Distal humerus fractures should be fixed as soon as possible within 1–2 weeks. Open fractures represent a case of emergency and should therefore be operated immediately. Surgical approach and implant use depend on the fracture type.

Type A.1: These extra-articular epicondylar fractures represent mostly avulsion fractures of the collateral ligaments or forearm muscles. These fractures are often displaced and, even if undisplaced, would need long-term immobilization in case of conservative treatment. Therefore, ORIF with lag screws is recommended using a lateral or medial approach. Using the medial approach, the ulnar nerve should always be exposed to avoid nerve damage.

Type A.2 + 3: These extra-articular metaphyseal fractures should be fixed through a dorsal approach using a double plating technique, which will be described in detail later. A minimum of three bicortical screws proximal and two screws distal to the fracture in both plates should be placed to provide sufficient stability. Monocortical screws may be used with locking plates. An olecranon osteotomy is not required. In selected cases, antegrade unreamed humeral nailing can be performed, if the distal fragment is large enough.

Type B.1 + 2: These intra-articular monocondylar fractures may be stabilized through a medial or lateral approach with lag screws in case of good bone quality. In case of osteoporotic bone, single plate osteosynthesis should be performed, optionally with a locking plate.

Type B.3: Several operative treatment options have been described for coronal shear fractures of the distal humerus. In former times fragment excision has been reported to gain good results. However, current literature supports ORIF whenever possible to restore the lateral column of the elbow. Fragment excision should only be performed in case of very small bony fragments or thin cartilaginous bowls. Excision of bigger capitellar fragments may lead to valgus instability – especially in medial collateral ligament insufficient elbow.

ORIF represents the treatment of choice in order to reconstitute an anatomic and stable elbow. According to Dubberly´s classification type I fractures can be faced through a lateral muscle splitting approach. Type II fractures require a more extensive lateral approach with lateral collateral ligament division in order to expose the lateral trochlea. Type III fractures necessitate a dorsal approach with performance of an olecranon osteotomy to ensure a sufficient overview of the whole distal humerus articular surface. In case of posterior comminution autologous bone grafting may be considered to support osteosynthesis. Several implants have been described for the maintenance of capitellar and trochlear fractures such as K-wires, cortical and cancellous screws of various diameters optionally in lag screw technique, bioabsorbable screws and pins, and headless compression screws. Biomechanical studies support the use of 4.0 mm partially threaded cancellous screws in posteroanterior direction as these could provide higher stability compared to first generation headless compression screws. However, more recent biomechanical in-vitro studies comparing conventional screws with new generation headless screws report equal or even higher compressive forces and stability whilst causing less cartilage damage for the headless compression screws. Threaded K-wires may be used to fix small fragments not amenable to screw osteosynthesis. Non-threaded K-wires should not be used due to their high risk of migration. Plate osteosynthesis may be performed in case of distinct posterior comminution. Stabilization of the coronal shear fractures may be performed arthroscopically by the experienced elbow arthroscopist, too. In the elderly patient with poor bone quality and fracture comminution, elbow arthroplasty may be required.

Type C.1–3: Intra-articular fractures are faced through a dorsal approach. The ulnar nerve is exposed and can be transposed anteriorly. Olecranon osteotomy is recommended to assure sufficient overview of the distal humerus articular surface. The articular surface should be reconstructed first. Afterwards, the articular surface block is fixed to the humeral shaft with two plates. In younger patients with good bone quality, nonlocking 3.5-mm reconstruction or 3.5-mm limited contact dynamic compression (LC-DC) plates may be used. Locking plates provide higher stability and are of advantage, especially in the elderly patient with poorer bone quality. Many implants and techniques have been described. Today, two techniques of double plating are mainly used: the Arbeitsgemeinschaft für Osteosynthesefragen (AO) technique with perpendicular plating and parallel plating introduced by O’Driscoll. The AO technique recommends perpendicular plating with one plate positioned medially on the ulnar column and one posterolaterally on the radial column. Long-standing experience exists for this technique and published series show excellent to good results. The concept of parallel plating is now recommended by some authors based on recent biomechanical studies, which reported significantly higher stability for parallel plating. Whether one of these techniques is superior to the other in a clinical setting is not known yet as no study exists comparing the two.