Chapter 17: T-Condylar Distal Humerus Fractures

Benjamin Shore, Peter M. Waters

Chapter Outline

Introduction to T-Condylar Distal Humerus Fractures

In T-condylar fractures, the fracture line originates in the central groove of the trochlea and courses proximal to the olecranon and coronoid fossae, where it divides and separates the medial and lateral bony columns of the distal humerus. If the proximal fracture lines are oblique, the fracture may be termed Y-condylar. T- and Y-condylar fractures are rare injuries in skeletally immature children and are often a transitional fracture seen in adolescents at the end of skeletal development. 

Incidence of T-Condylar Distal Humerus Fractures

The early modern literature reflects only reports by Blount5 and Zimmerman,33 who each described a case of a T-condylar distal humerus fracture in an 11-year-old patient. The average age of pediatric patients reported in four major case series15,18,23,25 was 12.8 years. Three studies have found that the nondominant arm is more likely to be injured 2.5 times greater than the dominant arm.20,22,25 Thus, Maylahn and Fahey,21 who reported six patients near skeletal maturity, were accurate when they said, “the fractures (T-condylar) take on the characteristics of an adult fracture and should be treated as such.” 
The actual incidence in younger children is certainly low, but it may be underdiagnosed because it is often confused with other fractures, such as those involving the lateral condylar physis or total distal humeral physis. Special imaging studies such as arthrograms or MRI scans may be necessary to demonstrate the intracondylar aspects in young children. The combination of an increased awareness of the possibility of this injury and a more aggressive diagnostic approach may result in more cases being recognized acutely and appropriately treated in this younger age group. 

Assessment of T-Condylar Distal Humerus Fractures

Mechanisms of Injury of T-Condylar Distal Humerus Fractures

The primary mechanism of this injury is the direct wedge effect of the articular surface of the olecranon on the distal end of the humerus. The sharp edge of the semilunar notch or coronoid process acts as a wedge to break the trochlea and split the condyles, which in turn separates the two columns of the distal humerus. Flexion and extension types of injuries have been described. 
The most common mechanism producing a flexion injury is a direct blow to the posterior aspect of the elbow, usually when the child falls directly on the flexed elbow. This flexion mechanism in young children contributes to its rarity because most upper-extremity injuries in children result from a fall on an outstretched hand and have a component of elbow hyperextension. In these flexion injuries, the wedge effect is produced at the apex of the trochlea by the central portion of the trochlear notch. The condylar fragments usually lie anterior to the shaft in these flexion injuries (Fig. 17-1A, B). 
Figure 17-1
A–D: Mechanism patterns.
 
A, B: The more common flexion pattern in which the condylar fragments are situated anterior to the distal shaft. C, D: An extensor pattern in which the condylar fragments are situated posterior to the distal shaft. The muscle origins on the respective condyles cause them to diverge in the coronal plane (arrows) and flex in the sagittal plane.
A, B: The more common flexion pattern in which the condylar fragments are situated anterior to the distal shaft. C, D: An extensor pattern in which the condylar fragments are situated posterior to the distal shaft. The muscle origins on the respective condyles cause them to diverge in the coronal plane (arrows) and flex in the sagittal plane.
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Figure 17-1
A–D: Mechanism patterns.
A, B: The more common flexion pattern in which the condylar fragments are situated anterior to the distal shaft. C, D: An extensor pattern in which the condylar fragments are situated posterior to the distal shaft. The muscle origins on the respective condyles cause them to diverge in the coronal plane (arrows) and flex in the sagittal plane.
A, B: The more common flexion pattern in which the condylar fragments are situated anterior to the distal shaft. C, D: An extensor pattern in which the condylar fragments are situated posterior to the distal shaft. The muscle origins on the respective condyles cause them to diverge in the coronal plane (arrows) and flex in the sagittal plane.
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A T-condylar fracture may also be caused by a fall on the outstretched arm with the elbow in only slight flexion. This extension mechanism has been suggested by patients in their description of the dynamics of the fall and indirectly by the position of the distal fragments in relation to the diaphyses of the humerus—in other words, lying posterior (Fig. 17-1C, D). In the extension type of injury, the coronoid portion of the semilunar notch produces the wedge effect. 
It has been suggested that contraction of the forearm flexor and extensor muscles may play a role in the displacement pattern of this fracture. Because of their origins on the epicondyles, they accentuate both the separation in the coronal plane and the forward displacement in the sagittal plane. This displacement pattern is often evident on the injury films (Fig. 17-1C, D). 

Associated Injuries with T-condylar Distal Humerus Fractures

Very little has been written on the type of associated injuries seen with T-condylar distal humerus fractures in children. In general, these are high-velocity injuries which are typically the result of high-energy mechanisms, such as motor vehicle collisions, high-speed sporting accidents or falls from significant heights.14 Open wounds, other ipsilateral upper limb injuries, and general systemic injury can occur because of the heightened energy of the trauma that occurs. 

Signs and Symptoms of T-condylar Distal Humerus Fractures

The history should focus on the mechanism and time of injury and the identification of other sites of injury. It is important to recognize any prior elbow injury or upper extremity surgery. Rounding out the history would include gathering information on pre-existing medical conditions, medication, and hand dominance. 
In addition to a complete physical examination, a detailed head-to-toe trauma assessment should be completed, to rule out significant concomitant injuries to the axial and appendicular skeleton. Focused examination of the injured extremity should include inspection for bruising, swelling, deformity, and evidence of any open injuries. A thorough circumferential inspection of the elbow is critical to avoid missing open wounds, which commonly occur on the posterior aspect.20 Careful examination of distal vascular status is performed, inspecting the distal extremity for color, turgor, and palpating the radial and ulnar pulses. If there is a questionable pulse in the setting of gross malalignment of the arm, gentle longitudinal traction can be used to realign the limb and often restore the distal pulse. A detailed distal neurologic examination including motor function, hand sensibility, and two-point discrimination (median and ulnar nerves) should be performed to identify injury to the median, ulnar, radial, anterior, and posterior interosseous nerve. At the conclusion of the examination, the arm is splinted for comfort in a padded posterior, above-elbow splint. 

Imaging and Other Diagnostic Studies for T-Condylar Distal Humerus Fractures

Clinically, these fractures are most often confused with extension-type supracondylar fractures. The extended position of the elbow, along with the massive swelling, is almost identical to that of the displaced extension type of supracondylar fracture. 
Plain radiographs are the cornerstone to the diagnosis. In older children, the differentiation must be made from that of a comminuted supracondylar fracture. Sometimes, the diagnosis is not obvious until the fragments have been partially reduced, which allows the vertical fracture lines splitting the trochlea to become more evident. In younger children, the diagnosis is much more difficult because the articular surface is cartilaginous and not visible on plain radiographs. In addition, because of its rarity, the possibility of a T-condylar fracture may not be considered in this age group. 
The diagnosis must exclude common fracture patterns of either the isolated lateral or medial condyles and complete separation of the distal humeral physis. In these latter fractures, an important sign is the presence of a medial or lateral Thurston–Holland fragment in the metaphysis.4 The key differential for the T-condylar fracture is the presence of a vertical fracture line extending down to the apex of the trochlea. 
If the diagnosis is suspected after a careful evaluation of the static radiographs, it can be confirmed with a preoperative CT scan for adolescent children, MRI in younger children, or varus/valgus stress films made while the patient is under general anesthesia.4 The use of contrast medium in the form of an arthrogram intraoperative can also be helpful to distinguish fracture lines and aid in the assessment of the quality of the articular reduction. 

Classification of T-Condylar Distal Humerus Fractures

Fracture Pattern

The fracture pattern in adolescents is similar to that in adults. The condylar fragments are often separated, with the articular surface completely disrupted. In addition to separation of the condylar fragments by the force of the original injury, the muscles that originate on these condylar fragments rotate them in both the coronal and sagittal planes (Fig. 17-1C, D). In the sagittal plane, the position of the condylar fragments in relation to the humeral shaft and metaphysis can either be anterior (flexor mechanism; Fig. 17-1B) or posterior (extension mechanism; Fig. 17-1D). 
In skeletally immature patients, the central portions of the condylar fragments are usually separated, but the articular surface may remain intact because of its large cartilage component (Fig. 17-2).23 Thus, the disruption and displacement are primarily in the osseous supracondylar area. The elasticity of the cartilage of the distal end of the humerus often acts as an opening hinge but protects the articular surface from being completely disrupted. 
Figure 17-2
Intact articular surface.
 
In this T-condylar fracture in a 7-year-old boy, the thick articular cartilage remains essentially intact, preventing separation of the condylar fragments. This fracture was secured with simple percutaneous pins.
In this T-condylar fracture in a 7-year-old boy, the thick articular cartilage remains essentially intact, preventing separation of the condylar fragments. This fracture was secured with simple percutaneous pins.
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Figure 17-2
Intact articular surface.
In this T-condylar fracture in a 7-year-old boy, the thick articular cartilage remains essentially intact, preventing separation of the condylar fragments. This fracture was secured with simple percutaneous pins.
In this T-condylar fracture in a 7-year-old boy, the thick articular cartilage remains essentially intact, preventing separation of the condylar fragments. This fracture was secured with simple percutaneous pins.
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Classification

Various classifications15,27 for adult T-condylar fractures have been proposed, but there are problems with applying these classifications to children's injuries. For example, the number of young children with this fracture is so small that it limits the experience of any one clinician in treating all types of fracture patterns. In addition, there is no useful classification for younger patients, in whom the unossified intact articular cartilage is not visible on plain radiographs. Toniolo and Wilkins30 proposed a simple classification based on the degree of displacement and comminution of the fracture fragments for pediatric T-condylar fractures. Type I fractures are minimally displaced (Fig. 17-3A, B, C). Type II fractures are displaced but do not have comminution of the metaphyseal fragments (Fig. 17-4AB). Type III fractures are displaced fractures with comminution of the metaphyseal fragments (Fig. 17-5A-F). 
Figure 17-3
Examples of Type I T-condylar fractures.
 
A: Lateral view of Type I undisplaced T-condylar fracture in a 6-year-old. B: AP of the t-Condylar fracture line (open arrows) was not appreciated until it healed. There are both medial and lateral Thurstan–Holland fragments (solid arrows) (Courtesy of Ruben D. Pechero, MD). C: Pre- and postoperative x-rays of minimally displaced intra-articular Type I T-condylar fracture in a 16-year-old boy treated with closed reduction and percutaneous screw fixation.
A: Lateral view of Type I undisplaced T-condylar fracture in a 6-year-old. B: AP of the t-Condylar fracture line (open arrows) was not appreciated until it healed. There are both medial and lateral Thurstan–Holland fragments (solid arrows) (Courtesy of Ruben D. Pechero, MD). C: Pre- and postoperative x-rays of minimally displaced intra-articular Type I T-condylar fracture in a 16-year-old boy treated with closed reduction and percutaneous screw fixation.
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Figure 17-3
Examples of Type I T-condylar fractures.
A: Lateral view of Type I undisplaced T-condylar fracture in a 6-year-old. B: AP of the t-Condylar fracture line (open arrows) was not appreciated until it healed. There are both medial and lateral Thurstan–Holland fragments (solid arrows) (Courtesy of Ruben D. Pechero, MD). C: Pre- and postoperative x-rays of minimally displaced intra-articular Type I T-condylar fracture in a 16-year-old boy treated with closed reduction and percutaneous screw fixation.
A: Lateral view of Type I undisplaced T-condylar fracture in a 6-year-old. B: AP of the t-Condylar fracture line (open arrows) was not appreciated until it healed. There are both medial and lateral Thurstan–Holland fragments (solid arrows) (Courtesy of Ruben D. Pechero, MD). C: Pre- and postoperative x-rays of minimally displaced intra-articular Type I T-condylar fracture in a 16-year-old boy treated with closed reduction and percutaneous screw fixation.
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Figure 17-4
Type II displaced T-condylar factures.
 
A: Type II displaced T-condylar fracture with very little metaphyseal comminution. B: Pre- and postoperative images of displaced Type II T-condylar fracture with significant displacement but no comminution, treated with olecranon osteotomy and bicolumn rigid fixation to facilitate early range of motion.
A: Type II displaced T-condylar fracture with very little metaphyseal comminution. B: Pre- and postoperative images of displaced Type II T-condylar fracture with significant displacement but no comminution, treated with olecranon osteotomy and bicolumn rigid fixation to facilitate early range of motion.
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Figure 17-4
Type II displaced T-condylar factures.
A: Type II displaced T-condylar fracture with very little metaphyseal comminution. B: Pre- and postoperative images of displaced Type II T-condylar fracture with significant displacement but no comminution, treated with olecranon osteotomy and bicolumn rigid fixation to facilitate early range of motion.
A: Type II displaced T-condylar fracture with very little metaphyseal comminution. B: Pre- and postoperative images of displaced Type II T-condylar fracture with significant displacement but no comminution, treated with olecranon osteotomy and bicolumn rigid fixation to facilitate early range of motion.
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Figure 17-5
Type III T-condylar fractures with significant displacement and comminution.
 
A, B: Type III—two views of markedly comminuted T-condylar fracture with multiple displaced fragments (arrows) in a 12-year-old. C–F: Pre-, intra-, postoperative, and final healed radiographs of a 12-year-old girl with displaced and severely comminuted distal humerus and ipsilateral distal radius fracture, treated with a combination of transarticular screw and cross-wire fixation. At 1 year she has made a complete recovery with comparable range of motion to her contralateral elbow.
A, B: Type III—two views of markedly comminuted T-condylar fracture with multiple displaced fragments (arrows) in a 12-year-old. C–F: Pre-, intra-, postoperative, and final healed radiographs of a 12-year-old girl with displaced and severely comminuted distal humerus and ipsilateral distal radius fracture, treated with a combination of transarticular screw and cross-wire fixation. At 1 year she has made a complete recovery with comparable range of motion to her contralateral elbow.
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A, B: Type III—two views of markedly comminuted T-condylar fracture with multiple displaced fragments (arrows) in a 12-year-old. C–F: Pre-, intra-, postoperative, and final healed radiographs of a 12-year-old girl with displaced and severely comminuted distal humerus and ipsilateral distal radius fracture, treated with a combination of transarticular screw and cross-wire fixation. At 1 year she has made a complete recovery with comparable range of motion to her contralateral elbow.
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Figure 17-5
Type III T-condylar fractures with significant displacement and comminution.
A, B: Type III—two views of markedly comminuted T-condylar fracture with multiple displaced fragments (arrows) in a 12-year-old. C–F: Pre-, intra-, postoperative, and final healed radiographs of a 12-year-old girl with displaced and severely comminuted distal humerus and ipsilateral distal radius fracture, treated with a combination of transarticular screw and cross-wire fixation. At 1 year she has made a complete recovery with comparable range of motion to her contralateral elbow.
A, B: Type III—two views of markedly comminuted T-condylar fracture with multiple displaced fragments (arrows) in a 12-year-old. C–F: Pre-, intra-, postoperative, and final healed radiographs of a 12-year-old girl with displaced and severely comminuted distal humerus and ipsilateral distal radius fracture, treated with a combination of transarticular screw and cross-wire fixation. At 1 year she has made a complete recovery with comparable range of motion to her contralateral elbow.
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A, B: Type III—two views of markedly comminuted T-condylar fracture with multiple displaced fragments (arrows) in a 12-year-old. C–F: Pre-, intra-, postoperative, and final healed radiographs of a 12-year-old girl with displaced and severely comminuted distal humerus and ipsilateral distal radius fracture, treated with a combination of transarticular screw and cross-wire fixation. At 1 year she has made a complete recovery with comparable range of motion to her contralateral elbow.
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In a child, the integrity of the articular surface may be difficult to determine without using arthrography or MRI. Because disruption of the articular surface is rare, this factor was not used in those general classification schemes. However, it is imperative to know the status of articular alignment pre- and posttreatment. 
In adolescents aged 12 years or older, classification and treatment follow similar patterns to those for adults. In general intra-articular humerus fractures are defined by column (medial, lateral, or both) and degree of comminution. The Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification is used most often (Fig. 17-6). T-condylar fractures in the adolescent are usually AO C1 and C2 injuries.25 Fortunately C3 injuries with marked comminution is rare in the adolescent. Metaphyseal–diaphyseal fractures are separate entities and need to be recognized as such for proper treatment and fixation decisions.10 
Figure 17-6
The AO classification of distal humerus fractures—fractures are classified as extra-articular, partial articular, and complete articular fracture and treatment can be tailored based on fracture classification.
 
(Redrawn from Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium—2007: Orthopaedic Trauma Association classification, database, and outcomes committee. J Orthop Trauma 2007; 21(suppl 10):S1–133, with permission.)
(Redrawn from 


Marsh JL,

Slongo TF,

Agel J
, et al.
Fracture and dislocation classification compendium—2007: Orthopaedic Trauma Association classification, database, and outcomes committee.
J Orthop Trauma 2007;
21(suppl 10):S1–133, with permission.)
View Original | Slide (.ppt)
(Redrawn from 


Marsh JL,

Slongo TF,

Agel J
, et al.
Fracture and dislocation classification compendium—2007: Orthopaedic Trauma Association classification, database, and outcomes committee.
J Orthop Trauma 2007;
21(suppl 10):S1–133, with permission.)
View Original | Slide (.ppt)
(Redrawn from 


Marsh JL,

Slongo TF,

Agel J
, et al.
Fracture and dislocation classification compendium—2007: Orthopaedic Trauma Association classification, database, and outcomes committee.
J Orthop Trauma 2007;
21(suppl 10):S1–133, with permission.)
View Original | Slide (.ppt)
(Redrawn from 


Marsh JL,

Slongo TF,

Agel J
, et al.
Fracture and dislocation classification compendium—2007: Orthopaedic Trauma Association classification, database, and outcomes committee.
J Orthop Trauma 2007;
21(suppl 10):S1–133, with permission.)
View Original | Slide (.ppt)
Figure 17-6
The AO classification of distal humerus fractures—fractures are classified as extra-articular, partial articular, and complete articular fracture and treatment can be tailored based on fracture classification.
(Redrawn from Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium—2007: Orthopaedic Trauma Association classification, database, and outcomes committee. J Orthop Trauma 2007; 21(suppl 10):S1–133, with permission.)
(Redrawn from 


Marsh JL,

Slongo TF,

Agel J
, et al.
Fracture and dislocation classification compendium—2007: Orthopaedic Trauma Association classification, database, and outcomes committee.
J Orthop Trauma 2007;
21(suppl 10):S1–133, with permission.)
View Original | Slide (.ppt)
(Redrawn from 


Marsh JL,

Slongo TF,

Agel J
, et al.
Fracture and dislocation classification compendium—2007: Orthopaedic Trauma Association classification, database, and outcomes committee.
J Orthop Trauma 2007;
21(suppl 10):S1–133, with permission.)
View Original | Slide (.ppt)
(Redrawn from 


Marsh JL,

Slongo TF,

Agel J
, et al.
Fracture and dislocation classification compendium—2007: Orthopaedic Trauma Association classification, database, and outcomes committee.
J Orthop Trauma 2007;
21(suppl 10):S1–133, with permission.)
View Original | Slide (.ppt)
(Redrawn from 


Marsh JL,

Slongo TF,

Agel J
, et al.
Fracture and dislocation classification compendium—2007: Orthopaedic Trauma Association classification, database, and outcomes committee.
J Orthop Trauma 2007;
21(suppl 10):S1–133, with permission.)
View Original | Slide (.ppt)
X

Outcome Measures for T-Condylar Distal Humerus Fractures

Common clinical outcomes recorded in T-condylar distal humerus fractures include, time to union, range of motion, and elbow strength as measured through Cybex testing. Functional outcome scores for both operative and nonoperative treatments such as the Objective Functional Elbow Index6 and the Disability of the Arm, Shoulder, and Hand8 (DASH) are frequently used to measure functional improvement after upper extremity surgery. 

Pathoanatomy and Applied Anatomy Relating to T-Condylar Distal Humerus Fractures

The elbow is a complex joint composed of three individual joints contained within a common articular cavity. Ossification of the distal humerus proceeds at a predictable rate. However, the rate of ossification in girls generally exceeds that of boys.9,11,12 In some areas, such as the olecranon and lateral epicondyle, the difference between boys and girls in ossification age may be as great as 2 years.11 Knowledge of the sequence and timing of ossification in the elbow will aide the treating physician in differentiating true intercondylar pathology from normal anatomic variant. 
The bone of the distal humerus is triangular in shape. The medial and lateral columns of the distal humerus form the supracondylar region and are characterized by sharp and thin ridges of bone, respectively.3 At the base of the triangle lies the trochlea, which represents the most distal portion of the humerus. It is important to realize that the lateral column of the distal humerus curves anteriorly along with the anteriorly translated articular surface of the distal humerus, but the medial column is straight in line with the humeral diaphysis. The spatial relationship between the medial column, lateral column, and trochlea are conceptually similar to a spool of thread being held between the thumb and index finger.16 
The surgical approach for distal humerus fractures most widely accepted is an extensile posterior incision through which all aspects of the elbow can be exposed including the anterior structures.24 The ulnar nerve is frequently a structure that needs to be identified and protected during open reduction and internal fixation. It passes through the cubital tunnel just posterior to the medial epicondyle and is held in close proximity to the distal elbow by Osborne's fascia. Higher on the lateral side the radial nerve pierces the intermuscular septum where it is vulnerable to injury by a fracture or surgical exposure. 

Treatment Options for T-Condylar Distal Humerus Fractures

Because of the rarity of this injury, treatment recommendations are based on isolated case or small retrospective case series and/or the application of adult treatment principles.1,4,15,18,23,25,26,31 Regardless of the treatment method, certain basic principles must be considered in dealing with these fractures. 
A treatment plan must be individualized for the specific fracture and the surgeon's level of expertise and experience. The following principles must be considered in planning a treatment method: 
  •  
    The T-condylar fracture is an articular fracture, so the first goal is to restore and stabilize the joint surface.
  •  
    Stability depends on the integrity of the lateral and medial supracondylar columns.
  •  
    Elbow articular mobility depends on articular congruity, correct alignment of the axis of motion, and debris- and bone-free fossae.
  •  
    Closed methods alone usually cannot produce an acceptable result because the muscle forces applied to the fragments make the fracture unstable.
  •  
    Most patients are adolescents with minimal potential for bone remodeling and should be treated with bicolumn open reduction and internal fixation similar to an adult.
  •  
    Although surgical reduction may produce an acceptable reduction on radiograph, it may add to the already extensive damage to soft tissues; this in turn can contribute to postoperative stiffness. Stable internal fixation that allows for immediate postoperative movement is important in reducing the risk of contracture development.

Nonoperative Treatment of T-condylar Distal Humerus Fractures

Indications/Contraindications

The majority of T-condylar distal humerus fractures are best treated with some form of open reduction and internal fixation. However, there is a narrow range of fractures that are indicated for management of these injuries with closed reduction and casting. Children who are under 8 years of age with robust periosteum and essentially nondisplaced fractures are good candidates for closed reduction and casting (Table 17-1). 
 
Table 17-1
T-condylar Distal Humerus Fractures
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Table 17-1
T-condylar Distal Humerus Fractures
Nonoperative Treatment
Indications Relative Contraindications
Young children <8 yrs with intact periosteum Fracture displacement >2 mm
Simple fractures without comminution, displacement, and angulation Fracture comminution
Ipsilateral arm injuries
X

Techniques

A very small number of T-condylar distal humerus fractures can potentially be treated with immobilization exclusively. Nondisplaced fractures can be splinted or casted until healing with close radiographic follow-up. An above-elbow cast is applied for at least 3 weeks with repeat x-rays on a weekly interval to detect interval displacement. Some clinicians perform a closed reduction for very minimally displaced fractures. Reduction under conscious sedation or anesthesia with in-line traction and live fluoroscopy is necessary to ensure that acceptable reduction is maintained. Review of reduction may be necessary with three-dimensional (3D) imaging in the form of CT or MRI. To be honest, we rarely treat fractures with any displacement closed. If a reduction is required, we view this as an unstable injury and at a minimum, will utilize three percutaneous pins to stabilize the anatomic alignment of the articular surface and both columns. 

Outcomes

The majority of T-condylar distal humerus fractures are treated operatively, and therefore it is very difficult to tease out the results of nonoperative management of these fractures. In our review of several series, only 4 of 48 combined fractures were treated nonoperatively.18,23,25 In these limited cases, all patients achieved a full arc of motion without complications from their fracture or treatment. 

Operative Treatment of T-condylar Distal Humerus Fractures

Indications/Contraindications

Adolescents with T-condylar distal humerus fractures are usually treated with bicolumn open reduction and internal fixation similar to an adult. Indications for open reduction and internal fixation include all displaced extra-articular fractures, displacement of the articular surface greater than 2 mm, comminution of the distal humerus with greater than two fracture fragments, and ipsilateral fracture(s) of the upper extremity. Open fractures, pending compartment syndromes, and avascular limbs are surgical emergencies. However, the majority of T-condylar distal humerus fractures can be treated electively within 72 hours from the initial injury. 
In adolescents, the majority of T-condylar distal humerus fractures are C1 according to the AO classification (Fig. 17-6). Therefore, choosing either a triceps splitting or triceps reflecting approach is sufficient to facilitate access for open reduction and internal fixation. In the rare circumstances of C2 or C3 fractures, especially in the setting of anterior comminution, an olecranon osteotomy is warranted to facilitate visualization and fixation of the articular surface. 

Closed Reduction and Percutaneous Pin/Screw Fixation

In young children (<8 years) with robust periosteum, the T-condylar distal humerus fracture may represent isolated hinging of the periosteum with minimal displacement of the intercondylar fracture. Careful preoperative imaging will demonstrate merely hinging of the articular surface without significant displacement. In younger children with minimal displacement, it is not unreasonable to perform a fluoroscopic guided reduction and stabilization with multiple percutaneous pins. Generally three smooth, appropriate-sized wires are used: One horizontally from the lateral to medial to stabilize the joint surface and two to stabilize the medial and lateral columns. These pins can either be divergent lateral entry or both medial and lateral entry pins. 
In older children with minimal displacement, especially single column intra-articular fractures, percutaneous reduction and cannulated column screw fixation is acceptable. This, to some degree violates standard adult principles of open reduction internal fixation. However, if anatomic articular alignment and stable internal fixation can be achieved percutaneously, then less invasive treatment is appropriate. It is critical to have superior fluoroscopic images intraoperatively to prevent the realization of persistent fracture fragment displacement and/or inadvertent screw malposition with the first set of postoperative radiographs. 
Preoperative Planning
Surgical planning includes decisions on percutaneous pin versus screw fixation and patient positioning in the operative room. Careful scrutiny of preoperative radiographs and 3Dimaging (usually CT scans) is imperative. Sometimes, intraoperative fluoroscopy images with traction realignment are essential in final decision making about surgical approach and fixation methods. Percutaneous treatment should only be chosen if anatomic reduction and stable fixation can be achieved with limited postoperative immobilization to lessen the risk of elbow contracture. 
Similar principles for displaced adult distal humerus intra-articular fractures are employed, with reduction and stabilization of the articular surface first, followed by stabilization of the medial and lateral columns. If percutaneous reduction and fixation is performed, a large, external bone holding the reduction clamp is used to facilitate interfragmentary reduction and compression of the joint, prior to pin or screw fixation. Accurate placement of a transverse pin to hold the articular segments in an anatomic position is critical. Depending on the degree of displacement and fracture fragment configuration, provisional or definitive fixation can be achieved with standard medial and lateral column pins as in a supracondylar humerus fracture. As noted above, in limited scenarios, these fractures can be treated definitively with closed reduction and percutaneous fixation using either smooth wires or cannulated screws (Table 17-2). 
 
Table 17-2
CRPP of T-condylar Distal Humerus Fractures
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Table 17-2
CRPP of T-condylar Distal Humerus Fractures
Preoperative Planning Checklist
  •  
    OR Table: Flat Jackson with addition of radiolucent hand table
  •  
    Position/positioning aids: Supine on hand table
  •  
    Fluoroscopy location: C-arm can come in from the head or foot of the bed when necessary
  •  
    Equipment: Large AO pelvic reduction clamps, c- or K-wires, cannulated screws (4 or 4.5 mm)
  •  
    Tourniquet (sterile/nonsterile): Sterile tourniquet can be used but not necessary
X
Positioning
Percutaneous fixation of T-condylar distal humerus fractures is usually performed in the supine position, but can be facilitated also in the lateral or prone position. Most commonly the patient is positioned supine with arm on a hand table. The arm is elevated on a stack of towels to facilitate easier screw insertion. Bringing the shoulder into abduction and elbow into extension can improve the quality of visualization of the fracture with C-arm imaging. Generally the young have enough rotatory motion about the shoulder to allow for proper visualization in the supine position. 
An alternative approach is to position the patient in the lateral position with an axillary roll to protect the brachial plexus on the nonoperative limb. In this position a large bump is fashioned or a specialized arm holder is used to hold the arm in internally rotated position at the shoulder with 90 degrees of flexion at the elbow. The C-arm machine can obtain acceptable images coming from the head or feet parallel to the bed. Finally, patients can be positioned in the prone position with the operative limb exposed on a separate small arm board/table or hanging off the side of the bed. In this position bolsters are used in a standard fashion similar to a spinal procedure to decompress the abdomen and protect the neurovascular structures. The arm is held similar to the lateral position, with internal rotation of the shoulder and 90 degrees of flexion at the elbow with minimal tension. Again, C-arm imaging is accessible from the head or foot of the bed. Prone positioning is most useful in obese patients. 
Surgical Approach(es)
In closed reduction and percutaneous pin/screw fixation, limited surgical exposure is performed. In some settings, small stab incisions are made to ensure that the large bone reducing forceps are able to be placed directly on bone (medial and lateral epicondyles most commonly) to generate the desired compressive effect. In general, wires are placed percutaneously from the lateral column of the distal humerus. On the medial side, small 1- to 2-cm incisions can be made to prevent inadvertent injury to the ulnar nerve. In addition, the arm is placed in a semi-extended position when passing wires/screws from the medial to lateral, to decrease the risk of iatrogenic ulnar nerve injury. 
Technique (Table 17-3)
 
Table 17-3
CRPP of T-condylar Distal Humerus Fractures
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Table 17-3
CRPP of T-condylar Distal Humerus Fractures
Surgical Steps
  •  
    Begin with performance of accurate AP/lateral and oblique fluoroscopic images of the distal humerus
  •  
    Make small stab incisions, to facilitate bone clamp application
  •  
    Under dynamic fluoroscopy verify that fracture reduction is being achieved with dynamic compression
  •  
    Once the fracture is in an acceptable position
    •  
      Place appropriate wires to achieve provisional stability
      •  
        Fix the articular fragment first
      •  
        Address column stability second
  •  
    Once the wires are in the correct position, confirm with live fluoroscopy to ensure adequate reduction and wire placement
  •  
    Measure screw lengths when appropriate and then overdrill guide wires
  •  
    Place the screw across the articular fragment first and then stabilize the medial/lateral columns
  •  
    Test stability with flexion and extension
X

Open Reduction Internal Fixation

Preoperative Planning

The surgical treatment of T-condylar distal humerus fractures involves consideration of three critical components: (1) Surgical approach—triceps splitting, triceps elevating, paratricipital, or olecranon osteotomy; (2) Type of fixation—single column, bicolumn orthogonal or parallel plating or rarely three plates; (3) Body positioning—prone, lateral decubitus, or supine (Table 17-4). 
 
Table 17-4
ORIF of T-condylar Distal Humerus Fractures
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Table 17-4
ORIF of T-condylar Distal Humerus Fractures
Preoperative Planning Checklist
  •  
    OR Table: Flat Jackson with fluoroscopic arm board extension
  •  
    Position/positioning aids: Prone position on bolsters to decompress abdomen and protect neurovascular structures
  •  
    Fluoroscopy location: C-arm can come in from the head or foot of the bed when necessary
  •  
    Equipment: Large AO pelvic reduction clamps, K-wires, cannulated screws and precontoured distal humerus plates or pelvic reconstruction plates
  •  
    Tourniquet (sterile/nonsterile): Sterile tourniquet used but can be let down if necessary because of timing
  •  
    Cautery: Monopolar and bipolar cautery to facilitate dissection of the ulnar nerve
  •  
    Penrose drain/Vessel loop: Used to isolate the ulnar nerve during the case
X

Positioning

Fixation of distal humerus fractures can be facilitated in the supine, lateral, or prone positions with the choice determined primarily based on the anticipated exposure, presence of concomitant injuries, and surgeon experience. 
In the setting of polytrauma, patients may be positioned in supine/sloppy lateral position with a large bump placed under the ipsilateral shoulder. Surgery can be performed with the arm across the chest, held in place by an assistant or a towel clamp. Bringing the arm into abduction and extension can aid with visualization of the fracture and improve the quality of C-arm imaging. 
An alternative approach is to position the patient in the lateral position with an axillary roll to protect the brachial plexus on the nonoperative limb. In this position a large bump is fashioned or a specialized arm holder is used to hold the arm in internally rotated position at the shoulder with 90 degrees of flexion at the elbow. The C-arm machine can obtain acceptable images coming from the head or feet parallel to the bed. 
Finally, patients can be positioned in the prone position with the operative limb exposed on a separate small arm board/table. In this position bolsters are used in standard fashion similar to a spinal procedure to decompress the abdomen and protect neurovascular structures. The arm is held similar to the lateral position, with internal rotation of the shoulder and 90 degrees of flexion at the elbow with minimal tension. Again, C-arm imaging is accessible from the head or foot of the bed. 

Surgical Approach(es)

A utilitarian skin approach is used for the majority of surgical approaches associated with T-condylar distal humerus fractures. A long curvilinear posterior skin incision is utilized with the distal extension lateral to the olecranon and then back to the midline onto the proximal ulna. By avoiding the tip of the olecranon, this prevents an irritating posterior scar. Skin and subcutaneous fasciocutaneous flaps are elevated extensively. The ulnar nerve requires careful attention, protection, mobilization, and decompression at this stage and throughout the remainder of the operation. An elastic loop is placed around the nerve, and the nerve is handled gently for the entire surgical procedure. 
Triceps Splitting Approach31 (Fig. 17-7
Figure 17-7
Paratricipital Approach.
 
The paratricipital approach is done through a longitudinal posterior skin incision. Medially (A) the ulnar nerve (black arrow) is identified. The medial intermuscular septum (forceps) is excised and the triceps muscle is elevated off the posterior aspect of the distal humerus (B). Laterally the triceps muscle is elevated off the posterolateral aspect of the distal humerus, allowing exposure of the lateral column, olecranon fossa, and posterior aspect of the trochlea (C). (L, lateral column; T, triceps.)
 
(From Bucholz RW, Court-Brown CM, Heckman JD, Tornetta P, Rockwood and Green's Fractures in Adults. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins 2010, with permission)
The paratricipital approach is done through a longitudinal posterior skin incision. Medially (A) the ulnar nerve (black arrow) is identified. The medial intermuscular septum (forceps) is excised and the triceps muscle is elevated off the posterior aspect of the distal humerus (B). Laterally the triceps muscle is elevated off the posterolateral aspect of the distal humerus, allowing exposure of the lateral column, olecranon fossa, and posterior aspect of the trochlea (C). (L, lateral column; T, triceps.)
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Figure 17-7
Paratricipital Approach.
The paratricipital approach is done through a longitudinal posterior skin incision. Medially (A) the ulnar nerve (black arrow) is identified. The medial intermuscular septum (forceps) is excised and the triceps muscle is elevated off the posterior aspect of the distal humerus (B). Laterally the triceps muscle is elevated off the posterolateral aspect of the distal humerus, allowing exposure of the lateral column, olecranon fossa, and posterior aspect of the trochlea (C). (L, lateral column; T, triceps.)
(From Bucholz RW, Court-Brown CM, Heckman JD, Tornetta P, Rockwood and Green's Fractures in Adults. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins 2010, with permission)
The paratricipital approach is done through a longitudinal posterior skin incision. Medially (A) the ulnar nerve (black arrow) is identified. The medial intermuscular septum (forceps) is excised and the triceps muscle is elevated off the posterior aspect of the distal humerus (B). Laterally the triceps muscle is elevated off the posterolateral aspect of the distal humerus, allowing exposure of the lateral column, olecranon fossa, and posterior aspect of the trochlea (C). (L, lateral column; T, triceps.)
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X
  •  
    Use long oblique fascial incisions from the medial and lateral epicondyles, to a more proximal connecting point in the midline.
  •  
    Reflect the resultant tongue of fascia from proximal to distal down to its insertion on the olecranon while protecting the ulnar nerve on the medial side.
  •  
    The triceps muscle is split in the midline and is retracted beyond the medial and lateral columns respectively with broad retractors.
  •  
    The radial and ulnar nerves are protected behind retractors during exposure, reduction, and fixation.
     
    Flexion of the elbow allows for visualization and fixation of the articular fragments.
Triceps Reflecting Approach (Bryan and Morrey)7,26 (Fig. 17-8
Figure 17-8
Triceps Split.
 
A midline approach is made through the center of the triceps tendon and medial head (A). The approach can be extended distally by splitting the triceps insertion to the olecranon and raisin medial and lateral full-thickness fasciotendinous flaps (B, C). To gain further exposure of the posterior trochlea, the elbow is flexed and the olecranon tip may be excised.
 
(From Bucholz RW, Court-Brown CM, Heckman JD, Tornetta P, Rockwood and Green's Fractures in Adults. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins 2010, with permission).
A midline approach is made through the center of the triceps tendon and medial head (A). The approach can be extended distally by splitting the triceps insertion to the olecranon and raisin medial and lateral full-thickness fasciotendinous flaps (B, C). To gain further exposure of the posterior trochlea, the elbow is flexed and the olecranon tip may be excised.
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Figure 17-8
Triceps Split.
A midline approach is made through the center of the triceps tendon and medial head (A). The approach can be extended distally by splitting the triceps insertion to the olecranon and raisin medial and lateral full-thickness fasciotendinous flaps (B, C). To gain further exposure of the posterior trochlea, the elbow is flexed and the olecranon tip may be excised.
(From Bucholz RW, Court-Brown CM, Heckman JD, Tornetta P, Rockwood and Green's Fractures in Adults. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins 2010, with permission).
A midline approach is made through the center of the triceps tendon and medial head (A). The approach can be extended distally by splitting the triceps insertion to the olecranon and raisin medial and lateral full-thickness fasciotendinous flaps (B, C). To gain further exposure of the posterior trochlea, the elbow is flexed and the olecranon tip may be excised.
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X
  •  
    The medial aspect of the triceps is elevated from the humerus along the intermuscular septum to the level of the posterior capsule. In children and adolescents, this can be achieved with subperiosteal elevation.
  •  
    The superficial fascia of the forearm is incised distally for about 6 cm to the periosteum of the medial aspect of the proximal ulna.
  •  
    The periosteum and fascia are carefully elevated as a single layer from the medial to lateral, distal to proximal. Care must be taken to maintain the continuity of the triceps, periosteum and fascia. The medial aspect of the junction between the triceps insertion and the superficial fascia and periosteum of the ulna is the weakest portion of the reflected tissue. Elevation off the apophysis is also delicate as buttonholing can occur here which will limit the length and strength of the triceps fascial flap and risk destabilizing the triceps insertion into the olecranon.
  •  
    At the conclusion of skeletal fixation, the triceps insertion periosteal sleeve is repaired directly to the bone with transosseus sutures or suture anchors.
  •  
    This approach is contraindicated in open fractures, where a portion of the triceps may become avascular secondary to the initial trauma from the fracture and further dissection increases this risk.
Olecranon Osteotomy (Fig. 17-9
Figure 17-9
Olecranon Osteotomy.
 
The olecranon osteotomy is approached via a longitudinal posterior skin incision (A). The ulnar nerve is exposed and may be prepared for anterior subcutaneous transposition (B). The subcutaneous border of the proximal ulnar is exposed and the nonarticular portion of the greater sigmoid notch between the olecranon articular facet and the coronoid articular facet is clearly defined. Medial and lateral retractors are then placed into the ulnohumeral joint and an apex distal chevron osteotomy entering into the bare area is marked on the subcutaneous border of the ulna. A microsagittal saw is used to complete two-thirds of the osteotomy (C) and two osteotomes, placed into each arm of the chevron, apply controlled leverage to fracture the remaining third (D).
 
(From Bucholz RW, Court-Brown CM, Heckman JD, Tornetta P, Rockwood and Green's Fractures in Adults. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins 2010, with permission).
The olecranon osteotomy is approached via a longitudinal posterior skin incision (A). The ulnar nerve is exposed and may be prepared for anterior subcutaneous transposition (B). The subcutaneous border of the proximal ulnar is exposed and the nonarticular portion of the greater sigmoid notch between the olecranon articular facet and the coronoid articular facet is clearly defined. Medial and lateral retractors are then placed into the ulnohumeral joint and an apex distal chevron osteotomy entering into the bare area is marked on the subcutaneous border of the ulna. A microsagittal saw is used to complete two-thirds of the osteotomy (C) and two osteotomes, placed into each arm of the chevron, apply controlled leverage to fracture the remaining third (D).
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Figure 17-9
Olecranon Osteotomy.
The olecranon osteotomy is approached via a longitudinal posterior skin incision (A). The ulnar nerve is exposed and may be prepared for anterior subcutaneous transposition (B). The subcutaneous border of the proximal ulnar is exposed and the nonarticular portion of the greater sigmoid notch between the olecranon articular facet and the coronoid articular facet is clearly defined. Medial and lateral retractors are then placed into the ulnohumeral joint and an apex distal chevron osteotomy entering into the bare area is marked on the subcutaneous border of the ulna. A microsagittal saw is used to complete two-thirds of the osteotomy (C) and two osteotomes, placed into each arm of the chevron, apply controlled leverage to fracture the remaining third (D).
(From Bucholz RW, Court-Brown CM, Heckman JD, Tornetta P, Rockwood and Green's Fractures in Adults. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins 2010, with permission).
The olecranon osteotomy is approached via a longitudinal posterior skin incision (A). The ulnar nerve is exposed and may be prepared for anterior subcutaneous transposition (B). The subcutaneous border of the proximal ulnar is exposed and the nonarticular portion of the greater sigmoid notch between the olecranon articular facet and the coronoid articular facet is clearly defined. Medial and lateral retractors are then placed into the ulnohumeral joint and an apex distal chevron osteotomy entering into the bare area is marked on the subcutaneous border of the ulna. A microsagittal saw is used to complete two-thirds of the osteotomy (C) and two osteotomes, placed into each arm of the chevron, apply controlled leverage to fracture the remaining third (D).
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  •  
    The olecranon osteotomy has been described as a standard approach for adult T-condylar distal humerus fractures.
  •  
    In our hands we reserve this approach in children and adolescents for complex T-condylar distal humerus fractures with significant intra-articular comminution (AO C3 T-condylar fractures).
  •  
    Similar to the paratricipital approach, the triceps is mobilized from the medial and lateral septa and followed distally to the elbow joint.
  •  
    A longitudinal cancellous screw is predrilled down the olecranon from the tip or apophysis.
  •  
    This screw is removed, and a chevron type osteotomy is performed at the deepest portion of the trochlear notch of the olecranon process and is coincident with an area devoid of articular cartilage (bare area).
  •  
    The chevron osteotomy points distally, and is initiated with a fine oscillating saw and completed with a thin osteotome.
  •  
    The triceps muscle and the osteotomized proximal half of the olecranon are then reflected superiorly.
  •  
    The osteotomy can alternatively be fixed with a precontoured olecranon plate or parallel K-wires and tension band technique.
  •  
    At the end of the reduction, the osteotomy is reduced and fixed with compression fixation with cancellous screw and washer fixation.

Technique (Table 17-5)

 
Table 17-5
ORIF of T-condylar Distal Humerus Fractures
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Table 17-5
ORIF of T-condylar Distal Humerus Fractures
Surgical Steps
  •  
    Longitudinal posterior midline skin incision, avoiding the tip of the olecranon
  •  
    Elevation of medial and lateral fasciocutaneous flaps as necessary
  •  
    Identification of the ulnar nerve, decompression, and mobilization for protection during the remainder of the procedure
  •  
    Surgical approach dictated by
    •  
      Fracture type
    •  
      Presence of associated injuries
    •  
      Degree of soft tissue injury
    •  
      Surgeon preference
  •  
    Exposure of fracture fragments, removal of intervening soft tissues and fracture hematoma
  •  
    Temporarily stabilize the joint anatomically with guide wires from the cannulated screw set (4 or 4.5 depending on the patient)
  •  
    Stabilize the anatomic joint fixation to columns temporarily
  •  
    Confirm anatomic alignment under direct visualization and fluoroscopically
  •  
    Replace temporary cannulated pin fixation with compressive screw fixation across the joint
  •  
    Convert the column fixation to orthogonal plates
    •  
      Medial 3.5 pelvic reconstruction or precontoured plate
    •  
      Posterolateral 3.5 reconstruction, dynamic compression, or precontoured plate
  •  
    Test stability and flexion and extension arc of motion
  •  
    Decide where the ulnar nerve should lie, in its original position or in a transposed position
X

Author's Preferred Treatment for T-Condylar Distal Humerus Fractures

Because this fracture is rare in children, there are limited standard recommendations for treatment. Our suggestions are based on a combination of our clinical experience and the experience of others in a few series.10,15,18,23,25,26,31 Our first imperative in these fractures is to re-establish the integrity of the articular surface to maintain the congruity of the joint. Usually, this cannot be achieved adequately by closed methods, so we proceed with an open surgical technique. In the young child, we have divided the simple classification into three types based on the degree of displacement or comminution to be helpful in guiding the aggressiveness of our treatment. In adolescents we guide our treatment according to the AO classification. 

Type I (Undisplaced or Minimally Displaced)

In Type I injuries, there is little displacement of the bony supracondylar columns. In children, the periosteum is often intact and can provide some intrinsic stability. In addition, the thicker articular and epiphyseal cartilage in skeletally immature children may still be intact, even if the bony epiphysis appears severed by a vertical fracture line. Because of this condition, we have found two methods to be successful for these types of fractures. 

Closed Reduction—Cast Application

Truly nondisplaced fractures can be treated in a cast. Again, it is imperative to judge completely stable fractures from injuries that can displace. Initial 3D imaging and careful radiographic follow-up are necessary to avoid an articular malunion. Because of the rapid healing in these nondisplaced fractures, the cast can be removed in 4 weeks and a hinged elbow brace initiated to permit early protected motion. 

Closed Reduction—Percutaneous Pin Fixation or Screw Fixation

The minimally displaced fractures in the young require minimal manipulation under general anesthesia and radiographic control to re-establish the supracondylar columns and articular surface anatomy. If there is minor anterior or posterior rotation in the sagittal plane of the metaphyseal portion of the column, a pin placed into that column can be used as a “joystick” to manipulate the fragment into a satisfactory position. Once a satisfactory reduction is achieved, the pin can then be advanced across the fracture site for fixation. These fractures usually require multiple pins placed percutaneously, such as those used in comminuted supracondylar fractures (Fig. 17-10). Because of the rapid healing, the pins can be removed at 3 to 4 weeks to allow early active motion. 
Figure 17-10
Closed reduction and pin fixation.
 
A, B: Two views of a Type II T-condylar fracture in a 15-year-old. C, D: Because an anatomic reduction was achieved by manipulative closed reduction, it was secured with simple multiple pin fixation placed percutaneously. The articular surface was minimally displaced. The pins were removed at 3 weeks. At this age, healing was rapid enough to pull the pins at 3 weeks to allow active motion. Ultimately, the patient was deficient only 10 degrees from achieving full extension.
A, B: Two views of a Type II T-condylar fracture in a 15-year-old. C, D: Because an anatomic reduction was achieved by manipulative closed reduction, it was secured with simple multiple pin fixation placed percutaneously. The articular surface was minimally displaced. The pins were removed at 3 weeks. At this age, healing was rapid enough to pull the pins at 3 weeks to allow active motion. Ultimately, the patient was deficient only 10 degrees from achieving full extension.
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Figure 17-10
Closed reduction and pin fixation.
A, B: Two views of a Type II T-condylar fracture in a 15-year-old. C, D: Because an anatomic reduction was achieved by manipulative closed reduction, it was secured with simple multiple pin fixation placed percutaneously. The articular surface was minimally displaced. The pins were removed at 3 weeks. At this age, healing was rapid enough to pull the pins at 3 weeks to allow active motion. Ultimately, the patient was deficient only 10 degrees from achieving full extension.
A, B: Two views of a Type II T-condylar fracture in a 15-year-old. C, D: Because an anatomic reduction was achieved by manipulative closed reduction, it was secured with simple multiple pin fixation placed percutaneously. The articular surface was minimally displaced. The pins were removed at 3 weeks. At this age, healing was rapid enough to pull the pins at 3 weeks to allow active motion. Ultimately, the patient was deficient only 10 degrees from achieving full extension.
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In the setting of mild intra-articular displacement, we employ the use of a large bone reducing forceps to help facilitate with our reduction. Often this can be applied percutaneously or through small stab incisions to ensure that the tines of the clamp are place directly onto the bone (usually medial and lateral epicondyles) of the distal humerus without injury to the neighboring neurovascular structures. Once the articular diastasis is corrected, guide wires from the cannulated screw set are placed with bicortical fixation perpendicular to the fracture line. Appropriate length screws with washers are placed over the guide wires. Compression is applied sequentially, alternating between screws to ensure optimal and balanced compression. 

Type II (Displaced without Comminution)

Open Reduction and Internal Fixation

If there is wide separation of the condylar fragments with marked disruption of the articular surface, stability and articular congruity can be established only with an open surgical procedure. We prefer a triceps-splitting approach for C1 distal humerus fractures and a triceps sparing Bryan–Morrey approach for C2 distal humerus fractures. Olecranon osteotomy is reserved for severely comminuted C3 articular fractures in adolescents. We place the patient supine in a “sloppy lateral” position to allow for easier lateral fluoroscopic imaging. A sterile tourniquet is used throughout the surgery. 

Reconstruction of the Articular Surface

Our first priority is to re-establish the integrity of the articular fragments—in other words, to convert it to a supracondylar fracture (Fig. 17-11). The olecranon and coronoid fossae must be cleared of bony fragments or debris to eliminate the chance of bony impingement against their respective processes with motion. The best way to stabilize the condyles is with a screw passed transversely through the center of the axis of rotation in such a manner as to apply transverse compression. This stabilization method may require a small temporary secondary transverse pin proximal to the screw to prevent rotation of the fragments as the guide hole is drilled or when the compression screw is being applied. This pin can be removed after the fragments are secured. 
Figure 17-11
Sequence of distal humerus reconstruction.
 
A–C: First, the articular portions are reassembled with provisional K-wire fixation, followed by screw fixation. D: K-wires can then also be used to provide temporary fixation of the distal humerus. E: A one-third tubular plate is attached to the medial side. F: A 3.5 mm pelvic reconstruction plate was attached to the posterolateral border.
A–C: First, the articular portions are reassembled with provisional K-wire fixation, followed by screw fixation. D: K-wires can then also be used to provide temporary fixation of the distal humerus. E: A one-third tubular plate is attached to the medial side. F: A 3.5 mm pelvic reconstruction plate was attached to the posterolateral border.
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Figure 17-11
Sequence of distal humerus reconstruction.
A–C: First, the articular portions are reassembled with provisional K-wire fixation, followed by screw fixation. D: K-wires can then also be used to provide temporary fixation of the distal humerus. E: A one-third tubular plate is attached to the medial side. F: A 3.5 mm pelvic reconstruction plate was attached to the posterolateral border.
A–C: First, the articular portions are reassembled with provisional K-wire fixation, followed by screw fixation. D: K-wires can then also be used to provide temporary fixation of the distal humerus. E: A one-third tubular plate is attached to the medial side. F: A 3.5 mm pelvic reconstruction plate was attached to the posterolateral border.
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In most adolescents, this is essentially an adult type of fracture pattern. Direct visualization of the reduction of all fracture fragments is mandatory. It is critical to get the joint surface anatomic and rigidly fixed. A single, short-threaded cancellous screw and washer is most commonly used. A 3.5 mm to 4.5 mm diameter screw is placed from lateral to medial depending on the size of the bone and the available space between the articular surface and the olecranon fossa. Open physes further complicate the delicacy of exact screw placement in this region. The ulnar nerve is protected on the medial side. Once anatomic reduction and fixation of the articular surface is achieved, secure fixation of the columns is performed next. However, do not rush to column fixation unless the joint surface is reduced correctly. In younger teenagers, the joint cartilage can buckle and tear and this can make the anatomic alignment harder to discern than in more skeletally mature patients in which the bony fragments interdigitate nicely (Fig. 17-12AC). 
Figure 17-12
 
A–C: Type II displaced T-condylar fracture. This fracture was initially treated with distal transarticular compression screw for stability and then followed by single lateral column fixation
A–C: Type II displaced T-condylar fracture. This fracture was initially treated with distal transarticular compression screw for stability and then followed by single lateral column fixation
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Figure 17-12
A–C: Type II displaced T-condylar fracture. This fracture was initially treated with distal transarticular compression screw for stability and then followed by single lateral column fixation
A–C: Type II displaced T-condylar fracture. This fracture was initially treated with distal transarticular compression screw for stability and then followed by single lateral column fixation
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Stabilization of the Supracondylar Columns

Once the condylar and articular integrity has been re-established, the distal fragments must be secured to the proximal fragment by stabilizing the supracondylar fragment columns. The decision here is how important it is to initiate early motion. In a younger child with rapid bony healing, pin fixation is often satisfactory; the pins can be removed after 3 weeks to start protected motion. In an older adolescent nearer to skeletal maturity, we prefer fixation—usually plates or less commonly, screws—that allows early motion (Figs. 17-11E,F and 17-13). Before applying the plates, the supracondylar columns can be stabilized temporarily with pin fixation (Fig. 17-13). 
Figure 17-13
T-condylar humeral fracture with plate and screw fixation.
 
A, B: Injury films of a Type II flexion pattern in a 16-year-old boy. C, D: Articular integrity was first restored with a transcondylar compression screw. The condyles were secured to the metaphysis and distal shaft using pelvic reconstruction plates placed at 90 degrees to each other.
A, B: Injury films of a Type II flexion pattern in a 16-year-old boy. C, D: Articular integrity was first restored with a transcondylar compression screw. The condyles were secured to the metaphysis and distal shaft using pelvic reconstruction plates placed at 90 degrees to each other.
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Figure 17-13
T-condylar humeral fracture with plate and screw fixation.
A, B: Injury films of a Type II flexion pattern in a 16-year-old boy. C, D: Articular integrity was first restored with a transcondylar compression screw. The condyles were secured to the metaphysis and distal shaft using pelvic reconstruction plates placed at 90 degrees to each other.
A, B: Injury films of a Type II flexion pattern in a 16-year-old boy. C, D: Articular integrity was first restored with a transcondylar compression screw. The condyles were secured to the metaphysis and distal shaft using pelvic reconstruction plates placed at 90 degrees to each other.
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Principles of Plate Fixation

The plates must be strong; thin semitubular plates are inadequate and may break.32 However, double stacking semitubular plates can be used in younger or thinner teenagers. Proper rotational bending is harder in these plates. Usually the reinforced malleable reconstructive type of plates used for fixation of pelvic fractures can be anatomically contoured and provide very secure fixation of the distal humerus. It is best to place the plates at 90 degrees to each other, which provides for a more stable construct.13,19,28,29 
Some of the plates specifically designed for distal humerus fracture fixation in the adult either do not fit anatomically or are too prominent for many pediatric patients. In the larger, skeletally mature adolescent, use of these plates is appropriate. Later plate removal may be necessary though. 

Type III (Displaced with Comminution)

Limited Open Reduction Followed by Traction

Sometimes, the supracondylar columns are too fragmented or contaminated by an open fracture to allow adequate definitive fixation acutely. In such cases, we have found that the best initial treatment method in children involves re-establishing the articular surface and joint congruity with a limited open reduction. The separated condyles are secured with a transverse screw providing compression through the axis of rotation. This procedure can usually be done with minimal soft tissue dissection. Once this is stabilized, the supracondylar columns are then re-established by placing the extremity in olecranon traction and allowing them to reconstitute with callus formation. The rotational displacement of the condyles created by the origins of the forearm muscles can be neutralized with olecranon traction, in which the elbow is suspended at 90 degrees of flexion. There is usually adequate stability from the callus around the fracture site at 2 to 3 weeks to discontinue the traction. While in traction, motion can be initiated. This technique can also be used in patients seen late with contaminated soft tissue abrasions or severe soft tissue problems. In selected patients, such as an adolescent with severe bone loss, plating followed by bone grafting may be indicated. Following 3 weeks of traction the elbow is then immobilized in a hinged cast brace for an additional 2 to 3 weeks. This immobilization allows the initiation of protected active motion. With the present emphasis on short hospitalization, however, we find that skeletal traction is less acceptable for both social and financial reasons. 
Multiple Pin Fixation Treatment
In this time of extreme sports even in the young, there are instances of severely comminuted fractures in which the patient's bone will not allow for screw or plate fixation but the fracture is too displaced and/or comminuted to be successfully treated closed. In these instances, open reduction and pin fixation of each fracture fragment is a treatment option. There are times when even suture repair of fractures is required. The fixation does not allow for immediate motion but is started as soon as feasible (see Fig. 17-5, Fig. 17-14). 
Figure 17-14
A treatment algorithm for the management of T–Condylar distal humerus fractures according to age and displacement.
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Postoperative Care
In situations where closed reduction and pin fixation is performed, a well-padded circumferential cast is applied for a total of 3 to 6 weeks depending on the degree of healing appreciated on the postreduction radiographs. Patients are then transitioned into a hinged-elbow brace and physical therapy is initiated until full range of motion is achieved. Wires are removed when appropriate healing is appreciated. 
Children treated with closed reduction and percutaneous screw fixation are transitioned from their circumferential cast at 7 to 10 days and placed into a hinged elbow brace. Increasing motion is permitted over time and healing. Physical therapy is initiated at the first postoperative visit and protected therapy is continued until full range of motion is achieved. Return to sports is dependent on bony healing, restoration of strength and maximum motion, usually at 3 months. 
If plate fixation is used, we place the extremity in a well-padded soft dressing and hinged brace. We initiate continuous passive motion (CPM) in hospital for all T-condylar fractures treated with ORIF. Patients remain in hospital until full flexion–extension is achieved in usually 5 days. Patients are discharged on home CPM up to 23 hours/day for 3 weeks followed by CPM for part time for another 3 weeks. The active motion of postoperative therapy is performed in a hinged elbow brace with full motion allowed. A mild 10-degree extension contracture in these patients is anticipated in the best results. 
Potential Pitfalls and Preventative Measures (Table 17-6)
 
Table 17-6
T-condylar Distal Humerus Fractures
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Table 17-6
T-condylar Distal Humerus Fractures
Potential Pitfalls and Preventions
Pitfall Preventions
Articular malreduction Appropriate skin and soft tissue exposure, with visualization of critical articular components
Begin with joint reduction and stabilization, convert from three- or four-part fracture to a two-part supracondylar type fracture
Inadequate stabilization to allow for early range of motion In most T-condylar fractures, rigid fixation is necessary to allow for early range of motion
Use rigid plate fixation for both medial and lateral columns to facilitate early mobilization
Ulnar nerve irritation At the end of the case examine the ulnar nerve with flexion and extension
Consider ulnar nerve transposition if there is evidence of tether or impingement of the nerve during an arc of motion
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Treatment Specific Outcomes
The literature reflects good results with surgical management of displaced distal humerus articular fractures. Zimmerman33 advocated establishing an anatomic reduction with internal fixation so that early motion could facilitate a more rapid rehabilitation. In the two young children described by Beghin et al.4 operative intervention was necessary to achieve a satisfactory reduction. A review of four series15,18,23,25 supports surgical management: 44 of the 48 elbows in these combined series were treated operatively. The investigators of these series maintained that open reduction and internal fixation was the best way to restore the integrity of the articular surface and stabilize the fracture sufficiently to allow early mobilization. All but one of the patients in this combined series who were treated surgically had good or very good results at follow-up. 
Kanellopoulus and Yiannakopoulos17 described closed reduction of the intra-articular component, with fixation by partially threaded pins for interfragmentary compression. Two elastic titanium intramedullary nails were used for stabilizing the supracondylar component. The T-condylar fractures in two adolescents healed without complications after using this technique. Both patients returned to sports with full elbow range of motion at 6 weeks after surgery. 
The triceps splitting approach, as described by Campbell, was first advocated by Van Gorder.31 Kasser et al.18 has demonstrated in children, that the triceps splitting approach did not appear to cause significant muscle dysfunction according to Cybex testing, and concluded that an olecranon osteotomy was unnecessary. The authors concluded that this approach gives adequate exposure of the fracture and the articular surface and does not seem to produce any loss of strength from splitting the triceps. Although one reported patient had radiographic evidence of osteonecrosis of the trochlea,23 another had a nonunion,18 and many had some loss of range of motion, none of these surgically treated patients demonstrated any significant loss of elbow function or discomfort. 
Alonso-Llames described a paratricipital approach for the treatment of supracondylar and intracondylar fractures in children.2 Bryan and Morrey7 described a triceps-sparing approach in which the extensor mechanism is reflected laterally, exposing the whole distal humerus. Re et al.25 found that both the Bryan–Morrey (Triceps Reflecting) and olecranon osteotomy approaches yielded improved extension compared to the triceps-splitting approach. Recently, Remia et al.26 evaluated triceps function and elbow motion in nine patients with T-condylar fractures treated with open reduction through a Bryan and Morrey triceps-sparing approach and compared them to those reported after a triceps-splitting approach. No statistically significant differences were found in function or range of motion. 
The surgeon must choose the surgical approach that will allow for the best exposure with the least risk. The priority is adequate visualization of all fracture fragments, especially the joint surface, to achieve rigid anatomic fixation. Early motion is desired to lessen the risk of postinjury contractures about the elbow. 

Management of Expected Adverse Outcomes and Unexpected Complications in T-Condylar Distal Humerus Fractures

It is important to emphasize to the parents initially that this is a serious fracture. Because of the considerable soft tissue injury and the involvement of the articular surface of the distal humerus, stiffness and loss of motion of the elbow can be expected regardless of the treatment mode.15,21,23 In adolescents, failure to provide solid internal fixation that facilitates early motion (i.e., using only pin fixation) can result in a satisfactory radiographic appearance but considerable dysfunction because of residual loss of elbow motion. 
Although neurovascular complications have not been mentioned in the few cases reported in the literature, the incidence is probably about equal to that of supracondylar fractures. Because these fractures occur late in the growth process, partial or total growth arrest caused by internal fixation is not thought to be a major complication. Likewise, because these are older children, little remodeling can be expected. Nonunion,18 osteonecrosis of the trochlea,23 and failure of internal fixation have also been reported as complications. 
Aside from stiffness, the biggest risk is fracture malunion caused by inadequate reduction and/or fixation. Extra-articular malunion can be tolerated especially if mild. Intra-articular malunion is clearly a real risk for pain, loss of motion and function, and eventually arthritis. Intra-articular malreduction should be avoided. 
Hardware irritation and/or impingement can occur. Obviously all smooth wires need to be removed after the fracture is healed. Hardware that contributes to impingement pain and/or loss of motion needs to be similarly removed (Table 17-7). 
 
Table 17-7
T-condylar Distal Humerus Fractures
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Table 17-7
T-condylar Distal Humerus Fractures
Common Adverse Outcomes and Complications
Postoperative elbow stiffness
Fracture malunion
Fracture nonunion and hardware failure
Osteonecrosis of trochlea
Hardware impingement and irritation
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Summary, Controversies, and Future Directions Related to T-Condylar Distal Humerus Fractures

Caring for children and adolescents with T-condylar distal humerus fractures is challenging. The risks of intra-articular incongruity and postoperative stiffness are real concerns. Attention to detail with anatomic stable fixation allows for early range of motion post injury that lessens the risk of postinjury contracture. 

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