Lecestre et al ⁵ have shown that following internal fixation of comminuted articular fractures satisfactory results can be expected in only 61% of cases. Bonnevialle and Ferron in 2002⁶ reported a 25% loss of upper limb function in elderly patients following distal humeral fractures. Kocher et al⁷ reviewed 169 patients treated surgically for distal humeral fractures, 32 of whom were more than 65 years old (average age 78 years). Satisfactory results were obtained in only 75%.

In a meta-analysis Helfet and Schmeling ⁸ found 25% unsatisfactory results, while John et al⁹ in a review of 49 patients older than 75 years noted 20% unsatisfactory results. One-third of the patients in this study had persistent pain. Pereles et al¹⁰ showed that only 25% of their patients were pain free. More recently, Pajarinen and Bjorkenheim¹¹ found older age and poor bone quality to be determinant prognostic factors for unsatisfactory results.

Srinivasan et al ¹² reported their experience of ORIF in 21 patients with a mean age of 85 years (range 75–100 years) and identified fair or poor outcomes in 43%. Proust et al¹³ in 2007 reviewed 34 patients (36 fractures) with an average age of 78 years who had sustained AO type C fractures treated surgically with ORIF. At 35 months average follow-up, only 58% of the patients had satisfactory results. The average range of motion in extension/flexion was 38–116°. A high complication rate of 56% was noted, with nine non-unions and four mechanical failures.

At our institution in Toulouse, 53 patients with distal humeral fracture were reviewed and the results correlated with age and fracture type. The Mayo Elbow Performance Score (MEPS) score was 86 points for the overall group but only 79 points for patients older than 65 years, and only 76 points for patients older than 65 years with AO type C fractures (unpublished data).

Surgical techniques and rehabilitation ^14,¹⁵

The patient is positioned supine on the operating table and the involved arm placed over a bolster and across the chest (Fig. 19.1). A straight 18 cm posterior skin incision is centred just lateral to the tip of the olecranon (Fig. 19.2).

Figure 19.1 Patient supine with the arm across the chest (1, ulnar crest; 2, ulnar nerve).

Figure 19.2 Posterior incision lateral to the tip of the olecranon.

The ulnar nerve is identified, released from the medial epicondyle and exposed to its first motor branch (Fig. 19.3). The extensor mechanism is then detached from the olecranon in continuity, from medial to lateral allowing dislocation of the elbow (Fig. 19.4). Alternatively, the triceps can be left attached on the olecranon and the fracture fragments removed by releasing all soft tissue attachments, including the capsule.

Figure 19.3 Identification of the ulnar nerve (1, flexor carpi ulnaris; 2, medial epicondyle).

Figure 19.4 Detachment of the triceps from medial to lateral on the olecranon (1, Sharpey’s fibres; 2, motor branch of the ulnar nerve)

The humeral preparation is straightforward. The fractured fragments are removed (Fig. 19.5), and the canal prepared using the humeral reamers (Fig. 19.6). The depth of insertion of the humeral component is defined by the flange of the implant resting on the roof of the coronoid fossa.