title: Management of acute distal humeral fractures in patients with rheumatoid arthritis. A case series.
abstract: BACKGROUND
  The best surgical treatment for a patient with rheumatoid arthritis and an acute distal humeral fracture is not well established. Because of the distorted anatomy of the arthritic elbow joint and the adjacent osteoporotic bone, total elbow arthroplasty may be favored over open reduction and internal fixation in these patients. We retrospectively analyzed a series of patients with rheumatoid arthritis in whom an acute distal humeral fracture had been treated with either open reduction and internal fixation or total elbow arthroplasty; our purpose was to evaluate their outcomes and to identify any influence of age, fracture type, or the extent of the rheumatoid involvement of the elbow joint on the choice of procedure.
  
  
  METHODS
  Between 1982 and 2002, an acute distal humeral fracture was treated surgically in sixteen elbows in fourteen patients with rheumatoid arthritis, and the results were retrospectively reviewed at a minimum of twenty-four months postoperatively. Six elbows were treated with open reduction and internal fixation (Group 1) and ten elbows, with primary total elbow arthroplasty (Group 2). Postoperatively, the elbows were examined with standard radiographs, and the clinical outcome was assessed with the Mayo Elbow Performance Score (MEPS).
  
  
  RESULTS
  Six patients (six elbows) died before the time of the study, but they had been followed for more than twenty-four months and therefore were included in the series. The eight patients (ten elbows) who were still alive were examined. The mean duration of follow-up was forty-nine months in Group 1 and sixty-six months in Group 2. The MEPS averaged 93 points in Group 1 and 96 points in Group 2. Radiographically, all fractures had healed uneventfully in Group 1 and no prosthesis was loose in Group 2. We could not identify any difference between Groups 1 and 2 with respect to patient age, fracture type, or extent of the rheumatoid arthritis.
  
  
  CONCLUSIONS
  Distal humeral fractures in patients with rheumatoid arthritis can be treated successfully with immediate open reduction and internal fixation or with total elbow arthroplasty. Our data suggest that open reduction and internal fixation can be successful when there is mild arthritic involvement. We favor total elbow arthroplasty for patients with severe articular involvement.
  
  
  METHODS
  Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.
authors.affiliation: Department of Orthopaedics, University of Zurich, Balgrist, Forchstrasse 340, Zurich, Switzerland. bernhard.jost@balgrist.ch
authors.forename: Bernhard
authors.initials: B
authors.lastname: Jost
authors.forename: Robert A
authors.initials: RA
authors.lastname: Adams
authors.forename: Bernard F
authors.initials: BF
authors.lastname: Morrey
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001172:Arthritis, Rheumatoid / Q000150:complications* / Q000175:diagnosis / Q000601:surgery; D019643:Arthroplasty, Replacement; D015331:Cohort Studies; D004551:Elbow Joint; D005260:Female; D005593:Fracture Fixation, Internal; D006801:Humans; D006810:Humeral Fractures / Q000150:complications* / Q000175:diagnosis / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D017060:Patient Satisfaction; D016059:Range of Motion, Articular; D012189:Retrospective Studies; D016896:Treatment Outcome