Distal humerus fractures: epidemiology and surgical management trends in hospitalized patients in Qatar

Abstract

Background

Distal humerus fractures, while relatively rare, can lead to significant complications and disability. Understanding the epidemiology, treatment, and complications of these fractures is crucial for improving patient outcomes. This study aimed to describe the epidemiology of distal humerus fractures in Qatar, highlighting the mechanisms of injury, fracture types, and treatment outcomes.

Methods

A retrospective cross-sectional study was conducted on patients aged 18 years and above who sustained distal humerus fractures within Qatar’s public health-care system from January 2017 to December 2018. Data were collected from electronic medical records across 5 public hospitals, including demographics, mechanisms of injury, fracture classification, treatment modalities, and complications. The incidence rates were calculated using population data from the Qatar Ministry of Development Planning and Statistics.

Results

Out of 100 patients with 101 distal humerus fractures, the overall incidence was 2.15 per 100,000 persons per year, predominantly affecting young males (77%). The primary mechanisms of injury were low-energy falls (34%) and motor vehicle accidents (31%). The most common fracture patterns were the medial epicondyle alone (A1.2) (11.9%) and complete simple articular fracture types C1.1 (9.9%) and C2.1 (9.9%). Multiple injuries were present in 21.8% of patients. Surgical treatment was the mainstay, with orthogonal plating being the most common fixation method. Elbow stiffness was more common complication, occurring in 35% of cases.

Conclusion

The incidence of distal humerus fractures in Qatar is lower than reported in developed countries, likely due to the country’s demographic profile. Further research is needed to optimize treatment protocols and improve functional outcomes.

Distal humerus fractures, accounting for 2%-6% of all fractures and nearly 30% of all humeral fractures,¹⁸ are a significant clinical concern due to their potential for serious complications and substantial disability.⁸ These fractures have an incidence rate of 5.7-8.3 per 100,000 persons per year,^8,18,22 with a pronounced prevalence among young males and elderly females.

The observed bimodal age distribution of fractures is closely related to 2 primary mechanisms of injury.⁵ In the elderly, fractures often result from low-energy trauma, typically involving a direct impact on the elbow or an indirect impact from a fall on an outstretched hand. Conversely, in younger patients, fractures are predominantly caused by high-energy trauma, primarily stemming from road traffic or sports accidents. Notably, in the Middle Eastern region, the most frequent mechanisms of traumatic injuries include road traffic accidents, falls from height, impacts from heavy objects, and injuries to pedestrians.⁶

The unique demographic composition of Qatar, predominantly consisting of young, male expatriates, significantly influences the epidemiology of various injuries, including distal humerus fractures.⁴ The rapid expansion of the construction industry has led to a rise in work-related injuries, accounting for a substantial portion of fall-related injuries in the country.¹² This demographic and industrial landscape likely shapes a distinct pattern of distal humerus fractures in Qatar, differing from those observed in other regions.^8,15,18,22

A thorough understanding of the epidemiology, treatment, and complications of these fractures is essential for developing effective preventive and treatment protocols.¹⁵ This study aimed to characterize the epidemiological profile, treatment, and complications of distal humerus fractures encountered across Qatar’s public health-care system. We hypothesized that the incidence, characteristics, and outcomes of these fractures in Qatar would present unique aspects when compared to other global regions, reflecting the distinct demographic and socioeconomic context of the country.

Materials and methods

A retrospective analysis was conducted on patients diagnosed with distal humerus fractures treated across Qatar from January 2017 to December 2018. This study was centered at Hamad Medical Corporation, the primary public health-care provider and sole provider of fracture care in the country during the study period. For the purpose of this study, HMC’s electronic patient records database was extensively used for the identification of patients. The study was conducted following the approval from HMC’s Institutional Review Board (protocol number: MRC-01-20-832).

Patients aged 18 years and above who presented with acute distal humerus fractures, classified according to the AO Foundation/Orthopaedic Trauma Association classification,¹³ were included in this study. Those with initial injury dates before the study period or with incomplete medical records were excluded. A total of 5 records were excluded due to incomplete documentation, ensuring that the remaining data were accurate and reliable for analysis. Essential data collected included age, gender, mechanism of injury, follow-up duration, fracture type, concomitant injuries, open fractures, reoperations, plate configuration, surgical approach, and the occurrence and resolution of nerve dysfunction, where present. Patients with operations around the elbow for concomitant injuries without distal humerus fixation were categorized as conservatively managed. Incidence rates were calculated per 100,000 persons per year using population figures from the Qatar Ministry of Planning and Statistics.¹⁶ Subpopulation-specific rates were similarly calculated. Frequency data were presented as percentages.

Results

Incidence

Over 2 years, 100 patients with acute distal humerus fracture were identified, including 1 with bilateral fractures, totaling 101 fractures. Patient demographics are summarized in Table I. Considering that Hamad Medical Corporation is the primary health-care provider in Qatar, serving a population of approximately 2.7 million, the overall incidence of distal humeral fractures was determined to be 2.15 per 100,000 persons per year, based on the cases documented in 2017 (48 cases) and 2018 (53 cases). Patients were followed for a mean of 12 months.

Table I.

Summary of patient demographics.

Patient demographics	Male	Female	Total
Total patients (n)	77	23	100
Total distal humerus fractures (n)	78	23	101
Mean age (y)	31	41	33
Age range (y)	19-74	24-81	19-81
Incidence (per 100,000/y)	1.88 (1.4-2.6)	1.62 (0.9-2.9)	2.15 (1.6-2.8)

Trends in age and gender

The highest incidence of distal humerus fractures was in the 19-29 age group, accounting for 50% of the total. This peak is shown in Fig. 1. As age increased, the incidence decreased, with only 4% of fractures in those aged 60 years and above. Age-specific analysis revealed that the incidence was 3.2 per 100,000 per year in the 19-29 age group and increased to 5.0 per 100,000 per year in those over 60 years, as shown in Fig. 2. Males accounted for 77% of all cases (absolute numbers), while females represented 23% of all cases. Incidence peaks were observed in young males and elderly females. Statistical analysis showed significant differences between these groups (P = .03).

Figure 1.

The total number of fractures in each age group.

Figure 2.

Age- and gender-specific incidence per 100,000 per year.

Mechanisms and associated injuries

In this study, the most common cause of fractures was low-energy falls from a standing height, accounting for 34% of the cases. Motor vehicle collisions were the second most common, responsible for 31% of the injuries. Among young adults under 29 years, motor vehicle collisions were the leading cause, while in individuals over 60 years, low-energy falls were more common. Polytrauma (22%) and open fractures (23%) were statistically significant findings among patients (P = .02). Ipsilateral radius or ulna fractures occurred in 15% of cases but were not statistically significant.

Types of fracture

Based on the AO/OTA classification, the most common fracture types were A1.2 (11.9%), C1.1 (9.9%), and C2.1 (9.9%). The broader A1 group was more prevalent at 18.8%, followed by B1 and C3 groups, each at 13.9%. One unique fracture, not fitting the AO/OTA classification, was categorized as “other,” involving a coronal plane fracture of the posterior cortex rim. The distribution of fracture types by their AO/OTA classification subtypes is summarized in Fig. 3. Fractures varied by age; patients under 50 years experienced a wide range of fractures across almost all classification subtypes, while those over 65 years had fractures limited to types A2.2, B1.3, and C1.3.

Figure 3.

Number of fractures by the AO Foundation/Orthopaedic Trauma Association classification subtypes.

Treatment options

In this study, 72 distal humerus fractures were treated surgically, 26 nonoperatively, and 3 involved elbow surgery for concomitant injuries without fixation of the distal humerus. Most surgeries (78.7%) were single procedures, while 5.3% required external fixation followed by internal fixation. Unplanned secondary procedures were needed in 12% of cases, primarily for removing aseptic implants or treating stiff elbows. The olecranon osteotomy approach was used in 40.3% of cases, and the paratricipital approach was used in 33.3% of cases. Orthogonal plating was the most common hardware choice used in 36.1% of cases, with parallel plating used in 20.8% of cases.

Perioperative neurologic deficits

Neurologic deficits were present in a few cases at the time of injury: 2.1% had ulnar nerve deficits, 5.9% had radial nerve deficits, and 1% had both. After surgery, new ulnar neuropathy developed in 14.6% of patients, while radial and median neuropathy occurred in 2.7% and 1.3% of patients, respectively. Overall, the incidence of neuropathy increased from 8.9% at presentation to 20.8% postoperatively. For ulnar nerve management, transposition was performed in 12% of surgeries (9 out of 75 elbows). Among these, 3 patients developed new ulnar neuropathy postoperation. In cases with preoperative ulnar neuropathy, one out of two patients showed nerve recovery after transposition.

Other complications

Elbow stiffness was the most common complication, affecting 35% of cases. Infection, heterotopic ossification, malunion, and arthritis each occurred in 3% of fractures. There were no cases of nonunion, but 1 case of delayed union was noted in an olecranon osteotomy. Table II presents the causes and frequencies of these reoperations.

Table II.

Causes of secondary operations.

Causes of reoperations	Frequency
Staged fixation	4
Aseptic implant removal	9
Infection	2
Manipulation/Arthrolysis of stiff joint	4
Tendon transfer for nerve injury	1
Refracture	1
Total	21

Discussion

This study revealed an overall incidence of distal humerus fractures in Qatar of 2.15 per 100,000 persons per year, which is notably lower than the rates reported in Scotland (5.7 per 100,000 persons per year),¹⁸ Canada (7.7 per 100,000 per year),²¹ and Sweden (8.3 per 100,000 persons per year).⁸ One explanation for this lower incidence is Qatar’s unique population demographics, particularly the smaller proportion of elderly individuals. Working-aged males (20-54 years) comprise of 57.1% of the population, while elderly females (≥62 years) make up less than 1%.¹⁶ As a result, the high fracture incidence in elderly females has a limited impact on the overall rate due to their small representation in the population.

Further analysis of age and gender subpopulations in our study confirmed a bimodal distribution, with high incidences of distal humerus fractures in both young males and elderly females, consistent with the previous research.⁴ Adolescent males typically sustain these fractures due to high-energy trauma, while elderly females are affected by low-energy falls, as reported in the global literature.^8,14,18,22 These findings reinforce the role of demographic factors in distal humerus fracture epidemiology and contribute to a broader understanding of fracture patterns.

Qatar’s unique population, with a male majority (74%) largely due to its migrant workforce, is reflected in the fracture data, where males accounted for 77% of distal humerus fractures.¹⁶ Elderly females primarily sustained fractures from low-energy mechanisms, often linked to reduced bone density and osteoporosis. In contrast, young males predominantly sustained fractures from high-energy trauma. Low-energy falls in younger individuals likely represent isolated cases rather than a broader issue of compromised bone health. Osteoporosis prevalence in postmenopausal women in Qatar is 12.3%,⁷ with vitamin D insufficiency affecting up to 92.7% of the population.^6,14 These factors likely contribute to the significant rise in fracture incidence among women aged >80 years, as shown in Fig. 2, where incidence increases from 2.36 per 100,000 in the 19-29 age group to 26.18 per 100,000 in those aged >80 years.

The AO/OTA classification, widely used for comparative analysis of fracture patterns, highlights demographic influences.¹³ In Scotland, Type A fractures were most common, while Canada showed a balanced distribution with Type A2.3 prevalent in elderly females.^18,22 Sweden reported 38.6% Type A, 25.3% Type B, and 35.4% Type C fractures, with A2 and C3 common in the elderly.⁸ In France, 60.5% of fractures in elderly patients were Type C, primarily C3.⁹ In this study, Qatar’s younger, working-age population showed a unique pattern, with A1.2, C1.1, and C2.1 fractures predominantly in patients under 40 years, contrasting the elderly predominance seen elsewhere. This unique distribution can likely be attributed to Qatar’s larger working-age population and smaller elderly demographic.

Achieving anatomic joint reduction minimizes post-traumatic arthritis, while rigid fixation enables early mobilization, reducing elbow stiffness. Double plate fixation, favored for its biomechanical superiority, is the preferred method for fractures involving both columns.²⁰ Recent studies suggest that parallel plating is either more effective or comparable to orthogonal plating in outcomes.^11,25,26 In Qatar, orthogonal plating was the most common fixation method, followed by parallel plating. Olecranon osteotomy and paratricipital approaches were the preferred surgical techniques, with implant configuration and approach significantly correlated with fracture configuration.

Ulnar neuropathy, a common complication after distal humerus fracture fixation, has an incidence of 0%-51% (average 12%).¹⁸ In our cohort, ulnar neuropathy increased from 2.1% at injury to 15.3% postoperatively, with only 3 of 12 patients showing resolution within an average follow-up of 544 days. Studies by Ahmed et al and Chen et al suggest that ulnar nerve transposition may increase this risk,^2,10 while Vazquez et al and a Canadian randomized controlled trial reported no significant differences based on surgical methods.^21,24 In this study, radial nerve palsy was initially present in 5.9% of fractures and was less frequent than ulnar neuropathy postoperatively, with a 5.5-fold higher risk of ulnar nerve injury during surgery.

Elbow stiffness is a recognized complication following distal humerus fractures, defined as a range of motion less than 30°-130°.^3,17,27 In this study, 35% of cases exhibited stiffness, with 83% of these patients under 40 years, highlighting the significant impact on their active lifestyles. At our institution, the lack of standardized supervised postoperative rehabilitation protocols likely contributes to this outcome, as rehabilitation decisions are left to individual surgeons. No significant association was found between fracture complexity or mechanism of injury and stiffness development (P > .05). Variability in reported stiffness rates in the literature stems from differences in follow-up, definitions, and patient populations.¹ Despite its high incidence, only 4 patients underwent manipulation or arthrolysis. Studies by Spitler et al and Rotman et al show that early manipulation significantly improves motion, with gains of 38°-54°, which was sustained over a 3-year follow-up period.^19,23 These findings support a broader adoption of manipulation under anesthesia for treating elbow stiffness.

This retrospective study relied on patient records explicitly mentioning “distal humerus fracture” or “distal humeral fracture,” which may have excluded cases using different terminology. Additionally, short follow-up periods and Qatar’s high expatriate turnover complicated long-term data collection, particularly for complications. Despite these limitations, the study highlights the need for targeted prevention strategies, especially for young males injured in motor vehicle accidents and falls, and provides valuable insights for improving fracture management in Qatar.

Conclusion

The incidence of distal humerus fractures in Qatar is lower than reported in developed countries, likely due to the country’s demographic profile. Further research is needed to optimize treatment protocols and improve functional outcomes.

Acknowledgments

The authors would like to thank Dr. Prem Chandra from the Medical Research Center of Hamad Medical Corporation for his invaluable assistance in statistical analysis and interpretation of the data.

Disclaimers:

Funding: Open access funding was provided by the The Medical Research Center at Hamad Medical Corporation.

Conflicts of interest: The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.