Providential non-union of the medial condyle of distal humerus: a case report

INTRODUCTION

Fractures of the distal humerus of the adult represent about 2% of all traumatic skeletal lesions.¹ Neglected, they are often complicated by non-union.² According to the Mitsunaga classifications of 1982, there are 5 types according to the seat.³ Despite the fact that they can cause mild pain, instability and loss of grip strength, in some cases they do not require surgical treatment.^4-6 Several therapeutic options have been described in the literature, ranging from internal fixation to arthrodesis and arthroplasty.^2,7 They have the advantage of improving the function and stability of the elbow, but it remains a source of significant complications.⁸ Non-union of the distal humerus is rare and that of its medial condyle even more. We report here a case of medial condyle non-union of the humerus complicating a fracture of the distal humerus in which the option of therapeutic abstention was adopted because of its providential nature.

CASE REPORT

He is a 19 years old trader, right-handed, with no particular past medical history, seen in consultation at 6 months of a neglected trauma of the right elbow during a fight. He was beaten on the elbow. The initial care was done by the bonesetter. Faced with the persistence of a relative functional impotence, a decrease in limb strength and transient pains, he makes an appointment for orthopedic consultation.

The physical examination found a good general condition, a muscular atrophy of the forearm estimate at 2 cm difference from the opposite side. He found a protrusion of the medial condyle with a discreet blow of the posterior ax. The palpation showed a disorganization of the anatomical bone configuration of the elbow. The Hueter line and the Nelaton triangle were not found respectively in full extension and in 90° bending. There was abnormal mobility with little pain in the medial condyle. The articular amplitudes were respectively at -25° and 130° for extension and flexion. Pronation was at 30° and supination at 60°.There was no instability in varus and forced valgus. Elbow use was normal (Figure 1). There was no sensory, motor or vascular disorder. The general examination was otherwise normal. Borberg and Morrey’s functional score (Table 1) of the elbow attributed 30/40 points to mobility, 13/20 to strength, 5/5 to stability and 28/35 points to pain. For an overall score of 76/100, evaluating the function of the elbow at the average level.

The radiograph of the elbow in frontal and lateral incidence showed of a non-union of the type E medial condyle according to Mitsunaga classification. It was associated with a partial dislocation of the humeroulnar joint (Figure 2). The CT scan of the elbow confirms the nonunion of the medial condyle and show a filling of the olecranon and coronoid dimples (Figure 3). Which thus defines a providential nonunion because it concedes a useful functional arc at 105° with a preserved stability. In view of these observations the therapeutic abstention associated with a follow-up was chosen as an indication.

DISCUSSION

Non-union is one of the rare complications of neglected fractures of the distal humerus of the adult.² They were classified in 1982 by Mitsunaga in 5 types according to the seat namely type A in supra-condylienne, type B in T-condylienne, type C in lateral condyle, type D trans-condylienne and type E in condyle medial (Figure 4), which is the subject of this case report is the rarest.³

In the literature dealing with the management of non-union of the adult's humeral palette, surgery is indicated in almost all cases.^4,5,9,10 The Ackermann and al series of 20 cases in 16 years is a functional indication in only one case.⁹ The most common therapeutic indication is a cure of pseudarthrosis by placing a spongy allograft and osteosynthesis by screwed or screwed plate.^4,5,10

The surgery has nonetheless significant complications that should be noted. Sim, Helfet, Jupiter, Saragaglia and theirs collaborators showed in their respective series that despite a well-conducted treatment, the nonunion of the distal humerus recurred with an incidence of 2 to 10%.^1,4,8,11 In their study, Ackermann and al emphasized that most patients who had been operated on in their series continued to have a major long-term disability. And this despite the consolidation gained.⁹ Kinik and al found 2.2% fixation failure, 11.1% nerve complications, 28.2% global heterotopic ossification and 11.1% movement amplitude limitations.¹²

In the literature, the therapeutic abstention in front of a non-union of the humeral pallet is an indication which is hardly ever envisaged. In our clinical case, she was selected for this medial condyle non-union in front of a partial filling of the olecranon and coronoid fossae on computed tomography, described by Kelberine and al in 2006 as one of the intra-articular etiologies of elbow stiffness.¹³

In doing so, this non-union becomes providential because being responsible for the conservation a functional arc of the elbow at 105°. At the teaching conference of the SOFCOT of 2013, Begue emphasized the particular interest of the tomodensitometry of the elbow in the radiological assessment, because it makes it possible to search the elements of providence of the non-union.¹⁴

According to Sears and al, the therapeutic objective in these cases is to obtain a slightly painful and functional elbow, without cutting the bridges to possible future surgical procedures and by delaying as much as possible a prosthesis.¹⁵ A surgical procedure of cure of this non-union therefore would have engaged the functional prognosis of the elbow. This especially since our patient had a score of 76/100; which corresponds to a pretty good function according to the Broberg and Morrey classification.

CONCLUSION

Non-union of the distal humerus is a rare complication of traumatic elbow injuries. That of the medial condyle is almost not described in the literature. His diagnosis is easy on radiography with the help of Matsunaga’s classification. Although the therapeutic indication is almost always surgical, the postoperative complications come to erode the functional prognosis of the elbow. In the presence of medial condyle nonunion, the function of which is preserved, it is important to weigh the risk/benefit balance before deciding on a surgical indication. The analysis of the axial sections of the CT of the elbow makes it possible to know if this pseudarthrosis has a providential character. This avoids making the patient run the known risks of elbow surgery.

ACKNOWLEDGEMENTS

The authors thank all those who participated in the development of this work.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

1. 1. Sim FH, Morrey BF. Non-union and delayed union of distal humerus fractures. In: The elbow and its disorders. 2nd ed. Philadelphia: In: W.B. Saunders Co; 1993: 367-382.
2. 2. Allende C, Allende BT. Post-traumatic distal humerus non-union. Int Orthop. 2009;33(5):1289‑94.
3. 3. Mitsunaga MM, Bryan RS, Linscheid RL. Condylar nonunions of the elbow. J Trauma. 1982;22(9):787‑91.
4. 4. Helfet D, Kloen P, Anand N, Rosen H. Open reduction and internal fixation of delayed unions and non-unions of fractures of the distal part of the humerus. J Bone Joint Surg Am. 2003;85(1):33‑40.
5. 5. Ring D, Gulotta L, Jupiter JB. Unstable nonunions of the distal part of the humerus. J Bone Joint Surg Am. 2003;85(6):1040‑6.
6. 6. Schatzker J. Intraarticular malunions and non-unions. Orthop Clin North Am. 1990;21(4):743‑57.
7. 7. Pogliacomi F, Aliani D, Cavaciocchi M, Corradi M, Ceccarelli F, Rotini R. Total elbow arthroplasty in distal humeral nonunion: clinical and radiographic evaluation after a minimum follow-up of three years. J Shoulder Elbow Surg. 2015;24(12):1998‑2007.
8. 8. Jupiter JB. The Management of Nonunion and Malunion of the Distal Humerus-A 30 years’ Experience. J Orthop Trauma. 2008;22(10):742.
9. 9. Ackerman G, Jupiter JB. Non-union of fractures of the distal end of the humerus. J Bone Joint Surg Am. 1988;70(1):75‑83.
10. 10. Gallay SH, Kee MD. Operative treatment of non-unions about the elbow. Clin Orthop. 2000;(370):87‑101.
11. 11. Saragaglia D, Rouchy RC, Mercier N. Fractures of the distal humerus operated on using the Lambda® plate: Report of 75 cases at 9.5 years follow-up. Orthop Traumatol Surg Res. 2013;99(6):707‑12.
12. 12. Kinik H, Atalar H, Mergen E. Management of distal humerus fractures in adults. Arch Orthop Trauma Surg. 1999;119(7‑8):467‑9.
13. 13. Kelberine F, Landreau P, Cazal J. Traitement arthroscopique des raideurs du coude. Chir Main. 2006;25:108‑13.
14. 14. Begue T. Fractures articulaires de l’extremite distale de l’humerus: Articular fractures of the distal humerus. In: Huten D, editeur. Conferences D’enseignement 2013. Paris: Elsevier Masson; 2013:67‑77.
15. 15. Sears BW, Puskas GJ, Morrey ME, Sotelo SJ, Morrey BF. Posttraumatic Elbow Arthritis in the Young Adult: Evaluation and Management. J Am Acad Orthop Surg. 2012;20(11):704.