with respect pro- tive functional treatment, but it carries the risks of
and supination. Physiotherapy was prescribed to non-union, loss of fixation, infection, and stiffness [9].
enhance extension. Radiographic control showed con- Nevertheless, operative treatment is recommended for
centric reduction of the elbow and a proper joint displaced fractures in recent studies [14]. Early mobi-
alignment. On follow up after 1 year she demonstrated a lization is critical for late functional outcome of elbow
range of motion of 0-30-130°. Mayo Performance Index fractures; however, its extend depends on the method
was 80 demonstrating a good result [7]. of primary treatment [18]. Elbow instabilities are rare

Fig. 2 Anteroposterior (a) and lateral (b) radiograph made days after surgery show stable realignment of the fracture fragments and
applied external device: Compass hinge (Smith and Nephew, Memphis, TE, USA). c Clinical impression of the hinge in place
190

cannot be sufficient. Alternatively a hinged external

fixation can span the joint, stabilize it, and permit early
functional treatment [20]. It fosters an immediate return
to a partial range of motion. In the literature we were
able to review that there is only one case described using
such a device lately after elbow instability due to a distal
humerus fracture, which was treated initially with
internal fixation [3].
Recently, there were reports using hinged external
fixation to provide stability and early mobilization for
complex elbow dislocations and fractures, example given
of the radial head, with good results [5, 6, 11, 16]. Those
findings suggest that operative treatment with changes
of anatomy is not necessary. Also repair of ligaments
seems not to be necessary. This shows that even in case
of dislocation there may be no mandatory need for open
reduction. Stable and concentric reduction is the key for
an acceptable outcome.
Biomechanical investigations using an elbow joint
spanning hinged external fixation showed correct joint
Fig. 3 Anteroposterior (a) and lateral (b) radiographs made position between 0 and 120° with variation of the central
4 weeks after hardware removal and 11 weeks after injury show a
bony consolidated fracture of the elbow axis through the radial and ulnar condyle of less than 3°
[17]. This underlines the need of on accurate placement
of external fixation where the hinge has to be co-linear
after injury of the distal humerus and external fixation with the axis of rotation of the joint [6].
is not typically used [4, 13]. Function and stability of Hinged external fixation combines advantages of
the ulno-humeral joint after trauma is dependent on closed reduction with minimal complications for wound
bony and soft tissue constraints, because those make it healing and early mobilization to enhance the functional
to one of the most stable articulations in the human outcome. We did not observe potential disadvantages
body. Therefore elbow surgery remains a very chal- like poor stability or infection [3]. Our outcome was
lenging task. Due to lack of randomized trials, many satisfying and in our view justified an uncommon sur-
clinical decisions have to be based on empirical gical treatment.
evidence. We suggest that the use of a hinged external fixation
External fixation of juxta-articular fractures of the in distal humerus fracture is rarely indicated, but could
elbow has been reported earlier, after good results in be an interesting alternative of success for cases like the
treating such fractures in the lower extremity. In par- one we describe. Compromised patients with high risk of
ticular, those of the tibial plateau postulated gratifying infection and non-high demanders for function might
success applying this non-joint spanning technique to gain benefit of this treatment with early motion exercise.
the distal humerus for restoring limb alignment and Restoring a good function and avoiding neurovascular
permitting immediate joint motion [19]. In case of deficits should be the prerogatives of all treatment
unstable reduction or joint dislocation this technique strategies.

Fig. 4 Extension (a) and

Flexion (b) in clinical pictures
on an outpatient visit a few
weeks after hardware removal
 191

11. Pennig D, Gausepohl T, Mader K (2000) Transarticular fixa-

References tion with the capacity for motion in fracture dislocations of the
elbow. Injury 31:35–44
1. Beck E (1982) Konservative Behandlung von Brüchen am 12. Pennig D, Gausepohl T, Mader K, Wolfgarten B (2001) Dis-
distalen Oberarmende. Hefte Unfallheilkd 155:26–34 traction arthrolysis with humero-ulnar motion fixator. Ortho-
2. Fox RJ, Varitimidis SE, Plakseychuk A, Vardakas DG, Tom- pade 30:635–644
aino MM, Sotereanos DG (2000) The compass elbow hinge: 13. Ring D, Jupiter JB (1998) Fracture dislocation of the elbow. J
indications and initial results. J Hand Surg [Br] 25:568–572 Bone Joint Surg [Am] 80:566–580
3. Hall J, Schemitsch EH, McKee MD (2000) Use of a hinged 14. Ring D, Jupiter JB, Gulotta BA (2003) Articular fractures of
external fixator for elbow instability after severe distal humeral the distal part of the humerus. J Bone Joint Surg [Am] 85:232–
fracture. J Orthop Trauma 14:442–445 238
4. Jupiter JB, Mehne DK (1992) Elbow trauma: fractures of the 15. Robinson CM, Hill RM, Jacobs N, Dall G, Court-Brown CM
distal humerus. Orthopedics 15:825–833 (2003) Adult distal huneral metaphyseal fractures: epidemiol-
5. Jupiter JB, Ring D (2002) Treatment of unreduced elbow dis- ogy and results of treatment. J Orthop Trauma 17:38–47
locations with hinged external fixation. J Bone Joint Surg [Am] 16. Ruch DS, Triepel CR (2001) Hinged elbow fixation for recur-
84:1630–1635 rent instability following fracture dislocation. Injury 32:70–78
6. McKee MD, Bowden SH, King GJ et al (1998) The manage- 17. Schmickal T, Wentzensen A (2000) Treatment of complex el-
ment of recurrent complex elbow instability with a hinged bow injuries by joint-spanning articulated fixator. Unfallchir-
external fixator. J Bone Joint Surg [Am] 80:1031–1036 urg 103:191–196
7. Morrey BF, An KN, Chao EY (1993) Functional evaluation of 18. Seekamp A, Regel G, Blauth M, Klages U, Klemme R, Tsch-
the elbow. The Elbow and its disorders, Saunders, Philadel- erne H (1997) Long-term results therapy of open and closed
phia, pp 86–97 fracture of the elbow joint. Unfallchirurg 100:205–211
8. Müller ME, Nazarin S, Koch P, Siegel JH (1990) Compre- 19. Skaggs DL, Hale JM, Buggay S, Kay RM (1998) Use of a
hensive classification of fractures of the long bones, Berlin hybrid external fixator for a severely comminuted juxta-artic-
Heidelberg New York, Springer ular fracture of the distal humerus. J Orthop Trauma 12:439–
9. Obremskey WT, Bhandari M, Dirschl DR, Shemitsch E (2003) 442
Internal fixation versus arthroplasty of comminuted fractures 20. Volkov MV, Oreganesian OV (1975) Restoration of function in
of the distal humerus. J Orthop Trauma 17:463–465 the knee and elbow with a hinge distractor apparatus. J Bone
10. Palvanen M, Niemi S, Parkkari J, Kannus P (2003) Osteopo- Joint Surg [Am] 57:591–600
rotic fractures of the distal humerus in elderly women. Ann
Intern Med 139:236–237