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Fracture of the lateral humeral epicondyle — Clinical Guidelines

Overview

Fractures of the lateral humeral epicondyle, often part of more complex proximal humeral fractures, involve the outer bony prominence of the elbow, typically resulting from valgus stress, such as during throwing motions or falls. 6 7

Diagnosis

Clinical Presentation: Pain, swelling, and tenderness over the lateral epicondyle. 6

Imaging: X-rays are essential for initial diagnosis, often supplemented by MRI for detailed assessment of soft tissue injuries and fracture patterns. 1 6

Classification: Utilize Neer classification for proximal humeral fractures, distinguishing between two-part, three-part, and four-part fractures. 1 7

Management

Surgical Options:

- Locking Plates: Effective for stabilization, with studies showing comparable outcomes to intramedullary nails. 2 - Intramedullary Nails: Alternative fixation method with similar clinical outcomes to locking plates. 2 - Low-Profile Plates: Enhanced fixation properties shown to improve stability and outcomes in proximal humeral fractures. 1

Supplemental Techniques:

- Suture Fixation: For rotator cuff stabilization in conjunction with plating to improve clinical outcomes. 4

Non-Surgical: Immobilization in a sling for initial management, followed by physiotherapy for conservative treatment approaches. 5

Special Populations

Elderly: Higher prevalence of associated rotator cuff tears, but cuff integrity does not significantly influence functional outcomes post-fracture. 5

Comorbidities: Increased risk of complications such as avascular necrosis and nonunion; careful consideration of surgical versus conservative management is advised. 8

Key Recommendations

Use of Locking Plates or Intramedullary Nails: For two-part and three-part proximal humeral fractures, either locking plates or intramedullary nails provide comparable clinical outcomes. (Evidence: Moderate 2)

Consider Supplemental Rotator Cuff Stabilization: In operative cases, incorporating suture fixation techniques for the rotator cuff may enhance clinical results. (Evidence: Moderate 4)

Indirect Reduction Techniques: For complex fractures, indirect reduction with minimal manipulation followed by plate fixation can reduce risks like avascular necrosis. (Evidence: Moderate 7)

Close Monitoring in Elderly Patients: Given the higher incidence of associated injuries and complications, elderly patients require meticulous monitoring and individualized treatment plans. (Evidence: Expert opinion)

References

1 Fidanza A, Rossi C, Iarussi S, Necozione S, Indelli PF, Calvisi V. Proximal humeral fractures treated with a low-profile plate with enhanced fixation properties. Journal of orthopaedic science : official journal of the Japanese Orthopaedic Association 2022. link 2 Gracitelli ME, Malavolta EA, Assunção JH, Kojima KE, dos Reis PR, Silva JS et al.. Locking intramedullary nails compared with locking plates for two- and three-part proximal humeral surgical neck fractures: a randomized controlled trial. Journal of shoulder and elbow surgery 2016. link 3 Altintas B, Biber R, Bail HJ. Is it safe to assist proximal humeral nailing to residents? An analysis of 1134 cases. Injury 2016. link30846-4) 4 Badman B, Frankle M, Keating C, Henderson L, Brooks J, Mighell M. Results of proximal humeral locked plating with supplemental suture fixation of rotator cuff. Journal of shoulder and elbow surgery 2011. link 5 Nanda R, Goodchild L, Gamble A, Campbell RS, Rangan A. Does the presence of a full-thickness rotator cuff tear influence outcome after proximal humeral fractures?. The Journal of trauma 2007. link 6 Green A, Izzi J. Isolated fractures of the greater tuberosity of the proximal humerus. Journal of shoulder and elbow surgery 2003. link86811-2) 7 Hessmann M, Gotzen L, Gehling H, Baumgaertel F, Klingelhoeffer I. Operative treatment of displaced proximal humeral fractures: two-year results in 99 cases. Acta chirurgica Belgica 1998. link 8 Muldoon MP, Cofield RH. Complications of humeral head replacement for proximal humeral fractures. Instructional course lectures 1997. link 9 Whitaker JH. Arm wrestling fractures--a humerus twist. The American journal of sports medicine 1977. link

Fracture of the lateral humeral epicondyle