Two Choices For Elbow Fracture in Patients With Rheumatoid Arthritis

An elbow fracture in someone with rheumatoid arthritis (RA) is a bad break. Surgery is often needed. There are two basic choices: open reduction and internal fixation (ORIF) or total elbow replacement (TER). ORIF involves using a metal plate, wires, and/or screws to hold the broken bone(s) together. Plates and screws are referred to as instrumentation.

Which one of these two treatment approaches has the best results? Can one be recommended over the other? That's the subject of this study.

Three orthopedic surgeons from Mayo Clinic in Rochester, Minnesota put together a series of 16 cases of elbow fracture in patients with rheumatoid arthritis. Using X-ray results and the Mayo Elbow Performance Score (MEPS), they analyze the outcomes and report on them.

The Mayo Elbow Performance Score (MEPS) gives points (up to a total of 100 points) for pain, joint motion, stability, and function. A total score of 90 points or more is considered excellent. A rating of good means the patient scored between 75 and 90 points. Fair is 60 to 74 points. And poor is a total score less than 60 points.

Each category also had a range of scores to identify the specific area(s) of problem or deficiency. For example, pain was rated as none and given a score of 45 points, mild (30 points), moderate (15 points), or severe (zero points). Motion was given points based on degrees of joint motion present.

Stability (stable to unstable) was graded from 10 points for stable down to zero points for unstable. And points were assigned for function based on daily activities of combing the hair, eating, dressing, and personal hygiene. Looking at the points given in each category gives the surgeon an idea of which area might be the most problematic.

X-rays were used to classify the fractures according to type and severity. The AO classification system was used along with Mayo's own classification system. The AO method (named for the Swiss group that set it up) uses two numbers and a letter to label each fracture. The first number specifies which bone in the body was broken. The second number indicates the exact location of the fracture within that bone. And the letter identifies the number of bone fragments involved (a measure of fracture severity).

The authors note that elbow deformity caused by the arthritis and age-related osteoporosis of the bones make surgical management difficult. They found that ORIF works well for patients with mild arthritis. But joint replacement is usually needed for patients with severe arthritis. How did they come to these conclusions?

They reviewed the charts of 14 patients with 16 distal humeral (elbow) fractures. Two patients had bilateral (both) elbow fractures. The humerus is the upper arm bone. The distal portion of the bone refers to the bottom of the upper arm where it meets the bones of the forearm at the elbow. Besides looking at before and after X-rays, they also assessed the effect of age, fracture type, and severity of arthritis at the elbow joint.

The fractures occurred as a result of a fall in all patients. Everyone in the study had arthritis for at least 20 years (some as long as 55 years). They were all treated surgically within 10 days of the injury. They either had an ORIF or an elbow replacement.

The decision as to which procedure to use was based on X-ray findings, strength of the bone, and patient preferences. Whenever possible, the surgeons tried to use ORIF because it preserves the joint and is a less invasive procedure. Everyone was followed for at least two years. Post-operative X-rays were used to look at the fracture site for signs of healing and signs of implant or instrumentation loosening.

After analyzing all the data, looking at the X-rays, and reviewing the MEPS scores, the authors were able to see that age and type of fracture did not make a difference in results between the two groups. The less involved ORIF surgery was recommended for younger adults whenever possible. Severity of arthritis did seem to make a difference. Fractures treated with ORIF healed well with no problems. Total elbow joint replacement was reserved for patients with severe rheumatoid arthritis (even for younger patients).

This was the first study ever published to compare the results of treatment for elbow fracture in patients with rheumatoid arthritis. The authors looked for the best treatment approach based on patient personal factors, extent of injury, and severity of arthritis. In summary, they found that the degree of joint involvement was a more important factor than the type of elbow fracture when treating arthritic patients.

References: Bernhard Jost, MD, et al. Management of Acute Distal Humeral Fractures in Patients with Rheumatoid Arthritis. A Case Series. In The Journal of Bone & Joint Surgery. Octboer 2008. Vol. 90-A. No. 10. Pp. 2197-2205.