CASE REPORT

OPEN FRACTURE LEFT SUPRACONDYLAR HUMERUS AND

MALUNION LEFT INTERCONDYLAR HUMERUS TREATED WITH
OPEN REDUCTION AND ELBOW HINGE EXTERNAL FIXATION : A
CASE REPORT

MADE ASMARA YOGA

1871111005

PROGRAM PENDIDIKAN DOKTER SPESIALIS I

PROGRAM STUDI ORTHOPAEDI DAN TRAUMATOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS UDAYANA
RUMAH SAKIT UMUM PUSAT SANGLAH
DENPASAR
2019
 Open Fracture Left Supracondylar Humerus and Malunion Left
Intercondylar Humerus Treated with Open Reduction and Elbow hinge
External Fixation : A Case Report
Made Asmara Yoga
Department of Orthopaedics and Traumatology
Sanglah General Hospital/Faculty of Medicine, Udayana University, Denpasar, Bali

Abstract
Introduction
An open fracture is one in which a break in the skin allows for direct communication of
the fracture site or fracture haematoma with elements external to the usual protection of the skin"
[1]. It is estimated that 1 in every 120 persons under the age of 65 years will have fracture and
3% of these fractures are open. Three to six million fractures occur yearly in the United States.
Thus fractures are a major public health concern [2, 3]. The degree of soft tissue and bony
injuries vary with the amount of energy dissipated during the fracturing process and this
eventually also affect the healing process and complication rate. Due to the exposure of the
fracture site to the environment and other peculiarities of open fractures, their management poses
a serious challenge to every practicing orthopaedic surgeon in spite of recent advances in
management protocols. There is increased risk of infections, delayed unions, non-unions and
increased amputation rate.
The management of open fractures has been a continuing source of controversy within
the orthopedic society [1, 2]. Damage in soft tissues and local perfusion represents major issues
in treatment of open fractures. For the assessment of open fractures, the Gustilo-Anderson
classification system was widely used [3]. Depending on severity of the lesion, treatment might
include debridement and internal and external fixation in the acute management [4, 5].
Case Report
A 61-years-old right-handed male came to the outpatient clinic with chief complain of
pain on his left elbow since three weeks ago. The patient got into a motor accident. He fell from
his motorcycle and landed on his left elbow. He was unable to lift his arm and do daily activity
properly, such as lift a spoon in the last 3 years. Patient also had history of left elbow trauma 3
years ago. During that time, he did not seek doctor / medical care, instead he went to bonesetter
to treat his condition. Several manipulations were done by the bonesetter but until now, patient
cannot use his left arm properly.
 Physical examination of left elbow showed swelling, and S-shaped deformity with no
bruise. There was wound approximately 5 mm x 5 mm with no active bleeding. Tenderness
around the elbow and paresthesia along the lateral border of the arm was apparent. His active and
passive elbow range of motion was also limited. Patient also not able to do wrist extension,
thumb extension, and finger extension. Left elbow plain x-ray demonstrated communitive
fracture of the supracondylar of the humerus.

Figure 1. Clinical picture of patient’s left elbow

Figure 2. Pre-operative x-ray of the left elbow,

showing communitive at the distal humerus to
medial epicondyle. Capitellum, trochlea and lateral
epicondyle are still intact.
 Figure 3. CT Scan 3D of left elbow

Patient undergone open reduction followed by screwing fragment supracondylar and elbow
hinge external fixation.

Figure 4. Clinical Picture Durante Op

Figure 5. Post-operative X-ray of left elbow

 Figure 6. Clinical picture Post Op

Discussion
Distal humerus fractures represent 2% of all adult elbow fractures. Malunion is a rare but serious
complication of distal humerus fractures. There can be significant sequelae of failure to
reestablish anatomic joint congruity resulting in pain, stiffness, and instability. Delayed union
and nonunion have been reported to be 2% to 10%. In addition, patients may develop ulnar
neuropathy as a result of perineural fibrosis or neurapraxia due to joint laxity or progressive
valgus deformity. In this report, we present a case in which the patient has a fracture that affect
the supra and also intercondyle humerus due to malunion and stiff yet unstable elbow joint.
There are several surgical options for malunion of the distal humerus, including revision open
reduction and internal fixation, arthrodesis, total elbow arthroplasty, and hemiarthroplasty.
Revision corrective osteotomy with rigid fixation remains the procedure of choice for young
active individuals.
Besides extensive open or closed soft-tissue damage, the main indications for the use of external
fixation are residual instability or polytraumatized patients. The function of the external fixation
is to establish quickly and temporarily a stable position of the elbow joint. The application takes
place most often in the supine position. External fixation is only of limited suitability for the
treatment of distal humerus fractures, since an anatomical reduction is not possible and because a
long position of rest is accompanied by substantial limitations of movement in the region of the
elbow joint. Therefore, the function of external fixation is temporary stabilization until the
prerequisites exist for internal osteosynthesis. The standard construct consists the placing of two
Schanz screws in the humerus and the ulna. In the region of the humerus shaft, attention must be
paid to the radial nerve. The Schanz screws are inserted proximal to the crossing of the radial
nerve anterolateraly. Sufficiently large skin-incisions with blunt dissection of the bones and
insertion of drilling sleeves are indispensable for the protection of the nerves.
With the forearm in neutral position, Schanz screws are inserted from a posterolateral aspect
directly to the proximal third of the ulna. It is an easily recognizable and palpable bone. The
radius shaft should only be included for limitation of the rotation movement of the forearm. If
the fixation is installed in the three tube modular technique it can easily switch to movement
fixation, in cases of persisting instability, by installing a movement bracket.
A hinged external fixator (Compass Hinge, Smith and Nephew, Memphis, TN) was applied in
every case to maintain concentric ulnohumeral reduction while allowing for mobilization of the
extremity. The elbow was taken through ROM and relaxing incisions were made around pins
where skin tension was noted. The initial expected duration of the fixator was 6 to 8 weeks.
Even for geriatric patients the anatomical reconstruction of the joint with sufficient stability has
to be the primary therapeutic goal, thus providing the prerequisite for early functional
rehabilitation and especially for daily activities (handling the walker). Primary stability in
osteoporotic bones can be achieved through the use of angular stable osteosynthesis. Most
complications are the loss of the reduction with implant failure due to poor bone quality.
Therefore in exceptional cases a postoperative immobilization, a corresponding orthesis or a
supplemental installation of a movement fixator is possible. If reconstruction is not possible due
to the complexity of the fracture or the bone quality, then the joint replacement is indicated.
Ulnar neuropathy is common in distal humerus malunions. Poor initial reduction can lead to
progressive valgus instability and deformity. Deformity and fibrosis lead to ulnar nerve insult,
eventually digressing to neuropathic symptoms. McKee et al reported that 9 of 13 patients with
distal humerus malunions were concurrently experiencing clinical dysfunction of their ulnar
nerve.
Historically, extensive reconstructive procedures required to restore elbow function were poorly
tolerated owing to prolonged immobilization that caused elbow joint contracture and loss of
function. With the use of the hinged external fixator, it is possible to reestablish the anatomic
axis of the ulnohumeral joint and allow for early concentric ROM while maintaining a stable
fixation construct. After open reduction and repair of osseous and ligamentous stabilizers of the
elbow, a hinged external fixator allows for immediate concentric joint motion while the soft
tissues are protected and allowed to heal in the optimal position for motion

Conclusions
We report a case of open fracture left supracondylar humerus and malunion left
intercondylar humerus treated with open reduction and elbow hinge external fixation.
References

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