Mechanisms of Injury and Associated Injuries
Signs and Symptoms
Imaging and Other Diagnostic Studies
Pathoanatomy and Applied Anatomy
Nonoperative Treatment of Distal Humerus Fractures (Extra-articular and Complete Articular Fractures)
Nonoperative Treatment of Partial Articular Fractures (B3)
Special Circumstances and Management of Expected Adverse Outcomes and Unexpected Complications
Open Distal Humerus Fractures
Elbow Stiffness and Heterotopic Ossification
Wound Complications and Infection
Olecranon Osteotomy Complications
Total Elbow Arthroplasty Complications
Author’s Preferred Treatment
RTA, road traffic accident.
Data from Robinson CM, Hill RM, Jacobs N, et al. Adult distal humeral metaphyseal fractures: epidemiology and results of treatment. J Orthop Trauma. 2003;17(1):38–47.
MVC, motor vehicle collision.
ORIF, open reduction and internal fixation; TEA, total elbow arthroplasty; TRAP, triceps reflecting anconeus pedicle; LCL, lateral collateral ligament; EDC, extensor digitorum communis; MCL, medial collateral ligament.
OO, olecranon osteotomy; TS, triceps split; n/a, not applicable; PRUNE, patient rated ulnar nerve evaluation; TR, triceps reflecting; TRAP, triceps reflecting anconeus pedicle; PT, paratricipital; BM, Bryan-Morrey; TT, triceps tongue; ROM, range of motion.
MEPS, Mayo Elbow Performance Score; HO, heterotopic ossification; CRPS, complex regional pain syndrome; DASH, Disabilities of the Arm, Shoulder and Hand; UN, ulnar nerve palsy; UP, uncoupled prosthesis; H, wound hematoma or dehiscence; DS, deep infection; BW, bushing wear; UIF, ulnar implant fracture; HIF, humeral implant fracture; LES, Liverpool Elbow Score; SS, superficial infection; AS-U, aseptic loosening ulna; PF, periprosthetic fracture.
My preferred surgical approach for ORIF of A2, A3, B1, B2, C1, and C2 fractures is the paratricipital approach. For C1 and C2 fractures, and all C3 fractures, which are deemed fixable, and cannot be addressed via this less invasive approach, I prefer the olecranon osteotomy.
The paratricipital approach is also preferred for cases where the reparability of the fracture will be determined intraoperatively. If the fracture is deemed fixable, it may be conducted via the paratricipital approach or the approach can be converted to an olecranon osteotomy. In cases where the fracture is deemed irreparable, a TEA may be done via the original paratricipital approach.
For ORIF, surgeons should be familiar with all plating techniques, including parallel, orthogonal, and triple plating, as some fractures will lend themselves to one technique over another. Generally, I prefer the technique of parallel plating. The fixation principles and techniques used for AO/OTA type C (bicolumn) fractures are applicable to type A2 and A3 fractures. B1 and B2 (single column) fractures may be fixed with multiple screws; however, my preference is to use an ipsilateral single column plate.
Irreparable distal humerus fractures in an age-appropriate patient may be managed with a linked TEA. My preference is to resect the condyles and to conduct the replacement through a paratricipital approach. My indications for hemiarthroplasty for distal humerus fractures are narrow; typically, the fractures have a high degree of articular comminution with relatively simple noncomminuted columnar fracture in a more active elderly patient.