Introduction

Distal humerus fractures comprise 7% of all fractures and 30% of all elbow fractures. Approximately 7% are open fractures due to their subcutaneous location. Bimodal distribution includes young, accident-prone patients and elderly individuals with osteopenic bone. Highest incidence is observed among elderly women who are > 60 years of age (▶Video 23.1).

I. Preoperative

1. 
   

   History and physical examination

   
   
   
   
   1. 
      

      Mechanism of injury:

      
      
      
      
      1. 
         

         Low-energy falls (common in the elderly).

         
         
      2. 
         

         High-energy trauma with extensive comminution and intra-articular involvement. Gunshot wound, motor vehicle accident, and fall from a height

         
         
      3. 
         

         Typically results from an axial load.

      
      
   2. 
      

      Clinical evaluation

      
      
      
      
      1. 
         

         Present with elbow pain, swelling, and crepitus or gross instability with attempted range of elbow motion.

         
         
      2. 
         

         Perform a careful neurovascular examination, especially radial nerve, ulnar nerve, and distal arterial flow.

         
         
      3. 
         

         Assess compartment syndrome; serial compartment examinations may be required to avoid resultant Volkmann contracture.

   
   
2. 
   

   Anatomy

   
   
   
   
   1. 
      

      The elbow is a constrained hinge composed of two joints:

      
      
      
      
      1. 
         

         Ulnohumeral—flexion and extension of the forearm.

         
         
      2. 
         

         Radiocapitellar—forearm pronosupination.

      
      
   2. 
      

      Two columns—orientation in reference to the shaft (▶ Fig. 23.1 ):

      

      
      
      
      
      1. 
         

         Medial—45 degree in coronal plane.

         
         
      2. 
         

         Lateral—20 degree in coronal and 35 to 40 degree in sagittal plane.

         
         
      3. 
         

         Valgus alignment is 4 to 8 degree.

         
         
      4. 
         

         Internal rotation is 3 to 8 degree.

         
         
      5. 
         

         Carrying angle is 10 to 17 degree in full extension.

   
   
3. 
   

   Imaging

   
   
   
   
   1. 
      

      Radiographs:

      
      
      
      
      1. 
         

         Anteroposterior (AP) and lateral of the humerus and elbow.

         
         
      2. 
         

         Forearm and wrist when concomitant injuries are present.

         
         
      3. 
         

         Oblique—useful in diagnosing condylar fractures and degree of displacement.

         
         
      4. 
         

         Traction radiographs—improved delineation of fracture fragments and aid in preoperative planning.

      
      
   2. 
      

      Computed tomography (CT) scan—particularly useful for preoperative evaluation of intraarticular fractures with comminution. Three-dimensional CT reconstruction improves the inter- and intraobserver reliability of classification.

   
   
4. 
   

   Classification

   
   
   
   
   1. 
      

      Anatomic—based on the number of columns involved, the location of the fracture, and rotational displacement:

      
      
      
      
      1. 
         

         Supracondylar—extra-articular and extra-capsular (▶ Fig. 23.2a ).

         

         
         
      2. 
         

         Transcondylar—extra-articular and intra-capsular.

         
         
      3. 
         

         Columnar—intra-articular, lateral or medial condylar fracture, and capitellum/trochlea fracture (▶ Fig. 23.2b, c ).

         
         
      4. 
         

         Intercondylar—intra-articular (▶ Fig. 23.2d ).

      
      
   2. 
      

      Orthopaedic trauma association (OTA) classification—13-X:

      
      
      
      
      1. 
         

         13-A (extra-articular).

         
         
      2. 
         

         13-B (partial articular).

         
         
      3. 
         

         13-C (complete articular).

      
      
   3. 
      

      Specific types of intra-articular fractures:

      
      
      
      
      1. 
         

         Condylar—involving a single column (▶ Fig. 23.2b ):

         
         
         
         
         • 
           

           i. Milch type I fractures—lateral trochlear wall is attached to the shaft of the humerus, and forearm maintains alignment with humerus; therefore, more stable.

           
           
         • 
           

           ii. Milch type II fractures—lateral wall of the trochlea is attached to the displaced fracture fragment, and forearm follows fragment; therefore, less stable.

         
         
      2. 
         

         Capitellum fractures—coronal shear (▶ Fig. 23.2c ):

         
         
         
         
         • 
           

           i. Type I (Hahn-Steinthal)—involves most of the capitellum and may include part of the trochlea.

           
           
         • 
           

           ii. Type II (Kocher-Lorenz)—separation of articular cartilage with minimal attached subchondral bone.

           
           
         • 
           

           iii. Type III—severely comminuted multifragmentary fractures.

           
           
         • 
           

           iv. Type IV—McKee modification—significant extension of the fracture into the trochlea.

II. Treatment

1. 
   

   Initial management

   
   
   
   
   1. 
      

      Bicolumnar fracture—typically splinted in a position of comfort, general guidelines are a posterior splint 45 to 90 degrees of elbow flexion, 30 degrees of wrist extension, forearm in neutral rotation, and allow full metacarpophalangeal (MCP) range of motion (ROM).

      
      
   2. 
      

      Isolated lateral column fracture—splint forearm in supination.

      
      
   3. 
      

      Isolated medial column fracture—splint forearm in pronation.

   
   
2. 
   

   Definitive management

   
   
   
   
   1. 
      

      Nonsurgical treatment indications:

      
      
      
      
      1. 
         

         Nondisplaced or minimally displaced fractures.

         
         
      2. 
         

         Displaced fractures in elderly, low-demand patients and/or patients with extensive comorbidities:

         
         
         
         
         • 
           

           i. Splint 1 to 2 weeks before initiation of ROM exercises.

           
           
         • 
           

           ii. Wean out of removable splint by 6 weeks if there is progressive evidence of healing.

           
           
         • 
           

           iii. May accept 20 degree loss of condylar shaft angle.

         
         
      3. 
         

         Comminuted osteoporotic fractures in elderly “bag of bones”:

         
         
         
         
         • 
           

           i. Immobilization for 2 weeks in 90 degree of elbow flexion.

           
           
         • 
           

           ii. After 2 weeks, begin gentle ROM.

           
           
         • 
           

           iii. Goal is to ultimately achieve a minimally painful, functional pseudoarthrosis.

      
      
   2. 
      

      Surgical fixation:

      
      
      
      
      1. 
         

         Indications—displaced fractures and for those associated with an open or vascular injury.

         
         
      2. 
         

         Supracondylar fractures; OTA type A:

         
         
         
         
         • 
           

           i. Open reduction and internal fixation (ORIF)—plate and screws placed on the medial and lateral columns (▶ Fig. 23.3a,b ):

           

           
           
           
           
           • 
             

             Ninety-degree plating (orthogonal direct medial and posterolateral).

             
             
           • 
             

             Parallel plating (parallel direct medial and lateral).

         
         
      3. 
         

         Transcondylar fractures—Consider total elbow arthroplasty (TEA) for elderly patients with distal, comminuted fractures and poor bone quality (▶ Fig. 23.4a, b ).

         

         
         
      4. 
         

         Condylar fractures, partial articular; OTA type B—ORIF, lag screws with unilateral plating.

         
         
      5. 
         

         Capitellum fractures:

         
         
         
         
         • 
           

           i. ORIF

           
           
           
           
           • 
             

             Minifragment screw fixation from posterior to anterior.

             
             
           • 
             

             Countersunk minifragment screws from anterior to posterior.

             
             
           • 
             

             Headless screws.

             
             
           • 
             

             Minifragment plate fixation supplementation.

           
           
         • 
           

           ii. Excision for nonreconstructible parts of type II and III fractures as a last resort.

           
           
         • 
           

           iii. Consider replacement among elderly.

         
         
      6. 
         

         Trochlea fractures:

         
         
         
         
         • 
           

           i. ORIF for displaced fractures often repaired with minifragment or headless screw constructs similar to strategies for fixation of capitellum fractures.

         
         
      7. 
         

         Epicondylar fractures:

         
         
         
         
         • 
           

           i. ORIF if markedly displaced or evidence of elbow instability with ROM. Repair with small or minifragment screws.

           
           
         • 
           

           ii. Late presentation as a painful nonunion and unreconstructable fragment can be treated by excision.

         
         
      8. 
         

         Supracondylar process fracture:

         
         
         
         
         • 
           

           i. A congenital variant, and the supracondylar process is a bony protrusion on the anteromedial surface of the distal humerus.

           
           
         • 
           

           ii. Excision if there is evidence of arterial injury or nerve compression.

           
           
         • 
           

           i. Intercondylar fractures, OTA type C fractures:

           
           
         • 
           

           i. ORIF for displaced fractures—minifragment and small fragment articular fixation combined with bicolumnar plates (orthogonal versus parallel) (▶ Fig. 23.3a, b ).

           
           
         • 
           

           ii. TEA for elderly patients with severe comminution and/or nonreconstructible fractures with poor bone quality (▶ Fig. 23.4a, b ).

   
   
3. 
   

   Surgical approaches

   
   
   
   
   1. 
      

      Most supracondylar and intercondylar distal humerus fractures are treated through one of several described posterior approaches. The deep interval varies based upon fracture pattern and surgeon preference.

      
      
   2. 
      

      Superficial dissection is the same for the various deep interval approaches described below (▶ Fig. 23.5a ):

      

      
      
      
      
      1. 
         

         Posterior skin incision.

         
         
      2. 
         

         Develop medial and lateral subcutaneous flaps.

         
         
      3. 
         

         Identify the ulnar nerve as it emerges between intermuscular septum beneath Osbourne ligament, approximately 2 cm proximal to medial epicondyle or distally between the two heads of flexor carpi ulnaris (FCU) at the origin of the first motor branch. Mobilize it anteriorly.

         
         
      4. 
         

         There is conflicting evidence surrounding anterior subcutaneous transposition of the ulnar nerve versus in-situ decompression and return of the nerve to its normal anatomic location.

         
         
      5. 
         

         Develop a more anterior interval for single column, capitellum, or trochlea fractures through same posterior skin incision.

      
      
   3. 
      

      Deep dissection:

      
      
      
      
      1. 
         

         Paratricipital (Alonso-Llames) (▶ Fig. 23.5b, c ):

         
         
         
         
         • 
           

           i. Indications—extra-articular or simple partial articular fractures.

           
           
         • 
           

           ii. Create medial and lateral windows between the intramuscular septae and triceps.

           
           
         • 
           

           iii. Identify and protect the ulnar and radial nerves.

           
           
         • 
           

           iv. Pros—does not disrupt the extensor mechanism and it can be converted into an olecranon osteotomy.

           
           
         • 
           

           v. Cons—lack of visualization of the entire articular surface.

         
         
      2. 
         

         Triceps reflecting (Bryan-Morrey):

         
         
         
         
         • 
           

           i. Reflect extensor mechanism from a medial interval.

           
           
         • 
           

           ii. Subperiosteally dissect the extensor mechanism off the olecranon and take as a flap in continuity with the extensor compartment of the forearm.

           
           
         • 
           

           iii. Pros—more extensile and promotes increased visualization.

           
           
         • 
           

           iv. Cons—disrupts the extensor mechanism.

         
         
      3. 
         

         Triceps reflecting anconeus pedicle (TRAP):

         
         
         
         
         • 
           

           i. Reflect entire triceps along with anconeus off of olecranon as one flap.

           
           
         • 
           

           ii. Pros—improved articular visualization.

           
           
         • 
           

           iii. Cons—less extensile and disrupts the extensor mechanism.

         
         
      4. 
         

         Triceps splitting:

         
         
         
         
         • 
           

           i. Sharply dissect interval between long and lateral heads of triceps.

           
           
         • 
           

           ii. Identify the radial nerve which can be found:

           
           
           
           
           • 
             

             Crossing the lateral border of the posterior humerus at an average distance of 11 cm proximal to the proximal extent of the olecranon fossa (range 8–14 cm).

             
             
           • 
             

             Crossing the medial border of the posterior humerus at an average distance of 15 cm proximal to the proximal extent of the olecranon fossa (range 10–20 cm).

             
             
           • 
             

             Alternatively, the lateral brachial cutaneous nerve can be traced proximally to where it branches from the radial nerve proper at the level of the deltoid insertion near the lateral intermuscular septum.

           
           
         • 
           

           iii. Distally, it can be carried to the ulnar insertion and reflected off the olecranon but left in continuity with the fascia.

           
           
         • 
           

           iv. Pros—does not disrupt extensor mechanism.

           
           
         • 
           

           v. Cons—limited visualization of anterior surface.

         
         
      5. 
         

         Olecranon osteotomy:

         
         
         
         
         • 
           

           i. Indications—extensive articular involvement.

           
           
         • 
           

           ii. Contraindications—planned TEA.

           
           
         • 
           

           iii. Create a chevron-style osteotomy pointing distally at the level of the bare area of the olecranon approximately 2 to 2.5 cm distal to the proximal tip.

           
           
           
           
           • 
             

             Some surgeons prefer to drill and tap the proximal ulna for an intramedullary screw or plate prior to osteotomizing the olecranon to facilitate later fixation.

             
             
           • 
             

             Drill a small 2.0 mm hole at the distal apex of the planned osteotomy to prevent unwanted fracture propagation.

             
             
           • 
             

             Make initial cuts with an oscillating saw followed by osteotomes to prevent the kerf of the saw blade from removing articular cartilage that will lead to step off after final fixation.

             
             
           • 
             

             Reflect entire extensor mechanism proximally to allow visualization of the entire distal humerus.

             
             
           • 
             

             Repair the osteotomy:

             
             
             
             
             • 
               

               Kirschner wires and a tension band type construct.

               
               
             • 
               

               Long, large-fragment intramedullary screw fixation with a tension band.

               
               
             • 
               

               Plate fixation.

               
               
             • 
               

               Two small-fragment lag screws.

             
             
           • 
             

             Pros—best visualization of articular surface.

             
             
           • 
             

             Cons—risk of osteotomy nonunion and hardware prominence.

      
      
   4. 
      

      Lateral approach for lateral condyle and capitellar fractures:

      
      
      
      
      1. 
         

         Superficial dissection—direct lateral or posterior skin incision.

         
         
      2. 
         

         Deep interval:

         
         
         
         
         • 
           

           i. Most common—Kaplan interval between extensor carpi radialis brevis (ECRB) and extensor digitorum comminus (EDC).

           
           
         • 
           

           ii. Rarely used—Kocher interval between anconeus and extensor carpi ulnaris (ECU).

      
      
   5. 
      

      Medial approach for medial condyle, trochlea, and coronoid fractures—FCU splitting approach:

      
      
      
      
      • 
        

        i. Identify the ulnar nerve between the two heads of the FCU. Protect the nerve and allow it to retract posteriorly.

        
        
      • 
        

        ii. Incise the flexor—pronator muscle mass from the medial epicondyle distally toward the sublime tubercle and elevate the anterior head of the FCU off the anteromedial coronoid and proximal ulna.

        
        
      • 
        

        iii. Take care not to disrupt the underlying medial collateral ligament.

        
        
      • 
        

        iv. Elevate the anterior portion of the flexor pronator mass off of the medial supracondylar ridge as necessary.

   
   
4. 
   

   Fixation techniques

   
   
   
   
   1. 
      

      Anatomic articular reduction:

      
      
      
      
      1. 
         

         Use of K-wires and clamps.

         
         
      2. 
         

         Avoid decreasing the dimensions of the trochlea.

      
      
   2. 
      

      Stable internal fixation of the articular surface—minifragment and small fragment fixation.

      
      
   3. 
      

      Restoration of axial alignment.

      
      
   4. 
      

      Fixation of the articular segment to the metaphysis and diaphysis:

      
      
      
      
      1. 
         

         Orthogonal plating versus parallel plating (▶ Fig. 23.6 ).

         

         
         
      2. 
         

         Locking plates are often recommended in osteoporotic fractures and/or extensive articular comminution.

         
         
      3. 
         

         Avoid ending plates at the same level to prevent a stress riser.

      
      
   5. 
      

      Early ROM of the elbow.

   
   
5. 
   

   Complications

   
   
   
   
   1. 
      

      Fixation failure.

      
      
   2. 
      

      Malunion and nonunion.

      
      
   3. 
      

      Infection (0–6%)–most commonly with type 3 open fractures.

      
      
   4. 
      

      Ulnar nerve palsy/neuritis—10 to 30%.

      
      
   5. 
      

      Post-traumatic arthritis

   
   
6. 
   

   Rehabilitation

   
   
   
   
   1. 
      

      ORIF:

      
      
      
      
      1. 
         

         Postoperatively nonweight bearing with the elbow immobilized at 90 degrees of flexion.

         
         
      2. 
         

         Initiate elbow motion at 3 to 7 days postoperatively. Consider delay in mobilization for 2 to 4 weeks if stable fixation cannot be achieved and in noncompliant patients.

         
         
      3. 
         

         Two weeks postop—allow progression to full active, active-assisted, and passive elbow ROM if the wound has healed.

         
         
      4. 
         

         Six to twelve weeks postop—allow progression to WBAT if there is clinical and radiographic evidence of healing.

      
      
   2. 
      

      TEA:

      
      
      
      
      1. 
         

         Postoperatively immobilize with an anterior splint in near full extension to protect the wound.

         
         
      2. 
         

         Begin ROM when the skin has healed.

   
   
7. 
   

   Outcomes

   
   
   
   
   1. 
      

      ORIF:

      
      
      
      
      1. 
         

         The goal of treatment is a functional arc of elbow motion from 30 to 130 degrees and pronosupination of 150 to 160 degrees.

         
         
      2. 
         

         Greater than 90% rate of union.

         
         
      3. 
         

         Seventy five percent of flexion and extension strength.

      
      
   2. 
      

      TEA:

      
      
      
      
      1. 
         

         Average range of postoperative elbow motion is 25 to 130 degrees and good for excellent functional outcomes.

         
         
      2. 
         

         Good pain relief.

         
         
      3. 
         

         Must be able to abide by the lifelong weight bearing restrictions.