Chapter 35: Distal Humerus Fractures

George S. Athwal

Chapter Outline

Introduction to Distal Humerus Fractures

Distal humerus fractures remain some of the most challenging injuries to manage. They are commonly multifragmented, occur in osteopenic bone, and have complex anatomy with limited options for internal fixation. Treatment outcomes are often associated with elbow stiffness, weakness, and pain. A painless, stable, and mobile elbow joint is desired as it allows the hand to conduct the activities of daily living, most notably personal hygiene and feeding. Therefore, starting with a highly traumatized distal humerus and finishing with a stable, mobile, and pain- free joint requires a systematic approach. Thought is required in determining the operative indications, managing the soft tissues, selecting a surgical approach, obtaining an anatomic articular reduction, and creating a fixation construct that is rigid enough to tolerate early range of motion. 
In 1913, Albin Lambotte110 challenged the leading opinions of conservative management for distal humerus fractures and advocated an aggressive approach, which consisted of open reduction and internal fixation (ORIF). He described the principles of osteosynthesis and believed anatomic restoration of anatomy correlated with a better return to function. Unfortunately, surgical outcomes in that era were plagued with a high risk of infection and hardware failure. In 1937, Eastwood46 described the technique of closed reduction under a general anesthetic and brief immobilization in a collar and cuff. He reviewed 14 patients treated with this technique and reported that 12 returned to their original occupation. He stated “a perfect anatomical reduction is not necessary in order to obtain a good result.” Evans,52 in 1953, termed this mode of treatment “bag of bones” and believed that although it may be appropriate for the elderly patient, it was not ideal for the young active patient. The controversy between operative and nonoperative management continued for decades to follow. Riseborough and Radin,186 in 1969, reported that operative treatment was unpredictable and often associated with poor outcomes, and therefore, they recommended nonsurgical management. Similarly, Brown and Morgan,25 in 1971, reported satisfactory results with nonoperative management of 10 patients with distal humerus fractures. Their patients were managed with early active motion and at final follow-up had an average arc of motion of 98 degrees. 
In the last quarter century, improved outcomes have been reported with surgery for distal humerus fractures. The principles set out by the Arbeitsgemeinschaft für Osteosynthesefragen—Association for the Study of Internal Fixation (AO-ASIF) group, including anatomic articular reduction and rigid internal fixation, allow for healing and early postoperative motion.64,108,125,130,161,189,195 The last decade has seen advances in the understanding of elbow anatomy, improvements in surgical approaches, new innovative fixation devices, and an evolution of postoperative rehabilitation protocols. 
In younger patients, ORIF of distal humerus fractures using modern fixation principles is considered the standard of treatment. In elderly patients, restoration of the anatomy and obtaining rigid internal fixation may be difficult because of poor bone quality and comminution of the articular surface and metaphysis. In cases where rigid internal fixation cannot be achieved to allow early range of motion, resultant prolonged immobilization often leads to poor outcomes. Other complications associated with potentially poor outcomes include malunion, nonunion, contracture, avascular necrosis, heterotopic ossification (HO), hardware failure, and symptomatic prominent hardware. In the elderly patient, the prolonged rehabilitation, propensity for stiffness, and increased reoperation rate associated with ORIF may convert a previously independent individual into a role of dependence.190 
Primary total elbow arthroplasty (TEA) has evolved to become a viable treatment option for elderly patients with articular fragmentation, comminution, and osteopenia.11,57,59,60,98,99,112,132,134,145 Most recently, there has been a renewed interest in distal humerus hemiarthroplasty for the treatment of distal humerus fractures,2,3,14,28,83,166 including fractures of the capitellum and trochlea. 
Partial articular fractures of the distal humerus are a distinct group of fractures that are different than distal humerus fractures. These fractures typically involve the capitellum and/or trochlea with variable involvement of other periarticular structures such as the epicondyles, the radial head, the medial collateral ligament (MCL), or the lateral collateral ligament (LCL) complex. These injuries are distal and do not extend proximal to the olecranon fossa to involve either column. Isolated fractures of the capitellum are rare43,190,222 and isolated fractures of the trochlea are even more rare.43,55 

Epidemiology of Distal Humerus Fractures

Extra-articular and Complete Articular Fractures

Approximately 7% of all adult fractures involve the elbow; of these, approximately one-third involve the distal humerus.8,162,191 Distal humerus fractures, therefore, comprise approximately 2% of all fractures. They have a bimodal age distribution,162,163,189,190 with peak incidences occurring between the ages of 12 and 19 years, usually in males, and those aged 80 years and older, characteristically in females (Fig. 35-1). In young adults, the fractures are typically caused by high-energy injures, such as motor vehicular collisions, falls from height, sports, industrial accidents, and firearms. In contrast, greater than 60% of distal humerus fractures in the elderly occur from low-energy injuries, such as a fall from a standing height.163,189 
Figure 35-1
The age- and gender-related incidence of distal humerus fractures.
 
(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.)
(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.)
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Figure 35-1
The age- and gender-related incidence of distal humerus fractures.
(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.)
(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.)
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Robinson et al.189 reviewed a consecutive series of 320 patients with distal humerus fractures over a 10-year period. They calculated an overall incidence in adults of 5.7 cases per 100,000 in the population per year with a nearly equivalent male-to-female ratio. The most common mechanism of injury was a simple fall from a standing height (Table 35-1) and the most common fracture pattern was an extra-articular fracture accounting for just under 40% of all fractures. Bicolumn or complete intra-articular fractures were the second most common, accounting for 37%. 
 
Table 35-1
Mechanism of Injury in 320 Distal Humeral Fractures
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Table 35-1
Mechanism of Injury in 320 Distal Humeral Fractures
Mechanism of Injury Number of Fractures (Number Open) Average Age in Yrs (Range) Males Females M:F Ratio
Simple fall 219 (12) 57 (12–99) 86 133 0.6:1
Fall from a height 5 (2) 27 (14–41) 3 2 1.5:1
RTA 42 (7) 33.2 (14–77) 27 15 1.8:1
Sport 41 (2) 22.9 (13–44) 34 7 4.9:1
Other 13 (0) 39.2 (14–92) 9 4 2.3:1
Total 320 (23) 48.4 (12–99) 159 161 1:1
 

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.

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The overall incidence of distal humerus fractures is increasing, mimicking the increasing incidence in hip, proximal humerus, and wrist fractures.90,100,101 Palvanen et al.162 studied trends in osteoporotic distal humerus fractures in Finnish women. They reported a two-fold increase in the age-adjusted incidence of distal humerus fractures from 1970 (12/100,000) to 1995 (28/100,000), and predicted an additional three-fold increase by 2030. An aging population with increasing life expectancy combined with the fact that most of these fractures require surgical treatment is likely to result in increased health care expenditures. The identification and implementation of preventative strategies may help offset some of the economic impact of this injury. The mainstay of current fracture prevention strategy is to screen for osteopenia and osteoporosis with bone mineral density measurements and then to treat with medication therapy.90 Other authors argue that a more important prevention strategy is to decrease the risk of falling. Falling is the greatest single risk factor for fracture100,101 and can be predicted based on clinical risk factors, such as age, weight, smoking, previous fracture, and mother’s hip fracture.21 

Partial Articular Fractures

The reported annual incidence of partial articular fractures of the distal humerus is 1.5 per 100,000 population with a marked female predominance.222 

Assessment of Distal Humerus Fractures

Mechanisms of Injury and Associated Injuries with Distal Humerus Fractures

Extra-articular and Complete Articular Fractures

The majority of distal humerus fractures occur in one of two ways, low energy falls or high energy trauma.189 The most common cause is a simple fall in the forward direction.163 In general, 70% of patients that sustain an elbow fracture fall directly on to the elbow because they are unable to break their fall with an outstretched arm.163 High-energy injuries are the cause of most distal humerus fractures in younger adults. Motor vehicle collisions, sports, falls from height, and industrial accidents predominate. These mechanisms are also associated with a higher likelihood of accompanying injuries such as open fractures, soft tissue injuries, other fractures in 16% of cases,53 and polytrauma (Table 35-2). 
Table 35-2
The Relationship between Injury Mechanism and Soft Tissue Injury
Gustilo Grade
Mechanism of Injury Closed Open (%) I II IIIa IIIb
Simple fall 207 12 (5%) 4 4 4 0
Fall from height 3 2 (40%) 0 0 2 0
MVC 35 7 (17%) 2 4 0 1
Sport 39 2 (5%) 0 2 0 0
Other 13 0 0 0 0 0
Total 297 23 (7%) 6 10 6 1
 

MVC, motor vehicle collision.

 

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.

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Partial Articular Fractures

Fractures of the capitellum and trochlea are typically caused by coronal shear forces. The capitellum is thought to be particularly susceptible to shear forces because its centre of rotation is more anterior in reference to the humeral shaft. The most common mechanism of injury is a simple fall on the outstretched hand from a standing height. In women, there is a bimodal distribution with peaks under the age of 19 and above 80 years. The increased prevalence of this injury in women over the age of 60 years is believed to be because of the increased elbow-carrying angle in women and osteoporosis.65,222 In men there is a unimodal distribution with a peak incidence under the age of 19 with the mechanism of injury typically being high energy, such as motor vehicle collisions or falls from height. Other associated injuries, such as ligament tears and radial head fractures, occur in up to 20% of cases.43,181,190,221,222 

Signs and Symptoms of Distal Humerus Fractures

The history should determine the mechanism of injury, the energy level, and the time since injury. In patients with high-energy injuries, vigilance is required in identifying systemic injures and associated fractures. The pain from polytrauma and other concurrent issues such as inebriation and drug uses may make identification of all injuries difficult; patients and their families should be pre-emptively counseled on the possibility of delayed identification of occult injuries. 
Elderly patients, who comprise the majority of patients with distal humerus fractures, should be evaluated for the precipitants of the characteristic fall as they may have undiagnosed cardiac arrhythmias, cerebrovascular disease, polypharmacy, or alcohol dependence. Special attention is directed toward identifying comorbidities and reversible illnesses that may impact upon the treatment recommendations and perioperative risk. Mental status, the ability to cooperate with rehabilitation, ambulatory status, and the requirement of walking aides should be assessed. In addition, the preinjury functional abilities, demands, any limitations related to the upper extremities, as well as the patient handedness, each may affect the treatment decision-making. 
A thorough physical examination should be conducted in all cases, particularly with high-energy trauma to identify systemic injuries and associated fractures. The injured extremity should be circumferentially examined for abrasions, bruising, swelling, fracture blisters, skin tenting, and open wounds. Open distal humerus fractures are common133,140,189 and should be treated with a standard open fracture protocol involving removal of gross contamination, covering of the wound with a sterile dressing, splinting, antibiotics, tetanus, possible wound culture, and early surgical irrigation and debridement. 
A neurologic examination must be performed and accurately documented preoperatively and postoperatively. Gofton et al.64 reported that 26% of patients with distal humerus fractures had an associated incomplete ulnar neuropathy at the time of presentation. Vascular injuries, although rare in distal humerus fractures, should be assessed by examining the distal pulses, skin turgor, capillary refill, and color. Pulse diminution or other positive findings should trigger further examined with a brachial–brachial Doppler pressure index, which has been shown to be as specific and sensitive as arteriography in detecting brachial artery injuries.49,136,188 The normal brachial–brachial Doppler pressure index is approximately 0.95 and it rarely falls below 0.85.49,136,188 Patients with abnormal studies should be referred for vascular surgery consultation. Patients with excessive pain after high-energy trauma should be examined for compartment syndrome of the forearm. Compartment pressures should be conducted when the clinical examination is inconclusive.22 If compartment syndrome is diagnosed clinically or by pressure measurement, urgent surgical fasciotomies are required.135 
Specific to elderly patients, when considering elbow arthroplasty the contraindications must be addressed. Absolute contraindications to elbow arthroplasty include active infection and inadequate soft tissue coverage. The patient history requires probing questions to rule out common infections, such as urinary tract infections and active diabetic ulcers. Open wounds in low-energy distal humerus fractures are not an absolute contraindication to elbow arthroplasty, as they are typically small and clean. Such wounds, therefore, may undergo irrigation and debridement followed by staged elbow arthroplasty. 

Imaging and Other Diagnostic Studies for Distal Humerus Fractures

Standard anteroposterior and lateral radiographs of the elbow are usually sufficient for diagnosis, classification, and surgical templating. However, initial radiographs obtained in plaster or a splint may obscure the fracture pattern and should be repeated. In some cases where fracture shortening, rotation, and angulation distorts the images, gentle traction views with appropriate analgesia or conscious sedation may improve the yield of the radiographs. 
Computed tomography (CT) with three-dimensional reconstructions substantially improves the identification and visualization of fracture patterns.24 While CT is not required for all cases, it is recommended for certain situations. In patients where a less invasive approach for ORIF is contemplated, such as a paratricipital approach rather than an olecranon osteotomy, a CT scan can assist with decision-making and in identifying the locations of fracture fragments intraoperatively. In elderly patients with highly comminuted fractures, a CT scan may be useful in deciding whether an attempt should be made at ORIF versus proceeding directly to arthroplasty. When considering hemiarthroplasty for distal humerus fractures, a CT scan will confirm the articular fragmentation and the characteristics of the condylar fractures. 

Classification of Distal Humerus Fractures

Extra-articular and Complete Articular Fractures

Early classification schemes for fractures of the distal humerus were based on the anatomic location of the fracture and its appearance, using terms such as supracondylar, intracondylar, epicondylar, Y-type, and T-type. In 1990, Muller150 defined the anatomic boundaries of a distal humerus fracture as one with an epicenter that occurs within a square whose base is the distance between the medial and lateral epicondyles on an anteroposterior radiograph (Fig. 35-2). The AO group devised the first comprehensive classification of distal humerus fractures which was then adopted by the Orthopaedic Trauma Association (OTA) in 1996.56 In 2007, the AO Classification Supervisory Committee and the OTA Classification, Database and Outcomes Committee updated the compendium to its present form.123 
Figure 35-2
A distal humerus fracture is defined as a fracture with an epicenter that is located within a square whose base is the distance between the epicondyles on an anteroposterior radiograph.
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The AO/OTA classification is an alphanumeric system that assigns the first two digits of 13 to distal humerus fractures and classifies them based on the location and degree of articular involvement (Fig. 35-3). The system then further subclassifies fractures based on fracture line orientation, displacement direction, and degree of fragmentation.123 Type A fractures are extra-articular and may involve the epicondyles or occur at the distal humerus metaphyseal level. Although these fractures receive less attention in the literature than the more complex intra-articular type C fractures, they do account for one-quarter of all distal humerus fractures.189 
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Figure 35-3
The AO/OTA classification of distal humerus fractures.56,150
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Type B fractures are termed partial articular as there remains some continuity between the humeral shaft and the articular segment. Type B fractures include unicondylar fractures and sagittal plane or shear fractures of the articular surface involving the capitellum, trochlea, or both. Single column fractures involve either the medial or lateral column, are intra-articular, and account for approximately 15% of all distal humerus fractures.95,107,189 These fractures may also be classified by the Milch system,139 which is based on whether the lateral portion of the trochlea remains attached to the humeral shaft. In a Milch type I fracture, the medial or lateral column can be fractured but the lateral eminence of the trochlea remains attached to the humeral shaft. In a Milch type II fracture, the lateral eminence of the trochlea is apart of the column fracture. 
A “divergent” single column fracture has also been described which occurs predominantly in younger patients that are predisposed to this injury because of a septal aperture (fenestration) in the olecranon fossa.63,107 This fracture pattern is theorized to occur after an axial load is applied to the olecranon, which is then driven into the trochlea. A fracture occurs that splits the trochlea and propagates proximally between the columns to eventually exit either medially or laterally creating a “high” single column fracture. 
Type C fractures are termed complete articular, meaning there is no continuity between the articular segments and the humeral shaft. Type C fractures have historically been called intracondylar fractures and the AO/OTA system further subclassifies them into simple (C1), simple articular with metaphyseal fragmentation (C2), and fragmentation of the articular surface and metaphyseal zone (C3). This system is widely used in the literature and trauma databases, and helps to standardize research protocols and treatment outcomes. Unfortunately, the classification system does have weaknesses as it does not account for factors such as the distal fragment height and amount of displacement, both of which may influence treatment.77,183 The classification also does little to assist with the decision-making process between ORIF and arthroplasty and finally it has been criticized as being overly complex. 
The Mehne and Matta classification of distal humerus fractures is also popular.39,93 It is based on Jupiter’s model93 in which the distal humerus is composed of two divergent columns that support an intercalary articular segment (Fig. 35-4), which is similar to the AO concept of condyles. The classification has three main categories: Intra-articular, extra-articular intracapsular, and extracapsular. The intra-articular group is further subdivided in to bicolumn, single column, and articular fractures. The extra-articular intracapsular group consists of high and low transcolumn fractures, and the extracapsular group has medial and lateral epicondyle fractures (Fig. 35-5). This classification system has the same criticisms as the AO/OTA system with high complexity and moderate intra- and inter-rater reliability.93 The classification also does not consider the specific types of articular fracture and the degree of fragment displacement. It is the author’s opinion that the AO/OTA classification is preferred because it is more intuitive, it is ubiquitous, and because it is the official classification of the OTA. 
Figure 35-4
The medial and lateral columns support the articular segment.
 
The distalmost part of the lateral column is the capitellum and the distalmost part of the medial column is the nonarticular medial epicondyle. The trochlea is the medial part of the articular segment and is intermediate in position between the capitellum and the medial epicondyle. The articular segment functions architecturally as a tie arch.
The distalmost part of the lateral column is the capitellum and the distalmost part of the medial column is the nonarticular medial epicondyle. The trochlea is the medial part of the articular segment and is intermediate in position between the capitellum and the medial epicondyle. The articular segment functions architecturally as a tie arch.
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Figure 35-4
The medial and lateral columns support the articular segment.
The distalmost part of the lateral column is the capitellum and the distalmost part of the medial column is the nonarticular medial epicondyle. The trochlea is the medial part of the articular segment and is intermediate in position between the capitellum and the medial epicondyle. The articular segment functions architecturally as a tie arch.
The distalmost part of the lateral column is the capitellum and the distalmost part of the medial column is the nonarticular medial epicondyle. The trochlea is the medial part of the articular segment and is intermediate in position between the capitellum and the medial epicondyle. The articular segment functions architecturally as a tie arch.
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Figure 35-5
The Mehne and Matta classification of distal humerus fractures.93
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Partial Articular Fractures (B3)

In 1853, Hahn71 described an isolated capitellar fracture, which now bears his name along with Steinthal’s,209 who described the injury in 1898. The Hahn-Steinthal or conventional type I fracture27 involves the capitellar articular surface along with the subchondral bone (Fig. 35-6). The Kocher-Lorenz104,117 or conventional type II fracture27 is rare and consists of the capitellar articular surface along with a thin shell of subchondral bone. Bryan and Morrey27 modified this classification and added type III fractures which are comminuted capitellar fractures. A fourth fracture pattern was added by McKee et al.,126 which consisted of a type I fracture with medial extension to include the lateral half of the trochlea. 
Figure 35-6
The Hahn-Steinthal (type I) fracture of the capitellum involves the articular surface and a large portion of the subchondral bone (A).
 
The Kocher-Lorenz (type II) fracture involves the articular surface of the capitellum with a thin layer of subchondral bone (B).71,209
The Kocher-Lorenz (type II) fracture involves the articular surface of the capitellum with a thin layer of subchondral bone (B).71,209
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Figure 35-6
The Hahn-Steinthal (type I) fracture of the capitellum involves the articular surface and a large portion of the subchondral bone (A).
The Kocher-Lorenz (type II) fracture involves the articular surface of the capitellum with a thin layer of subchondral bone (B).71,209
The Kocher-Lorenz (type II) fracture involves the articular surface of the capitellum with a thin layer of subchondral bone (B).71,209
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The AO/OTA comprehensive classification of fractures123 classifies articular distal humerus fractures as type B3 (Fig. 35-3). Type B3 fractures are then further subclassified into capitellar, trochlear, and combined fractures. 
Ring et al.181 further examined articular shear fractures of the distal humerus and described them as a spectrum of injury. They observed that apparent isolated capitellar fractures on plain radiographs may turn out to be much more complex injuries when further imaged with CT. The authors identified five unique fracture patterns that progress in complexity (Fig. 35-7). 
Figure 35-7
The Ring et al.181 classification of distal humerus articular fractures has five patterns.
 
A type I fracture involves the capitellum and the lateral portion of the trochlea. This fracture pattern has previously been described as a conventional type IV fracture. A type II fracture is described as a type I fracture that may be comminuted but includes a fracture of the lateral epicondyle. A type III fracture is a type II fracture that has comminution behind the capitellum with impaction of bone posteriorly. A type IV fracture is a type III fracture with an additional fracture of the posterior trochlea. A type V fracture is a type IV fracture that includes fracture of the medial epicondyle.
A type I fracture involves the capitellum and the lateral portion of the trochlea. This fracture pattern has previously been described as a conventional type IV fracture. A type II fracture is described as a type I fracture that may be comminuted but includes a fracture of the lateral epicondyle. A type III fracture is a type II fracture that has comminution behind the capitellum with impaction of bone posteriorly. A type IV fracture is a type III fracture with an additional fracture of the posterior trochlea. A type V fracture is a type IV fracture that includes fracture of the medial epicondyle.
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Figure 35-7
The Ring et al.181 classification of distal humerus articular fractures has five patterns.
A type I fracture involves the capitellum and the lateral portion of the trochlea. This fracture pattern has previously been described as a conventional type IV fracture. A type II fracture is described as a type I fracture that may be comminuted but includes a fracture of the lateral epicondyle. A type III fracture is a type II fracture that has comminution behind the capitellum with impaction of bone posteriorly. A type IV fracture is a type III fracture with an additional fracture of the posterior trochlea. A type V fracture is a type IV fracture that includes fracture of the medial epicondyle.
A type I fracture involves the capitellum and the lateral portion of the trochlea. This fracture pattern has previously been described as a conventional type IV fracture. A type II fracture is described as a type I fracture that may be comminuted but includes a fracture of the lateral epicondyle. A type III fracture is a type II fracture that has comminution behind the capitellum with impaction of bone posteriorly. A type IV fracture is a type III fracture with an additional fracture of the posterior trochlea. A type V fracture is a type IV fracture that includes fracture of the medial epicondyle.
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Dubberley et al.43 recently reported another classification for capitellar and trochlear fractures, which was correlated to clinical outcome. The Dubberley et al.43 classification has three types with a modifier for distal posterolateral column comminution. A type I fracture involves primarily the capitellum with or without the lateral trochlear ridge. A type II fracture involves the capitellum and most of the trochlea as one piece, while in the type III fracture the capitellum and trochlea are separate pieces. The authors found that as the complexity of the articular fractures increased, the outcomes worsened. 

Outcome Measures for Distal Humerus Fractures

The outcome measurement tools for distal humerus fractures include scoring systems, range of motion, strength, rate of secondary surgeries, and complications.119 Elbow-specific scoring systems that are typically used are the Mayo Elbow Performance Score (MEPS) and the Patient-Rated Elbow Evaluation (PREE). Rarely, the American Shoulder and Elbow Surgeons Elbow Form (ASES-e) is utilized, which has a section for patient responses and a section for physician’s assessment of elbow function. The Disabilities of the Arm, Shoulder and Hand (DASH) score is frequently used and provides a global rating of upper extremity function. The outcome data related to the various treatment options for distal humerus fractures will be presented in the technique-specific sections below. 

Pathoanatomy and Applied Anatomy Relating to Distal Humerus Fractures

The elbow is anatomically a trocho-ginglymoid joint, meaning that it has trochoid (rotatory) motion through the radiocapitellar and proximal radioulnar joints and ginglymoid (hinge-like) motion through the ulnohumeral joint. An understanding of the complex bony anatomy of the elbow, the soft tissue stabilizers, and the adjacent neurovascular structures is imperative when surgically treating distal humerus fractures. 
The distal humeral shaft is triangular-shaped in cross section with its apex directed anteriorly. As the shaft approaches the distal humerus it bifurcates into two divergent cortical columns, termed the medial and lateral columns. The medial column diverges approximately 45 degrees from the humeral shaft in the coronal plane and terminates as the medial epicondyle. The lateral column, in the coronal plane, diverges at approximately 20 degrees from the shaft. As the lateral column extends distally it curves anteriorly creating a 35- to 40-degree angle with the shaft in the sagittal plane (Fig. 35-8). In the coronal plane, the trochlea is more distal than the capitellum resulting in a valgus alignment of 4 to 8 degrees. Overall, when including the ulna, the elbow has a valgus angle in extension of 10 to 17 degrees, termed the carrying angle. Axially, the distal humerus articular surface is internally rotated 3 to 8 degrees; therefore, as the elbow flexes it also internally rotates resulting in slight varus alignment. 
Figure 35-8
The distal humerus articular surface is aligned in 4 to 8 degrees of valgus relative to the shaft (A) and is angulated 35 to 40 degrees anteriorly in the sagittal plane.
 
The medial epicondyle is the termination of the medial column and remains on the axis of the shaft in the sagittal view (B), while the lateral epicondyle follows the capitellum into flexion (C). Axially, the entire distal humerus articular surface is internally rotated 3 to 8 degrees (D).
The medial epicondyle is the termination of the medial column and remains on the axis of the shaft in the sagittal view (B), while the lateral epicondyle follows the capitellum into flexion (C). Axially, the entire distal humerus articular surface is internally rotated 3 to 8 degrees (D).
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Figure 35-8
The distal humerus articular surface is aligned in 4 to 8 degrees of valgus relative to the shaft (A) and is angulated 35 to 40 degrees anteriorly in the sagittal plane.
The medial epicondyle is the termination of the medial column and remains on the axis of the shaft in the sagittal view (B), while the lateral epicondyle follows the capitellum into flexion (C). Axially, the entire distal humerus articular surface is internally rotated 3 to 8 degrees (D).
The medial epicondyle is the termination of the medial column and remains on the axis of the shaft in the sagittal view (B), while the lateral epicondyle follows the capitellum into flexion (C). Axially, the entire distal humerus articular surface is internally rotated 3 to 8 degrees (D).
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The posterior aspect of the lateral column is relatively flat and wide, well suited for application of a posterolateral plate. The lateral column terminates in the capitellum anteriorly. The articular surface of the capitellum starts at the most distal aspect of the lateral column and encompasses an arc of approximately 180 degrees in the sagittal plane. Posterior fixation can be applied distally on the lateral column because of the absence of cartilage; however, lengths of screws directed anteriorly into the capitellum must be carefully scrutinized to prevent perforation into the radiocapitellar joint. 
The trochlea, which is Greek for pulley, is the intervening segment of bone between the terminal ends of the medial and lateral columns that articulates with the greater sigmoid notch of the ulna. It is covered by articular cartilage anteriorly, inferiorly, and posteriorly, creating an arc of almost 270 degrees. The trochlea is shaped like a spool with a central sulcus which articulates with the central ridge of the greater sigmoid notch of the proximal ulna. 
Superior to the trochlea and between the medial and lateral columns lies the olecranon fossa posteriorly and the coronoid fossa anteriorly. These fossae lie adjacent to each other and are separated by a thin bony septum. Occasionally, this septum is absent and a septal aperture exists. The olecranon fossa is matched to the olecranon and accepts it during extension; similarly, the coronoid fossa is matched to the coronoid and accepts it during flexion. The tolerances of the fossae to accommodate their respective bony processes are narrow; therefore, screw placement through the fossae should be avoided as it may lead to impingement and decreased elbow range of motion. In distal humerus fractures with excessive metaphyseal comminution requiring supracondylar shortening, recreation of the fossae with a burr will improve range of motion. 
In addition to the bony structures, there are several important soft tissue structures that require consideration when treating distal humerus fractures. The LCL complex consists of the radial collateral ligament, the lateral ulnar collateral ligament (LUCL), and the annular ligament. The annular ligament attaches to the anterior and posterior margins of the lesser sigmoid notch while the radial collateral ligament originates from an isometric point on the lateral epicondyle and fans out to attach to the annular ligament (Fig. 35-9). The LUCL also arises from the isometric point on the lateral epicondyle and attaches to the crista supinatoris of the proximal ulna. The LCL complex functions as an important restraint to varus and posterolateral rotatory instability.45,88 The LCL complex is vulnerable to injury during application of a direct lateral plate; therefore, exposure of the lateral aspect of the distal lateral column should not extend past the equator of the capitellum. 
Figure 35-9
The lateral collateral ligament complex is an important restraint to varus and posterolateral rotatory instability and consists of the radial collateral ligament, the lateral ulnar collateral ligament, and the annular ligament.
 
The annular ligament attaches to the anterior and posterior margins of the lesser sigmoid notch while the radial collateral ligament originates from an isometric point on the lateral epicondyle and fans out to attach to the annular ligament. The lateral ulnar collateral ligament also arises from the isometric point on the lateral epicondyle and attaches to the crista supinatoris of the proximal ulna.
The annular ligament attaches to the anterior and posterior margins of the lesser sigmoid notch while the radial collateral ligament originates from an isometric point on the lateral epicondyle and fans out to attach to the annular ligament. The lateral ulnar collateral ligament also arises from the isometric point on the lateral epicondyle and attaches to the crista supinatoris of the proximal ulna.
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Figure 35-9
The lateral collateral ligament complex is an important restraint to varus and posterolateral rotatory instability and consists of the radial collateral ligament, the lateral ulnar collateral ligament, and the annular ligament.
The annular ligament attaches to the anterior and posterior margins of the lesser sigmoid notch while the radial collateral ligament originates from an isometric point on the lateral epicondyle and fans out to attach to the annular ligament. The lateral ulnar collateral ligament also arises from the isometric point on the lateral epicondyle and attaches to the crista supinatoris of the proximal ulna.
The annular ligament attaches to the anterior and posterior margins of the lesser sigmoid notch while the radial collateral ligament originates from an isometric point on the lateral epicondyle and fans out to attach to the annular ligament. The lateral ulnar collateral ligament also arises from the isometric point on the lateral epicondyle and attaches to the crista supinatoris of the proximal ulna.
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The MCL consists of an anterior bundle, posterior bundle, and transverse ligament. The anterior bundle is of prime importance in elbow stability (Fig. 35-10). It originates from the anteroinferior aspect of the medial epicondyle, inferior to the axis of rotation, and inserts on the sublime tubercle of the coronoid. The MCL functions as an important restraint to valgus and posteromedial rotatory instability.10,151 It is susceptible to injury at its origin during placement of a medial plate that curves around the medial epicondyle to lie on the ulnar aspect of the trochlea. 
Figure 35-10
The medial collateral ligament functions as an important restraint to valgus and posteromedial rotatory instability.
 
It consists of an anterior bundle, posterior bundle, and transverse ligament. The anterior bundle is of prime importance in elbow stability and it originates from the anteroinferior aspect of the medial epicondyle, and inserts on the sublime tubercle of the coronoid.
It consists of an anterior bundle, posterior bundle, and transverse ligament. The anterior bundle is of prime importance in elbow stability and it originates from the anteroinferior aspect of the medial epicondyle, and inserts on the sublime tubercle of the coronoid.
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Figure 35-10
The medial collateral ligament functions as an important restraint to valgus and posteromedial rotatory instability.
It consists of an anterior bundle, posterior bundle, and transverse ligament. The anterior bundle is of prime importance in elbow stability and it originates from the anteroinferior aspect of the medial epicondyle, and inserts on the sublime tubercle of the coronoid.
It consists of an anterior bundle, posterior bundle, and transverse ligament. The anterior bundle is of prime importance in elbow stability and it originates from the anteroinferior aspect of the medial epicondyle, and inserts on the sublime tubercle of the coronoid.
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The ulnar, radial, and median nerves cross the elbow and knowledge of their precise locations is required to safely manage distal humerus fractures (Fig. 35-11). The ulnar nerve pierces the medial intermuscular septum in the middle third of the arm to travel alongside the medial head of triceps. The arcade of Struthers, a musculofascial band present in 70% of the population,206 is a potential area of nerve compression located approximately 8 cm proximal to the medial epicondyle. As the nerve approaches the elbow it travels behind the medial epicondyle to enter the cubital tunnel, a fibro-osseous groove bordered by the medial epicondyle superiorly, olecranon laterally, and Osborne’s ligament medially. When the nerve exits the cubital tunnel it travels between the two heads of the flexor carpi ulnaris (FCU) muscle. 
Figure 35-11
Three peripheral nerves, the median, ulnar, and radial, cross the elbow joint along with a robust collateral blood supply.
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The radial nerve circles around the posterior aspect of the midhumeral shaft in the spiral groove. On average, the nerve enters the spiral groove 20 cm proximal to the medial epicondyle (74% of the length of the humerus) and exits approximately 14 cm proximal to the lateral epicondyle (51% of the length of the humerus).62 Along the lateral aspect of the humerus, two branches come off the nerve (nerve to the medial head of triceps and anconeus, and the lateral brachial cutaneous nerve) before it pierces the lateral intermuscular septum approximately 10 cm (36% of the length of the humerus) proximal to the lateral epicondyle.62 The nerve then lies between brachialis and brachioradialis where it bifurcates into the posterior interosseous nerve and the radial sensory nerve. The radial nerve is vulnerable to injury during exposure of distal humerus fractures with proximal shaft extension and during application of long posterolateral or direct lateral plates. 
The median nerve travels with the brachial artery between the biceps and brachialis muscles in the anteromedial aspect of the arm. The nerve passes under the bicipital aponeurosis to enter the medial antecubital fossa, medial to the biceps tendon and brachial artery. The nerve then passes between the heads of pronator teres. During fixation of distal humerus fractures, the median nerve is relatively protected from direct injury by the robust brachialis muscle. 
There is a consistent blood supply to the adult elbow which can be organized into three vascular arcades: Medial, lateral, and posterior.228 The lateral arcade is formed by the interosseous recurrent, radial recurrent, and radial collateral arteries and supplies the capitellum, radial head, lateral epicondyle, and lateral aspect of the trochlea. The medial arcade is formed by the superior and inferior ulnar collaterals and the anterior and posterior ulnar recurrent arteries and supplies the medial epicondyle and the medial aspect of the trochlea. The posterior arcade is formed by the medial collateral artery and contributions from the medial and lateral arcades and supplies the olecranon fossa and supracondylar area. 

Distal Humerus Fracture Treatment Options

Nonoperative Treatment of Distal Humerus Fractures (Extra-articular and Complete Articular Fractures)

Indications/Contraindications for Nonoperative Treatment

Nonoperative management of distal humerus fractures in young patients is rarely recommended and it is generally reserved for patients deemed medically unfit to undergo surgery (Fig. 35-12). Patients with nondisplaced fractures may also be managed with a trial of nonoperative management. These patients should be followed for the first 3 to 4 weeks with weekly serial radiographs to ensure displacement or angulation does not occur. Surgical fixation of these fractures, however, enhances stability, allows immediate motion, and obviously decreases the risk of delayed fracture displacement. Other circumstances are elderly patients with unrepairable distal humerus fractures where arthroplasty is the most reasonable option; however, it is contraindicated because of soft tissue compromise, such as skin loss. Once the soft tissue issues have been dealt with, delayed arthroplasty can be done if patients are sufficiently symptomatic. 
Figure 35-12
 
Radiographs of an 88-year-old man with a transcolumn fracture (AO/OTA A2) deemed medically unfit for surgery because of severe congestive heart failure and inoperable coronary artery disease (A, B). The patient was treated with a collar and cuff and early range of motion. Radiographs at 1-year follow-up (C, D). The patient has no pain with a functional range of motion (E, F).
Radiographs of an 88-year-old man with a transcolumn fracture (AO/OTA A2) deemed medically unfit for surgery because of severe congestive heart failure and inoperable coronary artery disease (A, B). The patient was treated with a collar and cuff and early range of motion. Radiographs at 1-year follow-up (C, D). The patient has no pain with a functional range of motion (E, F).
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Figure 35-12
Radiographs of an 88-year-old man with a transcolumn fracture (AO/OTA A2) deemed medically unfit for surgery because of severe congestive heart failure and inoperable coronary artery disease (A, B). The patient was treated with a collar and cuff and early range of motion. Radiographs at 1-year follow-up (C, D). The patient has no pain with a functional range of motion (E, F).
Radiographs of an 88-year-old man with a transcolumn fracture (AO/OTA A2) deemed medically unfit for surgery because of severe congestive heart failure and inoperable coronary artery disease (A, B). The patient was treated with a collar and cuff and early range of motion. Radiographs at 1-year follow-up (C, D). The patient has no pain with a functional range of motion (E, F).
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Techniques

Nonoperative management techniques include above-elbow casting, olecranon traction, and collar and cuff treatment, the so called “bag of bones” method. The traction method involves the placement of a transolecranon traction pin that is attached to weights through a pulley system.103 Traction is applied for 3 to 4 weeks, until there is sufficient early callous to allow cast bracing. The major disadvantages of this method are the complications associated with prolonged bed rest. Patients who are typically treated nonoperatively, the frail elderly, have significant medical comorbidities that put them at high risk of bed rest-related complications, such as deep venous thrombosis, pulmonary embolism, and decubitus ulcers. The technique is largely of historical significance and has little use in modern distal humerus fracture care. 
Collar and cuff treatment had been used for centuries before it was first reported in modern medical literature in 1937 by Eastwood.46 He described a closed reduction followed by application of a collar and cuff with the elbow between 90 and 120 degrees of flexion. The elbow is hung freely to allow gravity-assisted reduction via a ligamentotaxis-type effect. Shoulder motion and active elbow flexion are initiated at 2 weeks and progressed. 

Outcomes

In 1969, Riseborough and Radin186 compared operative to nonoperative management in 29 patients with intra-articular distal humerus fractures. They reported better range of motion and less pain with nonoperative management, consisting of skeletal traction or manipulation and casting. The surgically treated group was plagued with early fracture displacement because of hardware failure from nonrigid fixation constructs. Brown and Morgan25 in 1971 reported their results with nonoperative management of intra-articular distal humerus fractures in 10 patients at a mean follow-up of 2.5 years (range, 9 months to 4 years). At follow-up, the mean flexion was 128 degrees, the mean extension was 30 degrees, and the mean arc of motion was 100 degrees. Seven patients described no symptoms while three complained of elbow aches in cold and damp weather. In the present day, nonoperative management in active patients has been abandoned because of improved surgical techniques that have led to better outcomes. 

Nonoperative Treatment of Partial Articular Fractures (B3)

Closed reduction and casting is a described method for the treatment of displaced capitellar fractures.157,176 The reduction maneuver involves placing the elbow into full extension and forearm supination, which usually results in the capitellum spontaneously reducing. If still displaced, manual pressure over the capitellum and a slight varus force to the elbow may assist with the reduction. If successful, the elbow is flexed so the radial head captures the capitellar fragment and then fluoroscopy is used to confirm the reduction. The elbow is immobilized in an above-elbow plaster for 3 weeks with weekly radiographs to confirm maintenance of the reduction. If this technique is used, the author recommends postoperative CT imaging to confirm an anatomic reduction. 

Operative Treatment

Distal humerus fractures are generally complex injuries with associated fragmentation, bony instability, osteopenia, and soft tissue injury. The risk of functional impairment is relatively high when these injuries are managed nonoperatively. Contemporary literature would support improved patient outcomes and lower complication rates when these injuries are managed with surgery. ORIF of these injuries is considered gold standard. However, ORIF may not be attainable in elderly patients with osteopenia, comminution, and articular fragmentation or in patients with pre-existing conditions of the elbow such as rheumatoid arthritis (RA). In such cases where rigid internal fixation cannot be achieved to allow early range of motion, elbow arthroplasty has been shown to be a reliable treatment option with good patient outcomes. 

Timing of Surgery

Surgical fixation of distal humerus fractures requires preoperative planning, specialized implants, instruments, and surgical expertise. Medically fit and stabilized patients with noncompromised soft tissues may be best managed with early surgery within 48 to 72 hours.86 Early surgery may lead to decreased complications such as HO and stiffness. Polytrauma patients who are unstable or those with identified modifiable risk factors should be medically optimized preoperatively. In cases with injured soft tissues, such as excessive swelling, bruising, fracture blisters, or abrasions, delay of surgery may be most appropriate. Generally, patients admitted to the intensive care unit can be managed with a well-padded splint that is checked daily and removed every 2 to 3 days to examine the soft tissues for compromise and pressure points. In some cases, prolonged secondary surgical procedures may be contraindicated for several weeks because of medical issues. In these patients static external fixation may be of benefit to stabilize the extremity for pain control, transfers, hygiene, and wound care. Ideally, external fixator pins should be placed as far away as possible from planned internal fixation implants to decrease the likelihood of infection. Although no literature exists to define a suitable delay, surgery should be conducted within 2 or 3 weeks. Delay beyond this time interval is possible; however, ORIF is made more difficult with increased surgical time, difficult fracture reductions because of partial healing and callous, increased bleeding, and the increased risk of HO. 

Open Reduction Internal Fixation of Distal Humerus Fractures (Extra-articular and Complete Articular Fractures)

Indications/Contraindications.
Anatomic reduction and rigid internal fixation is considered the gold standard for most displaced intra-articular distal humerus fractures (AO/OTA types B and C). Rigid internal fixation allows fracture healing to occur anatomically while permitting early range of motion to maximize functional recovery. The traumatized elbow is particularly prone to stiffness; therefore, early motion is vital, but not at the expense of fracture displacement. In cases where sufficient fracture stability cannot be obtained to allow early motion, anatomic reconstruction of the articular surface and overall elbow alignment take precedence. An anatomically aligned stiff elbow with a healed articular surface can be subsequently managed with contracture release, but a fracture with hardware failure and articular nonunion or fragmentation may be difficult to manage with revision surgery. 
Surgical treatment is also recommended for displaced or angulated extra-articular fractures (transcolumn) of the distal humerus (AO/OTA types A2 and A3). Closed reduction and percutaneous Kirschner wire (K-wire) fixation has been described for treatment of these injuries in adults.92 The technique in adults is similar to the technique used in pediatric supracondylar fractures with crossing K-wires inserted medially and laterally. In adults, this technique may be modified to exchange the K-wires for 3.5- or 4.5-mm cannulated screws. Closed reduction and percutaneous fixation has several disadvantages when used in adults. The fixation is semi-rigid and therefore requires supplementary splinting for up to 6 weeks, which may lead to elbow stiffness. The K-wires are also inadequate for elderly patients with osteopenic bone. In general, the crossing K-wire or cannulated screw technique is not recommended for adult patients with AO/OTA type A2 or A3 fractures. 
ORIF is the preferred fixation technique for transcolumn fractures (AO/OTA types A2 and A3). These fractures can be exposed through a paratricipital approach or a limited triceps split. Exposure of the articular surface, as obtained from an olecranon osteotomy, is not required for these extra-articular fractures. Bicolumnar fixation is recommended with orthogonal or parallel plating techniques. When the transcolumn fracture line is just proximal to the articular segment, the pattern can be referred to as a “low” transcolumn fracture. Low transcolumn fractures have limited bone available for distal fixation; therefore, bicolumn plating is necessary with plates applied as distal as possible with as many screws as possible in the distal fragment. Commercially available precontoured plates have extra screw holes distally to allow high-density screw insertion into the distal articular segment. In certain low-transcolumn fractures in the elderly with severe osteopenia or pre-existing arthritis, TEA may be the most appropriate form of treatment. Elbow arthroplasty will be discussed later in this chapter. 
The commonly used classification systems do not account for fracture displacement, fracture angulation, or the severity of the soft tissue injury. These factors should be considered when deciding upon surgical management. In general, medically fit patients with distal humerus fractures with displacement or angulation meet the indications for surgical intervention. 
Preoperative Planning.
The goals in surgical treatment of distal humerus fractures are similar to those used for any periarticular fracture. The objectives are to obtain anatomic restoration of the articular surface and recreation of joint alignment with rigid internal fixation, stable enough to allow early range of motion. 
Anteroposterior and lateral radiographs of the elbow out of plaster are usually sufficient to determine the fracture pattern. If the radiographs are difficult to interpret or poorly demonstrate the articular fracture, a CT scan is preferred, with three-dimensional reconstructions, over traction radiographs requiring patient sedation. A CT scan can identify difficult fracture patterns such as coronal fractures of the capitellum or trochlea, “low” fracture types, and segmental articular fractures (for example, a fracture between the medial trochlea and the medial epicondyle, producing a free medial trochlear fragment). Three-dimensional images can also be manipulated to subtract the radius and ulna to allow unobstructed visualization of articular comminution. In elderly patients with comminuted fractures where ORIF may not be possible and elbow arthroplasty is considered, a CT scan may assist with the preoperative decision-making. 
While awaiting surgery, patients are placed in a well-padded elbow splint and are encouraged to elevate the arm, ice the elbow, and to maintain hand and finger range of motion. On the day of surgery, the skin and soft tissues are re-examined and the neurologic status is redocumented. Patients generally receive a general anesthetic with an upper extremity regional block for postoperative pain control and therapy. Preoperatively, prophylactic antibiotics are administered intravenously. 
Positioning.
The patient is positioned supine with a bolster placed under the ipsilateral scapula and the elbow is supported by another bolster made of wrapped sterile sheet on the patient’s chest (Fig. 35-13). The surgeon and assistant stand on the side of the injury while the scrub nurse and instruments are on the contralateral side, allowing the nurse to assist with arm positioning as required. A sterile tourniquet is used and the iliac crest is prepped and draped if bone grafting is anticipated. Portable (mini) fluoroscopy is used for all cases and is positioned on the operative side. 
Figure 35-13
 
The patient may be positioned supine with a bolster placed under the ipsilateral scapula (A) or lateral decubitus on a beanbag with the elbow flexed over an arthroscopy positioner (B). In circumstances when there is no surgical assistant available, a commercially available articulated arm positioner can also be used (C).
The patient may be positioned supine with a bolster placed under the ipsilateral scapula (A) or lateral decubitus on a beanbag with the elbow flexed over an arthroscopy positioner (B). In circumstances when there is no surgical assistant available, a commercially available articulated arm positioner can also be used (C).
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Figure 35-13
The patient may be positioned supine with a bolster placed under the ipsilateral scapula (A) or lateral decubitus on a beanbag with the elbow flexed over an arthroscopy positioner (B). In circumstances when there is no surgical assistant available, a commercially available articulated arm positioner can also be used (C).
The patient may be positioned supine with a bolster placed under the ipsilateral scapula (A) or lateral decubitus on a beanbag with the elbow flexed over an arthroscopy positioner (B). In circumstances when there is no surgical assistant available, a commercially available articulated arm positioner can also be used (C).
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In circumstances when there is no surgical assistant available, a commercially available articulated arm positioner is preferred (Fig. 35-13C). The patient can also be positioned in the lateral decubitus fashion on a beanbag with a small axillary bolster. The elbow is then flexed over an elbow arthroscopy positioner and the scrub nurse and instrumentation are positioned on the same side. In the rare circumstance of bilateral fractures, when a second surgical team is available, the patient may be positioned prone with the elbows flexed over a positioner to allow simultaneous surgery. 
Surgical Approaches.
The principles of internal fixation start with the selection of an appropriate surgical approach. The chosen approach should be accommodating to intraoperative findings, which may alter the surgical procedure. For example, a paratricipital approach may be used to initially access a noncomminuted intra-articular fracture (AO/OTA type C1 or C2); however, if the fracture proves difficult to reduce or if more comminution is present than expected, the approach can be converted to an olecranon osteotomy. Similarly, an olecranon osteotomy should not be the index approach for an elderly patient with a highly comminuted distal humerus fracture, which may be intraoperatively deemed unrepairable, necessitating TEA. AO/OTA type B1 (lateral column) fractures can be surgically approached by Kocher’s interval with proximal extension to expose the lateral column. AO/OTA type B2 (medial column) fractures can be approached via a Hotchkiss approach with proximal extension to expose the medial column. Single column fractures (medial and lateral) may also be exposed by the paratricipital approach, which allows visualization of the posterior aspects of both columns and the posterior aspect of the articular surface. In cases where there is extensive articular comminution (AO/OTA types B1.3 and B2.3) an olecranon osteotomy may be required for improved visualization of the fracture and improved access for fixation (Fig. 35-14). 
Figure 35-14
A 73-year-old woman with a comminuted intra-articular fracture of the medial column (AO/OTA type B1.3) treated with ORIF via an olecranon osteotomy (A–C).
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There are several surgical approaches described for exposure and fixation of distal humerus fractures. They can be classified based on direction; posterior, lateral, medial, and anterior, and then further subclassified based on their specific anatomic intervals (Table 35-3). The ideal approach to a specific fracture pattern should provide sufficient exposure to allow anatomic reconstruction of the fracture and the application of the required internal fixation with minimal soft tissue or bony disruption, to allow early mobilization. The selection of a surgical approach depends on multiple factors including fracture pattern, extent of articular involvement, associated soft tissue injury, rehabilitation protocols, and surgeon preference.169 
 
Table 35-3
Surgical Approaches to the Distal Humerus
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Table 35-3
Surgical Approaches to the Distal Humerus
Direction Surgical Approach Indications Contraindications Advantages Disadvantages
Posterior Olecranon osteotomy36,78,118,180 ORIF distal humerus and articular fractures (AO/OTA types B & C) Avoid if possibility of TEA Best visualization of the articular surface for reduction and fixation Nonunion and hardware prominence—related to osteotomy
Limited visualization of anterior articular surfaces
Paratricipital7,198 ORIF extra-articular and simple intra-articular fractures (AO/OTA types C1 & C2)
TEA
Comminuted intra-articular fractures Avoids disruption of the extensor mechanism, no postoperative restrictions related to approach required Limited visualization of the articular surfaces
Triceps splitting29,68 ORIF extra-articular and intra-articular fractures
TEA
Anterior coronal shear fractures of capitellum or trochlea
Prior olecranon osteotomy approach
Avoids complications associated with olecranon osteotomy Limited visualization of anterior articular surfaces
Risk of triceps insufficiency
Triceps reflecting26 TEA
ORIF intra-articular fractures
Anterior coronal shear fractures of capitellum or trochlea
Prior olecranon osteotomy approach
Traumatic triceps tendon tear
Avoids complications associated with olecranon osteotomy Limited visualization of anterior articular surfaces
Risk of triceps insufficiency
TRAP156 ORIF intra-articular fractures
TEA
Anterior coronal shear fractures of capitellum or trochlea
Prior olecranon osteotomy approach
Traumatic triceps tendon tear
Avoids complications associated with olecranon osteotomy
Preserves nerve supply to anconeus
Limited visualization of anterior articular surfaces
Risk of triceps insufficiency
Van Gorder219 ORIF intra-articular fractures
TEA
Anterior coronal shear fractures of capitellum or trochlea
Prior olecranon osteotomy approach
Avoids complications associated with olecranon osteotomy Limited visualization of anterior articular surfaces
Risk of triceps insufficiency
Lateral Kocher105 Lateral column fractures
Lateral epicondyle fractures
Capitellum ± lateral trochlear ridge fractures
Fixation of associated radial head and neck fractures
Medial articular fractures (trochlea) Good access to capitellum, and lateral column structures
Improved access to medial joint by releasing LCL
Good access to origin and insertion of LCL
No access to medial column
EDC split Lateral column fractures
Lateral epicondyle fractures
Capitellum ± lateral trochlear ridge fractures
Fixation of associated radial head fractures
Medial articular fractures (trochlea) Good access to capitellum, and lateral column structures
Improved access to medial joint by releasing LCL
No access to medial column
Kaplan102 Capitellum ± lateral trochlear ridge fractures
Fixation of associated radial head fractures
Medial articular fractures (trochlea)
Lateral collateral ligament injuries
Avoids disrupting extensor origin on lateral epicondyle
LCL is safe
No access to medial column
Difficult access to lateral epicondyle for ORIF fracture or LCL repair
Limited access to radial neck for fixation
Medial Hotchkiss over-the-top81 Medial epicondyle and medial column fractures
Trochlear fractures
Associated MCL tears requiring repair
Complex medial and lateral articular fractures
Good access to medial column and anteromedial joint capsule Difficult access to MCL for repair
Taylor and Scham215 Medial epicondyle and medial column fractures
Trochlear fractures
MCL tears and coronoid fractures
Complex medial and lateral articular fractures Good visualization of trochlea
Good access to MCL for repair and coronoid for ORIF
Reflection of flexors of medial ulna and medial epicondyle
Anterior Henry Vascular injury
Median nerve laceration
Requirement for plate fixation of columns or fixation of articular surface Good access to brachial artery and median nerve Limited access to medial and lateral columns
 

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.

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Skin incisions about the elbow may be placed posterior, lateral, medial, or anterior depending on the surgical approach selected. Most posterior approaches benefit from a posterior longitudinal skin incision which involves the elevation of full-thickness fasciocutaneous medial and lateral flaps.42 The posterior skin incision can be straight or curved around the olecranon, medially or laterally, depending on surgeon preference. It is the author’s preference to conduct a relatively straight posterior skin incision that curves gently around the medial aspect of the olecranon (Fig. 35-15A). The lateral approaches can be accessed via a direct lateral skin incision or by a posterior longitudinal skin incision with elevation of a lateral fasciocutaneous flap. Similarly, the medial approaches can be accessed via a direct medial skin incision or by a posterior longitudinal skin incision with elevation of a medial fasciocutaneous flap. There are several advantages to a direct midline posterior longitudinal skin incision, including access to both medial and lateral deep approaches and a decreased risk of cutaneous nerve injury.42 The disadvantage of selecting a posterior longitudinal skin incision for isolated medial or lateral approaches is the increased risk of flap complications such as seromas and rarely necrosis. 
Figure 35-15
 
An 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 ulna is exposed and the nonarticular portion of the greater sigmoid notch (the bare area) between the olecranon articular facet and the coronoid articular facet is clearly identified. This is accomplished by dissection along the medial and lateral sides of the olecranon to enter into the ulnohumeral joint. 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). Once conducted, the olecranon fragment along with the triceps tendon and musculature can be bluntly dissected off the posterior aspect of the distal humerus (E). At the completion of the case, provisional fixation of the olecranon fragment is done with crossing K-wires (F) followed by definitive compression plating (G).
An 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 ulna is exposed and the nonarticular portion of the greater sigmoid notch (the bare area) between the olecranon articular facet and the coronoid articular facet is clearly identified. This is accomplished by dissection along the medial and lateral sides of the olecranon to enter into the ulnohumeral joint. 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). Once conducted, the olecranon fragment along with the triceps tendon and musculature can be bluntly dissected off the posterior aspect of the distal humerus (E). At the completion of the case, provisional fixation of the olecranon fragment is done with crossing K-wires (F) followed by definitive compression plating (G).
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An 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 ulna is exposed and the nonarticular portion of the greater sigmoid notch (the bare area) between the olecranon articular facet and the coronoid articular facet is clearly identified. This is accomplished by dissection along the medial and lateral sides of the olecranon to enter into the ulnohumeral joint. 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). Once conducted, the olecranon fragment along with the triceps tendon and musculature can be bluntly dissected off the posterior aspect of the distal humerus (E). At the completion of the case, provisional fixation of the olecranon fragment is done with crossing K-wires (F) followed by definitive compression plating (G).
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Figure 35-15
An 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 ulna is exposed and the nonarticular portion of the greater sigmoid notch (the bare area) between the olecranon articular facet and the coronoid articular facet is clearly identified. This is accomplished by dissection along the medial and lateral sides of the olecranon to enter into the ulnohumeral joint. 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). Once conducted, the olecranon fragment along with the triceps tendon and musculature can be bluntly dissected off the posterior aspect of the distal humerus (E). At the completion of the case, provisional fixation of the olecranon fragment is done with crossing K-wires (F) followed by definitive compression plating (G).
An 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 ulna is exposed and the nonarticular portion of the greater sigmoid notch (the bare area) between the olecranon articular facet and the coronoid articular facet is clearly identified. This is accomplished by dissection along the medial and lateral sides of the olecranon to enter into the ulnohumeral joint. 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). Once conducted, the olecranon fragment along with the triceps tendon and musculature can be bluntly dissected off the posterior aspect of the distal humerus (E). At the completion of the case, provisional fixation of the olecranon fragment is done with crossing K-wires (F) followed by definitive compression plating (G).
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An 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 ulna is exposed and the nonarticular portion of the greater sigmoid notch (the bare area) between the olecranon articular facet and the coronoid articular facet is clearly identified. This is accomplished by dissection along the medial and lateral sides of the olecranon to enter into the ulnohumeral joint. 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). Once conducted, the olecranon fragment along with the triceps tendon and musculature can be bluntly dissected off the posterior aspect of the distal humerus (E). At the completion of the case, provisional fixation of the olecranon fragment is done with crossing K-wires (F) followed by definitive compression plating (G).
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Posterior Approaches to the Distal Humerus.
There are several posterior approaches and they can be broadly classified into three general types: Olecranon osteotomy, paratricipital (triceps-on), and triceps-off type approaches (such as the triceps splitting, triceps reflecting, and the triceps tongue approaches). The selection of a particular type of posterior approach depends on several factors including the degree of articular visualization required for anatomic reduction and internal fixation, the appropriateness of primary arthroplasty, patient factors (elderly, low demand), fracture characteristics (articular comminution), and any associated injuries (i.e., triceps laceration or olecranon fracture) that may make one approach more favourable. 
Olecranon Osteotomy.
The olecranon osteotomy was first described by MacAusland118 and has undergone several modifications.30,58,180 When compared to other posterior approaches, osteotomy of the olecranon provides the best visualization of the distal humerus articular surface,225 which is its main advantage. The main disadvantages of the approach are the complications associated with an osteotomy, including nonunion, malunion, and hardware irritation. Olecranon osteotomies are most commonly used for AO/OTA type C fractures, which require superior visualization of the articular fragments for anatomic reduction and internal fixation. An osteotomy can also be used for partial articular fractures (AO/OTA type B), especially if they are comminuted. Relative contraindications to an osteotomy are very anterior articular fractures (AO/OTA type B3) which can be difficult to visualize through an osteotomy and if a TEA is planned as it may lead to problems with implant stability and osteotomy healing and fixation. 
As for all posterior approaches, the ulnar nerve requires identification and protection to avoid iatrogenic nerve injury during fracture manipulation and fixation (Fig. 35-15B). It remains unclear whether the ulnar nerve should be transposed or replaced in the cubital tunnel at the conclusion of the procedure. Wiggers et al.224 demonstrated that the occurrence of postoperative ulnar neuropathy was independent of whether or not the ulnar nerve was transposed at the time of fracture fixation. Conversely, Chen et al.32 reported a four times increase in the rate of postoperative ulnar neuropathy after transposition. Presently, as there exists no level 1 evidence for or against transposition, it is my preference to conduct a formal anterior subcutaneous ulnar nerve transposition at the conclusion of the procedure. 
Once the subcutaneous border of the proximal ulna is exposed, the nonarticular portion of the greater sigmoid notch (the “bare area”) between the olecranon articular facet and the coronoid articular facet should be clearly identified. This is done by subperiosteally dissecting along the medial and lateral sides of the olecranon to enter into the ulnohumeral joint. Dissection should not proceed distally as it places the collateral ligament insertions at risk. Medial and lateral retractors are then placed into the ulnohumeral joint to protect the soft tissues and to allow direct visualization of the “bare area.” An apex distal chevron osteotomy entering into the bare area is then marked on the subcutaneous border of the ulna (Fig. 35-15C). A microsagittal saw is used to complete two-thirds of the osteotomy. To avoid unpredictable propagation of the osteotomy, multiple perforations are carefully created through the remaining third using a K-wire. Two osteotomes, placed into each arm of the chevron, apply controlled leverage to the olecranon fragment causing fracture of the remaining third (Fig. 35-15D). The fractured surface of the olecranon improves fragment interdigitation and facilitates anatomic reduction and stability during the repair. A chevron-shaped osteotomy provides rotation stability, increased surface area for healing, and protects the collateral ligament insertions.167 A transverse olecranon osteotomy is also an option as it is technically simpler and can be performed more rapidly.58,80 Following the osteotomy, the olecranon fragment along with the triceps tendon and musculature can be bluntly dissected off the posterior aspect of the distal humerus (Fig. 35-15E). Typically, the anconeus muscle must be divided in order to reflect the triceps posteriorly which causes its denervation.156 Anconeus muscle denervation can be avoided by reflecting the anconeus muscle posteriorly along with the olecranon fragment and triceps.16 Once the osteotomy (Fig. 35-15F, G) is conducted, flexion of the elbow is used to maximize visualization of distal humerus articular surface. 
Fixation of the olecranon osteotomy can be achieved with tension band wiring,124 screw/tension band constructs, or with compression plating.64 The author’s preferred method of fixation is compression plating.78 When using this method, the plate is pre-fixed to the olecranon and then removed before conducting the osteotomy. This facilitates osteotomy reduction at the completion of the operative procedure. A 6.5- or 7.3-mm intramedullary compression screw may also be used for osteotomy fixation; however, care should be taken during screw insertion as malreduction is possible when the distal screw threads deflect into the normal varus bow of the ulna.66 
Paratricipital Approach (Triceps-On).
The paratricipital (bilaterotricipital, triceps sparing, or triceps-on) approach was first reported by Alonso-Llames7 in 1972 for the management of pediatric supracondylar fractures. The approach involves the creation of surgical windows along the medial and lateral sides of the triceps muscle and tendon without disrupting its insertion on the olecranon.198 
The approach starts with an extensile posterior skin incision and mobilization of the ulnar nerve. Along the medial side of the triceps, the interval between the triceps muscle and the medial intermuscular septum is developed (Fig. 35-16A) and the triceps muscle is elevated off the posterior aspect of the humerus (Fig. 35-16B). Laterally, the triceps is elevated off the lateral intermuscular septum and the posterior humerus in conjunction with the anconeus muscle (Fig. 35-16).7,198 Distally, the paratricipital approach allows visualization of the medial and lateral columns, the olecranon fossa, and the posterior aspect of the trochlea. A modification of the paratricipital approach involves the creation of a third surgical window in Boyd’s interval between the anconeus and lateral olecranon.14 The third surgical window allows improved visualization of the distal humerus articular surface. 
Figure 35-16
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.
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 35-16
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.
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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The paratricipital approach has several advantages including avoidance of an olecranon osteotomy; therefore, the risks of nonunion and symptomatic olecranon hardware are avoided. In addition, the triceps tendon insertion is not disrupted, allowing early active range of motion. This approach also preserves the innervation and blood supply of the anconeus muscle,198 which provides dynamic posterolateral stability to the elbow. Finally, if further articular exposure is required, the paratricipital approach can be converted into an olecranon osteotomy. If further proximal exposure is required for associated fractures of the humeral shaft, the lateral side of the paratricipital approach can be converted into the Gerwin et al.62 approach. This approach involves reflection of the triceps muscle unit from lateral to medial to expose 95% of the posterior humeral shaft and the radial nerve. 
The disadvantage of the paratricipital approach is the limited visualization of the articular surface of the distal humerus; therefore, the approach is usually inadequate for fixation of type C3 fractures. The several advantages of this approach certainly indicate its use for AO/OTA types A2, A3, B1, B2, and possibly C1 and C2 fractures.124,170,198 
In distal humerus fractures deemed unrepairable, where the intent is to proceed directly to TEA, the paratricipital approach is preferred because it avoids the problems associated with osteotomies and extensor mechanism healing in triceps detaching approaches. The approach is also useful in cases where an initial attempt at ORIF is planned and there is a possibility of an intraoperative conversion to TEA, should fixation be deemed unsuccessful. 
Triceps Splitting Approach.
The triceps splitting approach described by Campbell29 involves a midline split through the triceps tendon. The medial and lateral columns are exposed with subperiosteal dissection starting from the midline and moving outward (Fig. 35-17). Visualization of the articular surface of the distal humerus is challenging and can be improved by partial excision of the olecranon tip and flexion of the elbow. This approach can be extended proximally to the level of the radial nerve as it crosses the humeral shaft in the spiral groove. To expand the approach distally, the split can be extended through the triceps insertion to the subcutaneous border of the ulna. The triceps insertion on the olecranon is split midline, with release of Sharpey fibers creating medial and lateral fasciotendinous sleeves. At the conclusion of the procedure, the triceps tendon is repaired to the olecranon via transosseous nonabsorbable braided sutures. 
Figure 35-17
The triceps split approach described by Campbell involves a midline split through the triceps tendon and medial head (A).
 
The approach can be extended distally by splitting the triceps insertion on the olecranon and raising 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. For ORIF, the medial and lateral collateral ligaments are preserved (asterisk), however, to obtain further exposure for TEA, they may be released (D). O, olecranon; U, ulnar nerve; T, triceps.
The approach can be extended distally by splitting the triceps insertion on the olecranon and raising 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. For ORIF, the medial and lateral collateral ligaments are preserved (asterisk), however, to obtain further exposure for TEA, they may be released (D). O, olecranon; U, ulnar nerve; T, triceps.
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Figure 35-17
The triceps split approach described by Campbell involves a midline split through the triceps tendon and medial head (A).
The approach can be extended distally by splitting the triceps insertion on the olecranon and raising 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. For ORIF, the medial and lateral collateral ligaments are preserved (asterisk), however, to obtain further exposure for TEA, they may be released (D). O, olecranon; U, ulnar nerve; T, triceps.
The approach can be extended distally by splitting the triceps insertion on the olecranon and raising 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. For ORIF, the medial and lateral collateral ligaments are preserved (asterisk), however, to obtain further exposure for TEA, they may be released (D). O, olecranon; U, ulnar nerve; T, triceps.
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The advantages of the triceps splitting approach are its relative technical ease and the ability to convert from ORIF to TEA with few consequences. The disadvantages of the approach include limited visibility of the articular surface, and the requirement of postoperative protection of the triceps repair to decrease the risk of extensor mechanism disruption. In order to improve triceps healing, Gschwend et al.68 modified the approach to incorporate a flake of olecranon bone. McKee et al.133 compared the extensor mechanism strength of patients treated with an olecranon osteotomy versus a triceps splitting approach and found no statistical significant difference, concluding that both approaches are effective. 
Triceps Reflecting Anconeus Pedicle (TRAP) Approach.
The TRAP approach involves completely detaching the triceps from the proximal ulna with the anconeus muscle.156 The approach is done through a longitudinal posterior skin incision after identification of the ulnar nerve. Kocher’s interval is used to elevate the anconeus muscle and develop the distal lateral portion of the flap (Fig. 35-18A). The medial portion of the flap is created by subperiosteal dissection from the subcutaneous border of the ulna. The anconeus flap is then reflected proximally to expose the triceps insertion which is also sharply released (Fig. 35-18B). The entire triceps–anconeus flap is then reflected proximally releasing the triceps muscle from the posterior aspect of the distal humerus (Fig. 35-18C). This approach provides good exposure to the posterior elbow joint while protecting the neurovascular supply to the anconeus muscle. The TRAP approach also avoids the complications of an olecranon osteotomy and allows the use of the trochlear sulcus as a template to assist with articular reduction of the distal humerus. The major disadvantage of this approach is that the triceps is completely released from its insertion; therefore, there is a risk of triceps dehiscence and extensor weakness. 
Figure 35-18
The triceps reflecting anconeus pedicle (TRAP) approach is done through a longitudinal posterior skin incision after identification of the ulnar nerve.
 
The interval between anconeus and extensor carpi ulnaris is used to elevate the anconeus muscle and develop the distal lateral portion of the flap. The medial portion of the flap is created by subperiosteal dissection from the subcutaneous border of the ulna. The anconeus flap is then reflected proximally (A) to expose the triceps insertion which is also sharply released (B). The entire triceps–anconeus flap is then reflected proximally releasing the triceps muscle from the posterior aspect of the distal humerus (C). O, olecranon; FCU, flexor carpi ulnaris; ECU, extensor carpi ulnaris; LCL, lateral collateral ligament; A, anconeus; EDC, extensor digitorum communis.
The interval between anconeus and extensor carpi ulnaris is used to elevate the anconeus muscle and develop the distal lateral portion of the flap. The medial portion of the flap is created by subperiosteal dissection from the subcutaneous border of the ulna. The anconeus flap is then reflected proximally (A) to expose the triceps insertion which is also sharply released (B). The entire triceps–anconeus flap is then reflected proximally releasing the triceps muscle from the posterior aspect of the distal humerus (C). O, olecranon; FCU, flexor carpi ulnaris; ECU, extensor carpi ulnaris; LCL, lateral collateral ligament; A, anconeus; EDC, extensor digitorum communis.
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Figure 35-18
The triceps reflecting anconeus pedicle (TRAP) approach is done through a longitudinal posterior skin incision after identification of the ulnar nerve.
The interval between anconeus and extensor carpi ulnaris is used to elevate the anconeus muscle and develop the distal lateral portion of the flap. The medial portion of the flap is created by subperiosteal dissection from the subcutaneous border of the ulna. The anconeus flap is then reflected proximally (A) to expose the triceps insertion which is also sharply released (B). The entire triceps–anconeus flap is then reflected proximally releasing the triceps muscle from the posterior aspect of the distal humerus (C). O, olecranon; FCU, flexor carpi ulnaris; ECU, extensor carpi ulnaris; LCL, lateral collateral ligament; A, anconeus; EDC, extensor digitorum communis.
The interval between anconeus and extensor carpi ulnaris is used to elevate the anconeus muscle and develop the distal lateral portion of the flap. The medial portion of the flap is created by subperiosteal dissection from the subcutaneous border of the ulna. The anconeus flap is then reflected proximally (A) to expose the triceps insertion which is also sharply released (B). The entire triceps–anconeus flap is then reflected proximally releasing the triceps muscle from the posterior aspect of the distal humerus (C). O, olecranon; FCU, flexor carpi ulnaris; ECU, extensor carpi ulnaris; LCL, lateral collateral ligament; A, anconeus; EDC, extensor digitorum communis.
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Van Gorder Approach (Triceps Tongue).
The Van Gorder approach involves division of the triceps tendon at its musculotendinous junction.219 The approach is most commonly used for TEA and rarely for ORIF of distal humerus fractures. Transection of the triceps is done in the shape of a “V” so that a “V to Y” plasty can be done if lengthening of the extensor mechanism is required. As the triceps is completely divided in this approach, it has the same risks as the TRAP approach. This approach is indicated for ORIF of distal humerus fractures when there is an associated complete or high-grade partial triceps tendon laceration. 
Lateral Approaches to the Distal Humerus.
Lateral approaches to the elbow can be accessed via a direct lateral skin incision or by a posterior longitudinal skin incision with elevation of a lateral fasciocutaneous flap. The approaches that will be discussed are the Kocher, Kaplan, and the extensor digitorum communis (EDC) split. Access to the radiocapitellar joint can also be obtained through a lateral epicondylar osteotomy or via a concurrent fracture of the lateral epicondyle. 
The Kocher, Kaplan, and EDC split approaches are used to treat capitellar and radial head fractures. Proximal extension of these approaches can be used to access the lateral column, to treat partial articular lateral column fractures and some transcolumn fractures. 
The Kocher approach involves identification of the interval between extensor carpi ulnaris (ECU) and anconeus.105 This interval can be identified by a thin fat stripe or by the perforating branches of the recurrent posterior interosseous artery (Fig. 35-19A). The interval is developed by bluntly undermining the anconeus muscle which will allow identification of the elbow joint capsule and the capsular thickening that is the LUCL (Figs. 35-19B and C). Some of the common extensor tendon origin will have to be elevated off the LUCL to allow an arthrotomy to be made anterior to the ligament (Fig. 35-19D). The forearm is pronated during the approach, which moves the posterior interosseous nerve more anterior and distal. The radial neck is exposed by incising the annular ligament. This approach can be extended proximally by releasing the extensor carpi radialis longus (ECRL) and the brachioradialis off the anterolateral supracondylar ridge. To expose the posterolateral elbow joint and posterior aspect of the lateral column, another arthrotomy is made posterior to the LUCL and the triceps is elevated off the posterior lateral column. 
Figure 35-19
Kocher’s approach105 to the anterolateral elbow joint uses the interval between extensor carpi ulnaris (ECU) and anconeus (A).
 
This interval can be identified by a thin fat stripe (black arrow). The interval is developed by bluntly undermining the anconeus muscle which will allow identification of the elbow joint capsule and the capsular thickening that is the lateral ulnar collateral ligament (LUCL) (B, C). The posterior portion of the common extensor tendon origin will have to be elevated off the LUCL to allow an arthrotomy to be made anterior to the ligament (D). RH, radial head; EDC, extensor digitorum communis.
This interval can be identified by a thin fat stripe (black arrow). The interval is developed by bluntly undermining the anconeus muscle which will allow identification of the elbow joint capsule and the capsular thickening that is the lateral ulnar collateral ligament (LUCL) (B, C). The posterior portion of the common extensor tendon origin will have to be elevated off the LUCL to allow an arthrotomy to be made anterior to the ligament (D). RH, radial head; EDC, extensor digitorum communis.
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Figure 35-19
Kocher’s approach105 to the anterolateral elbow joint uses the interval between extensor carpi ulnaris (ECU) and anconeus (A).
This interval can be identified by a thin fat stripe (black arrow). The interval is developed by bluntly undermining the anconeus muscle which will allow identification of the elbow joint capsule and the capsular thickening that is the lateral ulnar collateral ligament (LUCL) (B, C). The posterior portion of the common extensor tendon origin will have to be elevated off the LUCL to allow an arthrotomy to be made anterior to the ligament (D). RH, radial head; EDC, extensor digitorum communis.
This interval can be identified by a thin fat stripe (black arrow). The interval is developed by bluntly undermining the anconeus muscle which will allow identification of the elbow joint capsule and the capsular thickening that is the lateral ulnar collateral ligament (LUCL) (B, C). The posterior portion of the common extensor tendon origin will have to be elevated off the LUCL to allow an arthrotomy to be made anterior to the ligament (D). RH, radial head; EDC, extensor digitorum communis.
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An easier, and some believe safer, approach to the radiocapitellar joint is the EDC split. This approach involves creation of a lateral elbow arthrotomy at the equator of the radiocapitellar joint (Fig. 35-20). The site of the arthrotomy is chosen by palpating the capitellum and radial head to determine the mid-equator. The structures below the equator include the LUCL and the posterolateral joint capsule which should not be incised as they are important elbow stabilizers. The arthrotomy, therefore, is made in-line with the tendon fibers of EDC at the equator of the radiocapitellar joint and may be extended proximally along the anterolateral aspect of the lateral column. Dissection below the mid-equator is avoided as it may disrupt the LUCL. 
Figure 35-20
The extensor digitorum communis (EDC) split approach.
 
The EDC tendon is split anterior to the mid-equator of the radiocapitellar joint to avoid injury to the lateral ulnar collateral ligament.
The EDC tendon is split anterior to the mid-equator of the radiocapitellar joint to avoid injury to the lateral ulnar collateral ligament.
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Figure 35-20
The extensor digitorum communis (EDC) split approach.
The EDC tendon is split anterior to the mid-equator of the radiocapitellar joint to avoid injury to the lateral ulnar collateral ligament.
The EDC tendon is split anterior to the mid-equator of the radiocapitellar joint to avoid injury to the lateral ulnar collateral ligament.
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The Kaplan approach uses the interval between ECRL and EDC to access the radiocapitellar joint.102 The approach provides good exposure of the radial head and capitellum and remains anterior to the LCL insertion. The forearm should be pronated during distal extension of the approach to maximize the distance to the posterior interosseous nerve.38 
Medial Approaches to the Distal Humerus.
Medial approaches to the elbow can be accessed by a direct medial skin incision or by a posterior longitudinal skin incision with elevation of a medial fasciocutaneous flap. When using a direct medial skin incision, care should be taken in identifying and protecting the branches of the medial antebrachial cutaneous nerve. The medial approaches can be used to treat isolated partial articular medial column fractures, trochlear fractures, coronoid fractures, and fractures of the medial epicondyle. 
Hotchkiss described the medial “over-the-top” approach, which starts with identification and transposition of the ulnar nerve.81,167 The medial supracondylar ridge is identified and the flexor–pronator origin is released off the ridge to the level of the medial epicondyle. At the medial epicondyle, the flexor origin is split distally in-line with its fibers. Dissection directly inferior to the medial epicondyle is avoided as it may disrupt the anterior bundle of the MCL. 
The medial coronoid, the anterior bundle of the MCL, and the posteromedial ulnohumeral joint can be accessed through an approach that starts at the floor of the cubital tunnel. The humeral head of the FCU, palmaris longus, flexor carpi radialis, and pronator teres are bluntly elevated off the anterior bundle of the MCL and joint capsule in a posterior to anterior direction. Once exposed, an arthrotomy is made anterior to the anterior bundle of the MCL to enter the anterior aspect of the ulnohumeral joint. The posteromedial aspect of the ulnohumeral joint is accessed by dividing the posterior and transverse bundles of the MCL. Taylor and Scham215 described a similar approach with the only difference being that the ulnar head of FCU is elevated anteriorly with the other flexors. 
Surgical Technique
Surgical Technique for AO/OTA Types A and C Fractures (Extra-articular and Complete Articular Fractures).
An extensile posterior skin incision is used with elevation of full-thickness medial and lateral fasciocutaneous flaps. The ulnar nerve is exposed, tagged, and prepared for anterior subcutaneous transposition, which will be done at the completion of the procedure. 
In patients with comminuted intra-articular AO/OTA type C3 fractures, I prefer a chevron-shaped osteotomy through the bare area, which is then fixated with a precontoured olecranon plate (please see section on Olecranon Osteotomy). The plate is preapplied to the olecranon before the osteotomy; this facilitates olecranon reduction and plate application at the end of the operative procedure. For simple articular fractures (AO/OTA type C1 and C2) and extra-articular fractures (AO/OTA type A2 and A3), I prefer the paratricipital approach7 (Fig. 35-16). This approach allows bicolumn exposure and plating with preservation of the triceps mechanism. Simple intra-articular fractures can be reduced indirectly by anatomic reduction of the supracondylar level fracture. The articular reduction can be assessed with elbow flexion and direct visualization of the posterior aspect of the trochlea or with fluoroscopy. The articular reduction may also be visualized directly by creation of a third surgical window in Boyd’s interval, between the anconeus muscle and the lateral olecranon.14 
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 carried out through 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 same approach. 
For AO/OTA type C fractures, once the distal humerus articular surface is adequately exposed, the fracture hematoma is evacuated and the raw fracture surfaces are cleaned of loose debris. The origins of the common flexor and extensor tendons are preserved on the epicondyles as are the collateral ligament origins. The fracture fragments can be manipulated manually or with small diameter K-wires used as joy sticks. I typically prefer K-wires for manipulation and provisional reduction of fracture fragments (Fig. 35-21A to D). Usually, I place one K-wire through the fractured surface of the medial trochlea, aiming toward the medial epicondyle, running along the trochlear axis. This K-wire is then pulled out through the medial epicondyle until its tip lies flush and perpendicular to the fracture surface of the medial trochlea. A similar K-wire is placed through the lateral articular fragment. These wires are then used to individually manipulate the fracture fragments, to reduce and interdigitate them. A large pointed reduction tenaculum is used to hold the reduction and to provide compression until the medial K-wire can be drilled into the lateral fragment and the lateral K-wire drilled into the medial fragment. This provides provisional fixation of the articular segment. 
Figure 35-21
Open reduction and internal fixation of an intra-articular distal humerus fracture via an olecranon osteotomy (A).
 
K-wires are used as joysticks to manipulate the fracture fragments in to an anatomic reduction (B). A large tenaculum is used to stabilize the reduction (C) while the K-wires are drilled into the opposite articular fragment (D) to provisionally fixate the segment. A small-diameter screw is then inserted from medial to lateral (E). After the articular segment is fixated, it is reduced to the shaft and provisionally stabilized with long bicortical K-wires inserted up each column (F). Definitive articular segment to shaft fixation is obtained with bicolumn plating in a parallel or orthogonal fashion (G–I). Ideally, as many screws as possible are inserted through the plates into the articular segment; the screws should be as long as possible and they should engage as many articular fragments as possible. Screws should not be placed through the olecranon fossa as they may lead to impingement and decreased range of motion.
K-wires are used as joysticks to manipulate the fracture fragments in to an anatomic reduction (B). A large tenaculum is used to stabilize the reduction (C) while the K-wires are drilled into the opposite articular fragment (D) to provisionally fixate the segment. A small-diameter screw is then inserted from medial to lateral (E). After the articular segment is fixated, it is reduced to the shaft and provisionally stabilized with long bicortical K-wires inserted up each column (F). Definitive articular segment to shaft fixation is obtained with bicolumn plating in a parallel or orthogonal fashion (G–I). Ideally, as many screws as possible are inserted through the plates into the articular segment; the screws should be as long as possible and they should engage as many articular fragments as possible. Screws should not be placed through the olecranon fossa as they may lead to impingement and decreased range of motion.
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K-wires are used as joysticks to manipulate the fracture fragments in to an anatomic reduction (B). A large tenaculum is used to stabilize the reduction (C) while the K-wires are drilled into the opposite articular fragment (D) to provisionally fixate the segment. A small-diameter screw is then inserted from medial to lateral (E). After the articular segment is fixated, it is reduced to the shaft and provisionally stabilized with long bicortical K-wires inserted up each column (F). Definitive articular segment to shaft fixation is obtained with bicolumn plating in a parallel or orthogonal fashion (G–I). Ideally, as many screws as possible are inserted through the plates into the articular segment; the screws should be as long as possible and they should engage as many articular fragments as possible. Screws should not be placed through the olecranon fossa as they may lead to impingement and decreased range of motion.
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Figure 35-21
Open reduction and internal fixation of an intra-articular distal humerus fracture via an olecranon osteotomy (A).
K-wires are used as joysticks to manipulate the fracture fragments in to an anatomic reduction (B). A large tenaculum is used to stabilize the reduction (C) while the K-wires are drilled into the opposite articular fragment (D) to provisionally fixate the segment. A small-diameter screw is then inserted from medial to lateral (E). After the articular segment is fixated, it is reduced to the shaft and provisionally stabilized with long bicortical K-wires inserted up each column (F). Definitive articular segment to shaft fixation is obtained with bicolumn plating in a parallel or orthogonal fashion (G–I). Ideally, as many screws as possible are inserted through the plates into the articular segment; the screws should be as long as possible and they should engage as many articular fragments as possible. Screws should not be placed through the olecranon fossa as they may lead to impingement and decreased range of motion.
K-wires are used as joysticks to manipulate the fracture fragments in to an anatomic reduction (B). A large tenaculum is used to stabilize the reduction (C) while the K-wires are drilled into the opposite articular fragment (D) to provisionally fixate the segment. A small-diameter screw is then inserted from medial to lateral (E). After the articular segment is fixated, it is reduced to the shaft and provisionally stabilized with long bicortical K-wires inserted up each column (F). Definitive articular segment to shaft fixation is obtained with bicolumn plating in a parallel or orthogonal fashion (G–I). Ideally, as many screws as possible are inserted through the plates into the articular segment; the screws should be as long as possible and they should engage as many articular fragments as possible. Screws should not be placed through the olecranon fossa as they may lead to impingement and decreased range of motion.
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K-wires are used as joysticks to manipulate the fracture fragments in to an anatomic reduction (B). A large tenaculum is used to stabilize the reduction (C) while the K-wires are drilled into the opposite articular fragment (D) to provisionally fixate the segment. A small-diameter screw is then inserted from medial to lateral (E). After the articular segment is fixated, it is reduced to the shaft and provisionally stabilized with long bicortical K-wires inserted up each column (F). Definitive articular segment to shaft fixation is obtained with bicolumn plating in a parallel or orthogonal fashion (G–I). Ideally, as many screws as possible are inserted through the plates into the articular segment; the screws should be as long as possible and they should engage as many articular fragments as possible. Screws should not be placed through the olecranon fossa as they may lead to impingement and decreased range of motion.
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Definitive fixation of the articular segment can be done with one or two centrally placed screws along the capitellar–trochlear axis (Fig. 35-22) or by screws placed through plates that are applied in a parallel fashion (Fig. 35-23). Ideally, intrafragmentary compression is best, however, not at the expense of shortening the trochlea in the medial–lateral plane. The trochlea is particularly susceptible to shortening when central comminution exists and lag screw fixation is used. In these instances, fully threaded (nonoverdrilled) position screws rather than lag screws should be used to stabilize the articular segment. Once the provisional articular reduction is obtained with transfixing K-wires, I typically place a single fully threaded standard screw (2.7, 3, or 3.5 mm) along the axis of the articular segment to maintain the reduction (Fig. 35-21E). This screw is usually inserted medial to lateral with its starting point located in the centre of the trochlea. A small diameter axis screw is used to minimize its effect on other screws that will eventually be used to fixate the articular segment through plates to the diaphysis. When using small diameter screws, my preference is not to use titanium as the resistance encountered during screw insertion in good quality bone has been known to shear off the screw heads. 
Figure 35-22
Anteroposterior and lateral radiographs (A, B) of a comminuted intra-articular distal humerus fracture (AO/OTA type C3) in an active 85-year-old woman.
 
The articular fragments were first fixated with two (black arrow) centrally placed screws along the capitellar–trochlear axis (C, D). The reduced articular segment was then fixated to the shaft with triple plating. At 12 months follow-up, the fractures have healed and the patient has functional range of motion (E, F).
The articular fragments were first fixated with two (black arrow) centrally placed screws along the capitellar–trochlear axis (C, D). The reduced articular segment was then fixated to the shaft with triple plating. At 12 months follow-up, the fractures have healed and the patient has functional range of motion (E, F).
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Figure 35-22
Anteroposterior and lateral radiographs (A, B) of a comminuted intra-articular distal humerus fracture (AO/OTA type C3) in an active 85-year-old woman.
The articular fragments were first fixated with two (black arrow) centrally placed screws along the capitellar–trochlear axis (C, D). The reduced articular segment was then fixated to the shaft with triple plating. At 12 months follow-up, the fractures have healed and the patient has functional range of motion (E, F).
The articular fragments were first fixated with two (black arrow) centrally placed screws along the capitellar–trochlear axis (C, D). The reduced articular segment was then fixated to the shaft with triple plating. At 12 months follow-up, the fractures have healed and the patient has functional range of motion (E, F).
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Figure 35-23
A bicolumn (AO/OTA type C1) fracture (A, B) treated with ORIF via an olecranon osteotomy.
 
The distal humerus articular segment is fixated with three medial and three lateral screws placed through parallel plates (C, D).
The distal humerus articular segment is fixated with three medial and three lateral screws placed through parallel plates (C, D).
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Figure 35-23
A bicolumn (AO/OTA type C1) fracture (A, B) treated with ORIF via an olecranon osteotomy.
The distal humerus articular segment is fixated with three medial and three lateral screws placed through parallel plates (C, D).
The distal humerus articular segment is fixated with three medial and three lateral screws placed through parallel plates (C, D).
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Small articular fracture segments that cannot be incorporated into the greater fixation construct should be independently fixated. These small articular fractures may be located anteriorly and can be exposed by internally rotating the appropriate column fragment. Supplementary implants should be available to address these small osteochondral fragments such as mini-fragment plates, headless compression screws, countersunk small diameter screws, threaded K-wires, and/or bioabsorbable pins. These supplementary implants require strategic placement such that they do not interfere with trochlear fixation and bicolumnar plate application that will link the articular segment to the diaphysis. 
The articular segment (AO/OTA type A fractures and AO/OTA type C fractures after articular fixation) requires rigid attachment to the medial and lateral columns or distal humerus shaft. This can be accomplished by orthogonal,77,94,200 parallel,193,194 or triple plating.64,124 No clinical superiority of either method has been reported when comparing orthogonal to parallel plating techniques. 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; however, it does have its disadvantages. Thin and active patients may complain of hardware irritation from a prominent lateral plate. Therefore, in cases with a “high” lateral supracondylar level fracture, a posterolateral plate may be preferable (Fig. 35-24). 
Figure 35-24
An AP injury radiograph (A) demonstrating a displaced intra-articular distal humerus fracture in association with an ipsilateral humeral shaft fracture.
 
The fractures were exposed via a paratricipital approach extended proximally in to a Gerwin et al. approach. The patient’s distal humerus fracture was fixated with orthogonal 3.5-mm dynamic compression plates (B, C) that were intra-operatively contoured. This technique has been popularized by the AO group and involves the placement of plates at 90-degree angles to each other. Usually, the lateral plate is placed as distal as possible along the posterior aspect of the lateral column. The medial plate is placed over the medial supracondylar ridge and curved around the medial epicondyle. R, “right” for right arm x-ray.
The fractures were exposed via a paratricipital approach extended proximally in to a Gerwin et al. approach. The patient’s distal humerus fracture was fixated with orthogonal 3.5-mm dynamic compression plates (B, C) that were intra-operatively contoured. This technique has been popularized by the AO group and involves the placement of plates at 90-degree angles to each other. Usually, the lateral plate is placed as distal as possible along the posterior aspect of the lateral column. The medial plate is placed over the medial supracondylar ridge and curved around the medial epicondyle. R, “right” for right arm x-ray.
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Figure 35-24
An AP injury radiograph (A) demonstrating a displaced intra-articular distal humerus fracture in association with an ipsilateral humeral shaft fracture.
The fractures were exposed via a paratricipital approach extended proximally in to a Gerwin et al. approach. The patient’s distal humerus fracture was fixated with orthogonal 3.5-mm dynamic compression plates (B, C) that were intra-operatively contoured. This technique has been popularized by the AO group and involves the placement of plates at 90-degree angles to each other. Usually, the lateral plate is placed as distal as possible along the posterior aspect of the lateral column. The medial plate is placed over the medial supracondylar ridge and curved around the medial epicondyle. R, “right” for right arm x-ray.
The fractures were exposed via a paratricipital approach extended proximally in to a Gerwin et al. approach. The patient’s distal humerus fracture was fixated with orthogonal 3.5-mm dynamic compression plates (B, C) that were intra-operatively contoured. This technique has been popularized by the AO group and involves the placement of plates at 90-degree angles to each other. Usually, the lateral plate is placed as distal as possible along the posterior aspect of the lateral column. The medial plate is placed over the medial supracondylar ridge and curved around the medial epicondyle. R, “right” for right arm x-ray.
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Orthogonal plating involves the placement of plates on both columns at approximately 90-degree angles (Fig. 35-24). Usually, the lateral plate is placed as distal as possible along the posterior aspect of the lateral column. The lateral plate should be contoured with a bend that matches the posterior curvature of the lateral column. To achieve maximum distal fixation, the end of the plate should lie just proximal to the posterior articular surface of the capitellum. Placement of the plate further distal may lead to impingement of the radial head against the plate in extension, resulting in pain and limited range of motion. Ideally, the lateral plate should be a 3.5-mm dynamic compression plate or equivalent. The medial plate is usually applied on the medial supracondylar ridge with contouring to curve around the medial epicondyle. The plate is typically a 3.5-mm reconstruction plate to allow easier bending; however, a 3.5-mm dynamic compression plate or a newer fracture-specific precontoured plate may be preferred. 
Parallel plating also uses two plates; however, the plates are placed relatively parallel to each other on their respective supracondylar ridges (Fig. 35-25). Screws into the articular segment are preferentially placed through the plates to link the articular segment to the humeral shaft. Ideally, the longest possible screws should be inserted through the plate, to capture as many articular fragments as possible, and to engage fragments that are secured to the opposite column.154,155,193 This technique may be difficult to achieve and not always possible to perform. For example, longer screws can deflect and bend as they pass one another, causing displacement of tenuously stabilized osteochondral fragments. 
Figure 35-25
A 21-year-old male sustained an intra-articular distal humerus fracture associated with a coronal shear fracture of the capitellum (A, B).
 
The capitellar fracture was fixated with a mini-fragment plate applied posteriorly and a headless compression screw. The articular segment was then rigidly linked to the humeral shaft with a parallel plating technique (C, D). C, capitellum.
The capitellar fracture was fixated with a mini-fragment plate applied posteriorly and a headless compression screw. The articular segment was then rigidly linked to the humeral shaft with a parallel plating technique (C, D). C, capitellum.
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Figure 35-25
A 21-year-old male sustained an intra-articular distal humerus fracture associated with a coronal shear fracture of the capitellum (A, B).
The capitellar fracture was fixated with a mini-fragment plate applied posteriorly and a headless compression screw. The articular segment was then rigidly linked to the humeral shaft with a parallel plating technique (C, D). C, capitellum.
The capitellar fracture was fixated with a mini-fragment plate applied posteriorly and a headless compression screw. The articular segment was then rigidly linked to the humeral shaft with a parallel plating technique (C, D). C, capitellum.
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My preference is that longitudinal K-wires are used to temporarily fix the reconstructed articular segment to the shaft to allow columnar plate application (Fig. 35-21F). Precontoured plates are then provisionally applied to the medial and lateral columns with K-wires placed distally and serrated bone reduction clamps proximally. Then, as many screws as possible are inserted through the plates into the articular segment (Fig. 35-21G); ideally the screws should be as long as possible and engage as many articular fragments as possible. Screws should not be placed through the olecranon fossa as they may lead to impingement. The plates are then fixated to the humeral shaft with the first diaphyseal screws inserted in an eccentric fashion to provide supracondylar fracture compression. Ideally, the plates should end at different levels on the humeral shaft to minimize the stress riser effect (Figs. 35-21H and I). Once ORIF of the distal humerus fracture is complete, the elbow is placed through a range of motion to ensure there is no impingement or instability. 
Metaphyseal bone loss may be present in high-energy comminuted distal humerus fractures. This bone loss can be addressed with supracondylar shortening or bridge plating with autologous bone graft or allograft. Supracondylar shortening involves removing the comminuted fragments of metaphyseal bone and compressing the reconstructed articular segment to the distal humeral shaft. Typically, the distal end of the shaft will require reshaping to increase the contact area between it and the articular segment.152 If absolute rigid fixation cannot be achieved to allow early range of motion, triple plating should be considered as recommended by Gofton6 and Jupiter and Mehne.93 Triple plating can also be useful for fixation of coronal plane fractures (Fig. 35-22). 
Several precontoured plating systems are available for fixation of distal humerus fractures. Although these plates are marketed as precontoured, they generally still require some contouring to match distal humeral anatomy. Newer precontoured locking plates are also available and are of two types, fixed angle locking and variable angle locking. These plates may offer enhanced fixation in osteopenic bone; however, this has not yet been shown to be clinically superior. The disadvantages of the fixed angle locking plates are the screws have predetermined trajectories, which may not accommodate all fracture patterns in all patients. In some plate designs, the predetermined screw trajectory aims toward the articular surface, which may predispose to joint penetration if screws are placed too long. 

Open Reduction Internal Fixation of Distal Humerus Fractures (Partial Articular Fractures)

Surgical Technique for AO/OTA Types B1 and B2 Fractures.
In general, the fixation principles and techniques used for AO/OTA type C (bicolumn) fractures are applicable to type B1 and B2 (single column) fractures. These fractures may be fixed with multiple screws or with single column plating.95 Single column plating has the advantage of providing an anti-glide construct at the proximal fracture line between the column and humeral shaft (Fig. 35-14). In certain highly comminuted partial–articular fractures in elderly patients with osteopenia, TEA may also be an appropriate treatment option. Elbow arthroplasty will be discussed later in this chapter. 
Surgical Technique for ORIF of Partial Articular Fractures
Surgical Technique for Capitellum Fractures ± Lateral Trochlear Ridge (AO/OTA Type B3.1).
Fractures of the capitellum with or without involvement of the lateral ridge of the trochlea can be approached through an extensile posterior skin incision or a direct lateral skin incision. The advantages of a posterior longitudinal skin incision are that it allows access both medially and laterally and it decreases the risk of cutaneous nerve injury.42 The deep lateral approach is via Kocher’s interval105 between anconeus and ECU. The arthrotomy is made anterior to the LUCL and is extended proximally along the anterior aspect of the lateral supracondylar ridge, which then allows access to the fractured capitellum. The fragment is typically anteriorly displaced and is reduced by elbow extension, forearm supination, and by application of a gentle varus force. Once an anatomic reduction is obtained the fragment is provisionally fixated with smooth small diameter K-wires. Permanent rigid internal fixation is obtained by countersunk screws138,202 placed anterior to posterior through the articular surface (Fig. 35-26), or by screws placed into the capitellum in a retrograde fashion from the posterior aspect of the lateral column, or by a combined method (Fig. 35-27). The placement of posterior to anterior screws has been shown to be biomechanically more stable and has the added clinical benefit of not violating the articular surface.48 In cases where rigid internal fixation is obtained, early active range of motion can be initiated. 
Figure 35-26
Fracture of the capitellum and the lateral ridge of the trochlea (A).
 
The double arc sign126 is evident on the lateral radiograph (arrow). One arc represents the subchondral bone of the capitellum and the other arc represents the lateral ridge of the trochlea. This patient underwent open reduction and internal fixation with three headless compression screws inserted anterior to posterior (B).
The double arc sign126 is evident on the lateral radiograph (arrow). One arc represents the subchondral bone of the capitellum and the other arc represents the lateral ridge of the trochlea. This patient underwent open reduction and internal fixation with three headless compression screws inserted anterior to posterior (B).
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Figure 35-26
Fracture of the capitellum and the lateral ridge of the trochlea (A).
The double arc sign126 is evident on the lateral radiograph (arrow). One arc represents the subchondral bone of the capitellum and the other arc represents the lateral ridge of the trochlea. This patient underwent open reduction and internal fixation with three headless compression screws inserted anterior to posterior (B).
The double arc sign126 is evident on the lateral radiograph (arrow). One arc represents the subchondral bone of the capitellum and the other arc represents the lateral ridge of the trochlea. This patient underwent open reduction and internal fixation with three headless compression screws inserted anterior to posterior (B).
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Figure 35-27
Fracture of the capitellum and lateral ridge of trochlea associated with a radial head fracture (A, B).
 
Through a posterior longitudinal skin incision, Kocher’s interval was used to approach the fractures for open reduction and internal fixation (C, D). C, capitellum; RH, radial head.
Through a posterior longitudinal skin incision, Kocher’s interval was used to approach the fractures for open reduction and internal fixation (C, D). C, capitellum; RH, radial head.
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Figure 35-27
Fracture of the capitellum and lateral ridge of trochlea associated with a radial head fracture (A, B).
Through a posterior longitudinal skin incision, Kocher’s interval was used to approach the fractures for open reduction and internal fixation (C, D). C, capitellum; RH, radial head.
Through a posterior longitudinal skin incision, Kocher’s interval was used to approach the fractures for open reduction and internal fixation (C, D). C, capitellum; RH, radial head.
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When there is comminution or impaction of the posterior aspect of the lateral column (Ring et al.181 type III and Dubberley et al.43 type B), it may prevent anatomic reduction of the anterior capitellar fracture. These impaction fractures may require disimpaction and possibly bone grafting to fill the bony defects. In case with severe posterior comminution that may compromise anterior articular fixation, supplemental posterior lateral column plating may be required. Capitellar fractures that involve the lateral epicondyle (Ring et al. type II) may be exposed by using the lateral epicondylar fracture as an osteotomy, reflecting the epicondylar fragment with the origin of the LCL distally (Fig. 35-28). After fixation of the capitellum, the lateral epicondyle fracture may be fixated with screws or a plate, if large enough. If the fragment is too small to fixate, it is treated as a lateral ligament tear with repair through bone tunnels. 
Figure 35-28
 
Posterolateral dislocation of the elbow associated with a capitellar fracture, lateral epicondyle fracture, and comminution and impaction of the posterior aspect of the lateral column (A–C). The lateral epicondyle fracture with the lateral collateral ligament (forceps) was reflected distally (D), allowing access to the free capitellar fragment (inset). Because of the posterior comminution, a posterolateral plate was required to support the articular segment (E).
Posterolateral dislocation of the elbow associated with a capitellar fracture, lateral epicondyle fracture, and comminution and impaction of the posterior aspect of the lateral column (A–C). The lateral epicondyle fracture with the lateral collateral ligament (forceps) was reflected distally (D), allowing access to the free capitellar fragment (inset). Because of the posterior comminution, a posterolateral plate was required to support the articular segment (E).
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Posterolateral dislocation of the elbow associated with a capitellar fracture, lateral epicondyle fracture, and comminution and impaction of the posterior aspect of the lateral column (A–C). The lateral epicondyle fracture with the lateral collateral ligament (forceps) was reflected distally (D), allowing access to the free capitellar fragment (inset). Because of the posterior comminution, a posterolateral plate was required to support the articular segment (E).
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Figure 35-28
Posterolateral dislocation of the elbow associated with a capitellar fracture, lateral epicondyle fracture, and comminution and impaction of the posterior aspect of the lateral column (A–C). The lateral epicondyle fracture with the lateral collateral ligament (forceps) was reflected distally (D), allowing access to the free capitellar fragment (inset). Because of the posterior comminution, a posterolateral plate was required to support the articular segment (E).
Posterolateral dislocation of the elbow associated with a capitellar fracture, lateral epicondyle fracture, and comminution and impaction of the posterior aspect of the lateral column (A–C). The lateral epicondyle fracture with the lateral collateral ligament (forceps) was reflected distally (D), allowing access to the free capitellar fragment (inset). Because of the posterior comminution, a posterolateral plate was required to support the articular segment (E).
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Posterolateral dislocation of the elbow associated with a capitellar fracture, lateral epicondyle fracture, and comminution and impaction of the posterior aspect of the lateral column (A–C). The lateral epicondyle fracture with the lateral collateral ligament (forceps) was reflected distally (D), allowing access to the free capitellar fragment (inset). Because of the posterior comminution, a posterolateral plate was required to support the articular segment (E).
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Rigid internal fixation of the Kocher-Lorenz117,126 or conventional type II osteochondral fractures is difficult as the fragments are thin and may be comminuted. Treatment options for these fractures include attempted fixation with bioabsorbable pins, excision of the fragment, osteochondral grafts, or capitellar arthroplasty. 
Surgical Technique for Capitellum and Trochlea Fractures (AO/OTA Type B3.3).
Capitellar fractures that involve a large portion of the trochlea also require anatomic reduction and rigid internal fixation. Generally, these fractures require improved exposure of the medial trochlea and several surgical approach options exist. The LCL origin on the lateral epicondyle can be released to allow the elbow to be hinged open laterally. By releasing the anterior and posterior joint capsules the distal humerus articular surface is booked open on the intact MCL. A similar approach utilizes a lateral epicondylar fracture, which may be reflected distally to hinge open the elbow joint. In addition, medial joint exposure can be obtained by a separate medial approach, such as the flexor–pronator split or the Hotchkiss medial “over-the-top” approach. Finally, an olecranon osteotomy can be used to obtain optimum distal humerus articular exposure. 
Once exposed, these fractures are rigidly secured with small diameter headless compression or standard countersunk screws inserted antegrade, or with standard screws inserted retrograde. Fractures that are comminuted or have epicondylar involvement may benefit from additional plate application. Bone grafting may also be required for fractures that are comminuted or impacted. 
Isolated trochlear fractures (AO/OTA type B3.2) are rare and should be treated with ORIF. Fixation may be done antegrade through the cartilage or retrograde from posterior through a medial deep approach. 
Surgical Technique for Arthroscopic Reduction and Percutaneous Fixation.
Arthroscopic reduction and percutaneous cannulated screw fixation is a described technique for treatment of isolated fractures of the capitellum.109 The indications are narrow and include an acute, noncomminuted, simple, isolated fracture of the capitellum. Relative contraindications are associated comminution, posterolateral impaction, delayed presentation, and associated instability. 
The technique is demanding and a prerequisite is experience with elbow arthroscopy. Generally, the set up involves arthroscopic equipment and instruments, intraoperative fluoroscopy, and cannulated screw instrumentation. The patient is positioned lateral decubitous with the affected elbow flexed over an arthroscopic elbow positioner. A sterile tourniquet is used and a C-arm fluoroscopy unit is positioned such that appropriate intraoperative images can be obtained during arthroscopy. The standard arthroscopy portals are marked and the elbow joint is entered anteriorly. The hemarthrosis is evacuated and the displaced capitellar fracture visualized. It is the author’s preference to now switch the camera to view the radiocapitellar joint from posterior. Through the posterolateral radiocapitellar portal, the radial head and the fracture bed of the capitellum will be visiable. A closed reduction is now conducted as outlined in the previous section on closed reduction and casting. The articular reduction, once obtained, will be visible from the posterolateral portal (Fig. 35-29) and can also be confirmed by viewing from anterior. Following an anatomic reduction, percutaneous cannulated screws can be placed posterior to anterior into the capitellum using fluoroscopic assistance. 
Figure 35-29
Radiograph and three-dimensional CT of a simple displaced fracture of the capitellum and lateral trochlea (A, B).
 
An arthroscopic reduction with percutaneous cannulated screw fixation was done. Viewing from the posterolateral portal, the radial head, proximal radioulnar joint, and the fracture bed of the capitellum are visible (C). After a reduction maneuver, the fracture reduction is assessed arthroscopically (D) and fluoroscopically (E). At 1-year follow-up after screw fixation, radiographs (F, G) demonstrate anatomic healing.
An arthroscopic reduction with percutaneous cannulated screw fixation was done. Viewing from the posterolateral portal, the radial head, proximal radioulnar joint, and the fracture bed of the capitellum are visible (C). After a reduction maneuver, the fracture reduction is assessed arthroscopically (D) and fluoroscopically (E). At 1-year follow-up after screw fixation, radiographs (F, G) demonstrate anatomic healing.
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Figure 35-29
Radiograph and three-dimensional CT of a simple displaced fracture of the capitellum and lateral trochlea (A, B).
An arthroscopic reduction with percutaneous cannulated screw fixation was done. Viewing from the posterolateral portal, the radial head, proximal radioulnar joint, and the fracture bed of the capitellum are visible (C). After a reduction maneuver, the fracture reduction is assessed arthroscopically (D) and fluoroscopically (E). At 1-year follow-up after screw fixation, radiographs (F, G) demonstrate anatomic healing.
An arthroscopic reduction with percutaneous cannulated screw fixation was done. Viewing from the posterolateral portal, the radial head, proximal radioulnar joint, and the fracture bed of the capitellum are visible (C). After a reduction maneuver, the fracture reduction is assessed arthroscopically (D) and fluoroscopically (E). At 1-year follow-up after screw fixation, radiographs (F, G) demonstrate anatomic healing.
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The outcome studies on arthroscopic reduction and percutaneous screw fixation are few. Kuriyama et al.109 described a case report of two patients and Hardy et al.72 of one patient, all with good outcomes and healing at short term follow-up. 
Implant Biomechanics for ORIF.
Controversy exists on which implant designs and plate configurations confer the greatest amount of stability when treating distal humerus fractures. Jacobson et al.89 tested five different distal humerus plating constructs in cadaveric specimens. They reported that a medially applied 3.5-mm reconstruction plate along with an orthogonally applied posterolateral 3.5-mm dynamic compression plate provided the greatest sagittal plane stiffness, and equivalent frontal plane and torsion stiffness, when compared to other constructs which included parallel and triple plating. Helfet and Hotchkiss75 also found that orthogonal plating provided greater rigidity and fatigue resistance when compared to a single “Y” plate or crossed screws. 
In contrast, Schemitsch et al.197 found that parallel plating with a medial 3.5-mm reconstruction plate and a lateral “J” plate had the greatest construct rigidity when compared to four other plate configurations, including orthogonal plating with 3.5-mm reconstruction plates. Self et al.200 found that parallel plating trended toward having greater rigidity and load to failure than orthogonal plating; however, the differences did not reach statistical significance. Arnander et al.,12 however, found that two 3.5-mm reconstruction plates applied in a parallel fashion did have statistically significant increased stiffness and strength in the sagittal plane when compared to two 3.5-mm reconstruction plates applied orthogonally. 
Locking plates have several theoretical advantages, especially when used in patients with severe osteopenia. Schuster et al.199 demonstrated that locking 3.5-mm reconstruction plates applied orthogonally had superior cyclic failure properties when compared to conventional nonlocked plates applied in a similar fashion in cadavers with low bone mineral density. Stoffel et al.210 compared the mechanical stability of two different commercially available precontoured locking distal humeral plating systems. They reported significantly higher stability in compression, external rotation, and a greater ability to resist axial plastic deformation in the parallel plate system versus the orthogonal plate system. It should be noted that no clinical difference has yet been demonstrated between parallel and orthogonal plating, and more likely than not, both are acceptable as long as the principles of rigid internal fixation are met. 
On the contrary, there is no debate in the use of 1/3 tubular plates, which have been shown to have insufficient strength and are susceptible to breakage.80,154,155,216 These plates should not be used in the primary two-plate construct; however, they may be used as a supplementary third plate. 
Postoperative Care.
Patients are placed in a well-padded plaster extension splint applied anteriorly and are encouraged to keep the arm elevated to minimize swelling. Active hand range of motion is started immediately. Elbow range of motion is started between days 2 and 7 postoperatively, depending on the status of the incision. Generally, active-assisted and active range of motion are encouraged (flexion, extension, pronation, and supination) for patients with a paratricipital approach or an olecranon osteotomy fixated with a plate. Passive extension is reserved for patients who underwent an extensor mechanism disrupting approach. Typically, a night extension splint is used for the first 6 weeks. At 6 weeks post operation, passive stretching and static progressive splinting are used if required. Strengthening may begin at 12 weeks, provided there is evidence of radiographic union. 
Potential Pitfalls and Preventative Measures.
Surgical reconstruction of a comminuted intra-articular distal humerus fracture requires a systematic approach, starting with the appropriate exposure and concluding with stable fixation in order to initiate early motion. Potential pitfalls include an ineffective exposure such as using a paratricipital approach to visualize and conduct ORIF on a highly comminuted distal humerus articular segment. Advanced approaches, such as an olecranon osteotomy or another extensor mechanism releasing approach, should be considered for effective visualization. The choice of plates with insufficient strength, such as semi-tubular plates, has been shown to increase the rate of implant failure, nonunion, and malunion. This is no longer an issue with commercially available fracture-specific contoured plating systems, which tend to have plates of sufficient strength. Other potential pitfalls include intra-articular screws, screws placed into the olecranon fossa resulting in impingement, decreasing the width of a comminuted trochlea fracture with lag screws, and radial nerve injury with placement of a long lateral plate. The above mentioned complications are preventable with awareness and sound surgical technique. Please see Table 35-4 for other potential pitfalls and their preventions. 
Table 35-4
Potential Pitfalls and Preventions for ORIF of Distal Humerus Fractures
Distal Humerus Fracture
Potential Pitfalls and Preventions
Pitfall Prevention
Missed skin tenting, excessive swelling, fracture blisters Application of a well-padded splint while awaiting surgery
Re-check skin, soft tissues, and neurovascular status immediately before surgery
Unrecognized coronal shear fractures and articular comminution (fracture line between medial trochlea and medial epicondyle) CT scan for complex fracture patterns (preferred) or traction radiographs
Appropriate surgical approach for visualization
Have supplementary fixation available (headless compression screws, threaded K-wires, and/or bioabsorbable pins)
Failure to recognize bone loss in open fractures CT scan for complex fracture patterns
Be prepared for bone grafting by adding it to the surgical consent form and by prepping and draping the iliac crest.
Understand technique of supracondylar shortening
Ineffective surgical exposure Critically examine fracture pattern and choose an approach that balances required visualization for ORIF vs. complications
Understand extensile options
Irreparable distal humerus fracture with comminution and osteopenia in an elderly patient Be prepared for total elbow arthroplasty, add to consent, and have the system available
Conduct a surgical approach that is conducive for elbow arthroplasty
Radial nerve injury with placement of a long lateral plate Understand radial nerve anatomy
Radial nerve identification and protection for “high” lateral column fractures
Inadequate fixation of “low” transcolumn fractures Place as many screws as possible into the distal articular segment
Use fracture-specific plates that allow high-density distal screw placement
Screws placed across the olecranon fossa causing impingement Use fluoroscopy to ensure all hardware is extra-articular and of appropriate length
Check elbow range of motion to ensure there is no impingement
Visually confirm the absence of intra-articular or impinging screws
Supracondylar nonunion Compress the articular segment to the shaft with plate compression technique
Be prepared to bonegraft or conduct supracondylar shortening in cases with bone loss
Ulnar neuropathy Identify and protect ulnar nerve during surgical approach and ORIF
Preoperative neurologic examination to document pre-existing nerve injuries
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Treatment-Specific Outcomes
Outcomes of ORIF of Extra-articular and Complete-Articular Fractures.
When the principles of anatomic restoration of the joint surface, bicolumn plating, and rigid internal fixation to allow early range of motion are employed, good outcomes can be expected for patients with intra-articular distal humerus fractures.6,13,41,47,57,67,69,82,159,160,161,190,193,205,216,229 When15,50,113,115,175 averaging the outcomes of 21 series published between 2002 and 2012 (Table 35-5), 85% of patients experienced good to excellent outcomes at a mean follow-up of 50 months. Doornberg et al.41 have shown that the rate of good to excellent outcomes is durable in the long term (12 to 30 years). Patients who sustain isolated intra-articular fractures of the distal humerus can expect some loss of elbow range of motion, although, functional range of motion (30 to 130 degrees) is usually attained. As would be expected, patients who sustain distal humerus fractures in association with polytrauma or severe soft tissue injuries can anticipate worse outcomes. 
Table 35-5
Summary of Outcomes of AO/OTA Type C (Intra-articular) Distal Humerus Fractures
Author Year Number of Fractures Average Age of Patients (Range) Percentage of Open Fractures Surgical Approach Average Follow-up in Months (Range) Outcome Assessment Used Percentage with Excellent or Good Outcomes Percentage with Satisfactory or Poor Outcomes
Pajarinen161 2002 18 44 (16–81) 28 OOa 25 (10–41) OTA 56 44
Ozdemir159 2002 34 38 (20–78) 15 OO 82 (24–141) Jupiter 62 38
Gupta69 2002 55 39 (18–65) 11 13 OO
42 TS
48 (24–108) Aitken 93 7
Robinson189 2003 119 53 (13–99) 15 OO 19 (5–32) n/a n/a n/a
Gofton64 2003 23 45 (14–89) 30 OOa 45 (14–89) DASH, PRUNE, ASES-e, SF-36 93 7
Yang229 2003 17 41 (16–69) 29 OO 17 (13–38) MEPS 88 12
Frankle57 2003 12 74 (65–86) 0 10 OO; 2 TS 57 (24–78) MEPS 67 33
Allende6 2004 40 42 (16–77) 25 31 OO; 9 TR 47 (13–94) Jupiter, OTA 85 15
Aslam13 2004 26 56 (18–82) 12 OO 35 (24–48) Broberg/Morrey 70 30
Soon205 2004 12 43 (21–80) 0 5 OO; 7 TS 11 (2–21) MEPS 92 8
Huang82 2005 19 72 (65–79) 5 OO 97 (60–174) Cassebaum, MEPS 100 0
Ozer160 2005 11 58 (16–70) 27 TRAP 26 (14–40) OTA 91 9
Sanchez-Sotelob193 2007 34 58 (16–99) 41 17 TRAP
5 OO
8 PT
2 BM
2 TT
24 (12–60) MEPS 84 16
Doornberg41 2007 30 35 (13–64) 30 20 OO 19 yrs (12–30 yrs) DASH
ASES-e
MEPS
87 13
Ek47 2008 7 41 (12–73) 14 BM 35 (6–78) MEPS, SF-36
DASH
100 0
Greinerb67 2008 12 55 (21–83) 42 OOa 10 (6–14) MEPS
DASH
100 0
Athwal15 2009 32 56 (19–88) 31 18 OO
12 TRAP
1 PT
1 TT
27 (12–54) MEPS
DASH
69 31
Liu115 2009 32 69 (62–79) n/a OO 24.5 (14–60) MEPS 100 0
Li113 2011 56 50 (18–70) 23 OO 30 (6–70) ROM n/a n/a
Puchwein175 2011 22 43 (15–88) 27 19 OOa 69 ± 33 Cassebaum
Jupiter
Quick-DASH
82 18
Erpeldingb,50 2012 17 47 (18–85) 21 PT 27 (5–82) MEPS
DASH
92 8
Total/Mean 628 50 21 47 85 15
 

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.

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Gofton et al.64 reported the patient-rated outcomes and physical impairments after orthogonal plating of AO/OTA type C distal humerus fractures in 23 patients. The SF-36 scores of patients at final follow-up compared to age- and sex-matched controls showed no significant differences. Patients rated their overall satisfaction at 93% and on functional assessment indicated a 10% subjective loss of function when comparing the affected to unaffected limb. The mean score on the DASH questionnaire was 12, which is very close to the overall normative score of 10.1.84 The isometric strength of the affected elbow was significantly reduced in all ranges, although, grip and pinch strength were not statistically different between affected and unaffected limbs. McKee et al.130 also found decreased strength in the affected elbows and rated it at approximately 75% of normal. The mean DASH score was 20 points, indicating a mild residual impairment. Two of the eight parameters of the SF-36, physical function, and role-physical, demonstrated small but significant differences between age-matched controls. 
Outcomes of ORIF of Partial Articular Fractures.
The outcomes after ORIF of capitellar fractures with or without involvement of the lateral trochlear ridge have been shown to be predictably good.34,43,54,65,87,120,138,172,179,181,196,202 More complex fracture patterns with involvement of the anterior trochlea also have a relatively good prognosis43,126,181,208; however, Dubberley et al.43 have shown that the outcomes do deteriorate with increasing fracture complexity. 

Total Elbow Arthroplasty for Distal Humerus Fractures

Indications/Contraindications.
Nonoperative treatment of distal humerus fractures, although appropriate for some elderly patients, often leads to loss of motion and unsatisfactory functional outcomes. Open reduction and rigid internal fixation is considered gold standard; however, it may not be attainable in elderly patients with osteopenia, comminution, and articular fragmentation or in patients with pre-existing conditions of the elbow such as RA (Fig. 35-30). In cases where rigid internal fixation cannot be achieved to allow early range of motion, resultant prolonged immobilization often leads to poor outcomes.4 TEA for such fractures is a reliable treatment option with good outcomes.11,57,60,74,97,98,99,112,147,149,173 
Figure 35-30
 
AP and lateral radiographs of a 79-year-old woman with rheumatoid arthritis and a displaced intra-articular medial column fracture (A, B) managed with a linked total elbow arthroplasty via a paratricipital approach (C, D).
AP and lateral radiographs of a 79-year-old woman with rheumatoid arthritis and a displaced intra-articular medial column fracture (A, B) managed with a linked total elbow arthroplasty via a paratricipital approach (C, D).
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Figure 35-30
AP and lateral radiographs of a 79-year-old woman with rheumatoid arthritis and a displaced intra-articular medial column fracture (A, B) managed with a linked total elbow arthroplasty via a paratricipital approach (C, D).
AP and lateral radiographs of a 79-year-old woman with rheumatoid arthritis and a displaced intra-articular medial column fracture (A, B) managed with a linked total elbow arthroplasty via a paratricipital approach (C, D).
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Absolute contraindications to TEA for distal humerus fractures include active infection and insufficient soft tissue coverage. The most important relative contraindication to elbow replacement for trauma is the younger active patient who is more appropriate for ORIF. Elderly patients with low-energy Gustilo and Anderson grade I open fractures are not an absolute contraindication to elbow arthroplasty. Generally, the wounds are punctures that are small and clean. However, if there has been a time delay until open fracture management or the cleanliness of a wound is questioned, a staged procedure with initial irrigation and debridement followed by splinting and antibiotics until definitive surgery is deemed appropriate. 
Distal humerus hemiarthroplasty is another surgical option for unreconstructible partial articular fractures (Fig. 35-31). In cases with severe articular destruction with preserved columns and collateral ligaments, hemiarthroplasty presents an attractive option that resurfaces the damaged articulation. The theoretical advantage of a hemiarthroplasty is the absence of polyethylene wear debris and the associated osteolysis; however, it is a technically demanding procedure and no literature exists to support its use over TEA. Further studies are required to determine the role of distal humerus hemiarthroplasty in elbow trauma. 
Figure 35-31
Fractures of the capitellum, trochlea, and lateral epicondyle (A) with associated osteochondral fragmentation (B) in a 78-year-old active woman.
 
As the fracture was deemed unrepairable intraoperatively, hemiarthroplasty was done via an approach that hinged open the elbow on the intact medial collateral ligament (C, D). The lateral epicondyle fracture was fixated with sutures through the axis of the implant (arrow) and with a precontoured unicortical plate (E, F).
As the fracture was deemed unrepairable intraoperatively, hemiarthroplasty was done via an approach that hinged open the elbow on the intact medial collateral ligament (C, D). The lateral epicondyle fracture was fixated with sutures through the axis of the implant (arrow) and with a precontoured unicortical plate (E, F).
View Original | Slide (.ppt)
As the fracture was deemed unrepairable intraoperatively, hemiarthroplasty was done via an approach that hinged open the elbow on the intact medial collateral ligament (C, D). The lateral epicondyle fracture was fixated with sutures through the axis of the implant (arrow) and with a precontoured unicortical plate (E, F).
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Figure 35-31
Fractures of the capitellum, trochlea, and lateral epicondyle (A) with associated osteochondral fragmentation (B) in a 78-year-old active woman.
As the fracture was deemed unrepairable intraoperatively, hemiarthroplasty was done via an approach that hinged open the elbow on the intact medial collateral ligament (C, D). The lateral epicondyle fracture was fixated with sutures through the axis of the implant (arrow) and with a precontoured unicortical plate (E, F).
As the fracture was deemed unrepairable intraoperatively, hemiarthroplasty was done via an approach that hinged open the elbow on the intact medial collateral ligament (C, D). The lateral epicondyle fracture was fixated with sutures through the axis of the implant (arrow) and with a precontoured unicortical plate (E, F).
View Original | Slide (.ppt)
As the fracture was deemed unrepairable intraoperatively, hemiarthroplasty was done via an approach that hinged open the elbow on the intact medial collateral ligament (C, D). The lateral epicondyle fracture was fixated with sutures through the axis of the implant (arrow) and with a precontoured unicortical plate (E, F).
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Preoperative Planning.
TEA is a technically demanding procedure and should be done by an experienced upper limb or trauma surgeon. As with ORIF, anteroposterior and lateral radiographs of the elbow out of plaster are usually sufficient to determine the fracture pattern. If the feasibility of ORIF is questioned in an elderly patient, a CT scan may assist with the preoperative decision making. 
Preoperatively, elbow radiographs should be templated to ensure implants of the appropriate size and lengths are available. Associated fractures or unique fracture patterns that may complicate elbow arthroplasty must be examined for, including proximal ulnar shaft fractures, olecranon fractures, and proximal fracture extension into the humeral diaphysis. While awaiting surgery, patients are placed in a well-padded elbow splint and are encouraged to elevate the arm, ice the elbow, and to maintain hand and finger range of motion. On the day of surgery, the skin and soft tissues are re-examined and the neurologic status is redocumented. 
Positioning.
Patients generally receive a general anesthetic with an upper extremity regional block for postoperative pain control and therapy. The patient is positioned supine with a bolster placed under the ipsilateral scapula and the elbow is supported by another bolster made of wrapped sterile sheet on the patient’s chest (Fig. 35-13). The surgeon and assistant stand on the side of the injury while the scrub nurse and arthroplasty instruments are on the contralateral side, allowing the nurse to assist with arm positioning as required. A sterile tourniquet is used. Before starting the operative procedure and inflating the tourniquet, prophylactic antibiotics are administered intravenously. 
Surgical Approach(es).
In general, posterior approaches are preferred in the exposure of distal humerus fractures in preparation for elbow arthroplasty. Although all posterior approaches may be used for arthroplasty, some have advantages over others. The paratricipital approach has the advantage of maintaining complete integrity of the extensor mechanisms while its disadvantage is that it increases the complexity of the procedure because it provides less visualization of the proximal ulna. The triceps splitting, triceps reflecting, and triceps dividing approaches all provide good visualization of the elbow joint; however, they all disrupt the triceps insertion in one way or another, and therefore require postoperative protection. Conducting a TEA through an olecranon osteotomy is possible, however, not encouraged. Ulnar component fixation may be compromised with certain implant designs. There are also concerns with osteotomy healing after disruption of the intramedullary blood supply by ulnar component cementation. 
My preferred approach for fractures deemed unreparable preoperatively, where the surgical plan is to proceed directly to TEA, is the paratricipital approach. This is also my preferred approach if an attempt at ORIF is planned for less comminuted articular fractures. In circumstances with high articular comminution in the elderly, where a complete attempt at ORIF is planned, with the intraoperative bailout being a TEA, I prefer the triceps split approach. The triceps split approach affords the best visualization of the joint for a complete attempt at ORIF, while still leaving the option open for a TEA if rigid internal fixation cannot be achieved. 
Another approach commonly used for TEA is the Bryan-Morrey approach.26 The approach has been termed “triceps-sparing” which has led to confusion. The approach does not “spare” the triceps, but rather detaches the triceps tendon in continuity with the ulnar periosteum and anconeus creating a large reflection or sleeve. The ulnar nerve is first identified and protected, and then the triceps insertion and the ulnar periosteum are sharply reflected off the proximal ulna in a medial to lateral direction (Fig. 35-32). The sleeve of tissue created incorporates the anconeus muscle. As with the triceps splitting approach, careful and solid repair of the triceps tendon is required via transosseous sutures. It is my preference not to use approaches that detach the extensor mechanism during arthroplasty for fracture; however, the Bryan-Morrey approach does allow better visualization of the joint, specifically the proximal ulna for ulnar component preparation and insertion. 
Figure 35-32
The Bryan-Morrey26 approach is commonly used for total elbow arthroplasty.
 
A posterior longitudinal skin incision is used and the ulnar nerve is identified and protected. The ulnar periosteum, triceps insertion, and anconeus muscle are sharply reflected off the proximal ulna in a medial (A) to lateral (B) direction. To access the articular surfaces for arthroplasty, the collateral ligaments are released.
A posterior longitudinal skin incision is used and the ulnar nerve is identified and protected. The ulnar periosteum, triceps insertion, and anconeus muscle are sharply reflected off the proximal ulna in a medial (A) to lateral (B) direction. To access the articular surfaces for arthroplasty, the collateral ligaments are released.
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Figure 35-32
The Bryan-Morrey26 approach is commonly used for total elbow arthroplasty.
A posterior longitudinal skin incision is used and the ulnar nerve is identified and protected. The ulnar periosteum, triceps insertion, and anconeus muscle are sharply reflected off the proximal ulna in a medial (A) to lateral (B) direction. To access the articular surfaces for arthroplasty, the collateral ligaments are released.
A posterior longitudinal skin incision is used and the ulnar nerve is identified and protected. The ulnar periosteum, triceps insertion, and anconeus muscle are sharply reflected off the proximal ulna in a medial (A) to lateral (B) direction. To access the articular surfaces for arthroplasty, the collateral ligaments are released.
View Original | Slide (.ppt)
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Technique.
Generally, a linked design of TEA should be used in the setting of distal humerus fracture. Unlinked designs may be used; however, great care must be taken in anatomically reducing and rigidly fixing the medial and lateral columns. Anatomic fixation of the columns allows appropriate tensioning of the MCLs and LCLs, which are required for unlinked implant stability. 
The key steps for insertion of a linked elbow arthroplasty are discussed via a paratricipital approach. McKee et al.131 have shown that condylar resection during TEA does not affect strength or functional outcome; therefore, through the medial arthrotomy while protecting the ulnar nerve, the MCL is released and the medial fracture fragments are excised. Similarly, through the lateral arthrotomy the LCL complex is released and the lateral fracture fragments are excised. The distal humeral shaft with the remaining metaphyseal bone can now be delivered from under the triceps and ulna. The humerus is then prepared following the steps outlined in the technical manual of the implant being used. Usually, the metaphyseal cutting blocks are not required, as the fractured condyles have already been excised. The keys to judging correct humeral component rotation are to examine the trefoil shape of the distal humerus shaft, as the posterior cortex is typically externally rotated about 14 degrees relative to the elbow flexion–extension axis.192 Reaming and broaching of the humeral canal is done as described in the technical manual and the canal is sized for a cement restrictor. The length of the humerus and the level of the joint line must also be re-created. This is done by placing the resected condyles onto the remaining humeral shaft to measure the location of the joint line. The tension in the soft tissues can also be used to judge appropriate humeral component length, once trial components are in place. Most humeral components are designed with an anterior flange that accepts a bone graft, which can be prepared from resected bone fragments. 
Preparation of the ulna with the paratricipital approach requires strategic retractor and arm positioning. The proximal ulna is delivered medial to the humeral shaft to avoid excessive tension on the ulnar nerve. The forearm is then rotated 90 degrees, the elbow is flexed, and a rake retractor is used to draw back the triceps insertion to allow exposure of the greater sigmoid notch. The tip of the olecranon may be excised to improve visualization of the greater sigmoid notch. The ulna is prepared as per the manufacturer’s recommendations. As with the humerus, particular attention should be taken to ensure correct ulnar component placement. The correct rotation of the ulnar component can be determined by ensuring the axis of rotation bisects the radial head and by ensuring the axis is parallel to the flat surface on the proximal dorsal ulna.44 
It is recommended that antibiotic laden bone cement be used and cement restrictors for the humeral and ulnar canals.53 Cement is inserted into the humerus first with a small diameter nozzle and then into the ulna. The ulnar cement is manually pressurized and the component is inserted followed by pressurization of the humeral cement and humeral component insertion. Excess bone cement is removed and the components are held still until the cement has cured. In cases with extremely small ulnar canals, an extra small cement injection nozzle may be required. The humeral and ulnar components can be cemented together as described or separately. Once cured, a wedge of bonegraft fashioned from the resected articular segment is placed underneath the anterior flange of the humeral component. The components are then linked and the elbow is taken through a range of motion to ensure there is no impingement. Conversely, the implants can be linked just after insertion and the elbow placed into extension until the cement cures. 
Postoperative Care.
After the surgical procedure, the elbow is splinted in extension with an anteriorly applied slab of plaster. The arm is elevated for 24 hours and active hand range of motion is started immediately. Elbow range of motion is started between days 7 and 10 days postoperatively, depending on the status of the incision and soft tissues. Generally, unrestricted active range of motion is encouraged (flexion, extension, pronation, and supination) for patients with a paratricipital approach while patients with a triceps split approach are restricted to gravity-assisted extension for 6 weeks to protect the triceps repair. 
Potential Pitfalls and Preventative Measures.
TEA for fracture should be conducted by an experienced trauma or upper extremity surgeon. The operative procedure requires a systematic approach, starting with the correct indications, the appropriate surgical approach, and adherence to the technical steps to ensure correct implantation and alignment. Potential pitfalls (Table 35-6) include an ineffective exposure, such as using an olecranon osteotomy to approach an unreconstructable distal humerus fracture in an elderly patient. Typically, for distal humerus fractures undergoing arthroplasty, a triceps-on approach is preferred. Other potential pitfalls are incorrect implant selection and alignment. In general, a linked TEA is preferred for the management of distal humerus fractures. Although unlinked designs may be used, they are technically challenging as anatomic fixation of the epicondylar fractures and repair of the ligaments would be required to ensure implant stability. Misalignment of the implants must also be prevented. Sabo et al.192 identified that in cases of distal humeral bone loss, where anatomic landmarks for alignment are absent, the flat posterior humeral cortical line can be used to refer correct humeral component rotation. Typically, the anatomic elbow flexion–extension axis is rotated 14 degrees internally relative to the posterior humeral cortex. The above mentioned pitfalls are preventable with awareness and good surgical technique. 
Table 35-6
Potential Pitfalls and Preventions of Total Elbow Arthroplasty for Distal Humerus Fractures
Total Elbow Arthroplasty for Distal Humerus Fracture
Potential Pitfalls and Preventions
Pitfall Prevention
Missed skin tenting, excessive swelling, fracture blisters Application of a well-padded splint while awaiting surgery
Re-check skin, soft tissues, and neurovascular status immediately before surgery
Ineffective surgical exposure Choose an approach that balances required visualization for arthroplasty vs. complications; recommend leaving triceps attached to olecranon
Understand extensile options
Inadequate exposure of ulna Resect tip of olecranon to improve access to ulna
Incorrect humeral component height (re-creation of joint line/axial position of the flexion–extension axis) Loosely reapproximate resected epicondylar fragments to the humeral shaft to judge the location of the elbow flexion–extension axis
Incorrect humeral component rotation The humeral component should typically be 14 degrees internally rotated as compared to the flat posterior humeral cortex
Malposition ulna The rotational axis of the ulnar component should bisect the radial head, and should be parallel to the ulnar flatspot
Osseous impingement The elbow should be placed through a range of motion to ensure there is no bony impingement with the implant. The tip of the olecranon or coronoid may require resection
Ulnar neuropathy Identify and protect ulnar nerve during surgical approach and during arthroplasty
Preoperative neurologic examination to document pre-existing nerve injuries
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Treatment-Specific Outcomes.
The outcomes of TEA for distal humerus fractures at short-term and midterm follow-up have been reproducibly good (Table 35-7).9,11,31,57,60,74,97,98,99,112,147,149,173 Most studies have used the Coonrad-Morrey implant (Zimmer, Warsaw IN), which is linked and described as semi-constrained because of its “sloppy” hinge. 
Table 35-7
Summary of Outcomes of Total Elbow Arthroplasty for the Management of Distal Humerus Fractures190
Author Year Number of Patients Average Age of Patients (Range) Surgical Approach Average Follow-up in Months Range of Motion (Arc) Outcome Assessment Used Percentage with Excellent or Good Outcomes Complications
Gambirasio59 2001 10 85 (57–95) Bryan-Morrey 18 101 MEPS 100% 1 HO, 1 CRPS
Garcia60 2002 16 73 (61–95) Triceps split 36 101 MEPS, DASH 100% 1 UN, 1 HO
Frankle57 2003 12 72 (65–88) Bryan-Morrey 45 113 MEPS 100% 2 UN, 1 UP, 1 H, 1 DS
Kamineni98 2004 43 69 (34–92) Bryan-Morrey 84 107 MEPS 93% 7 HO, 4 BW, 3 UIF, 1 HIF, 5 H, 1 DS
Lee112 2006 7 73 (55–85) Bryan-Morrey 25 89 MEPS 100%
Kalogrianitis97 2008 9 73 (45–86) Triceps split 42 118 MEPS, LES 88% 1 SS
Prasad173 2008 15 78 (61–89) Triceps tongue 56 93 MEPS 85% 1 CRPS, 1 AS-U
Chalidis31 2009 11 79 (75–86) Bryan-Morrey 33 107 MEPS 100% 1 UN, 1 PF
Antuna9 2012 16 76 (57–89) Paratricipital (14)
Olecranon osteotomy (2)
57 90 DASH, VAS, Patient subjective assessment 69% 8 UN, 3 DS
Total/Mean 139 75 44 102 93%
 

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.

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In a retrospective study, Frankle et al. compared ORIF to elbow arthroplasty in women over the age of 65 years with AO/OTA type C distal humerus fractures. They reported improved outcomes in the arthroplasty group at short-term follow-up. The small sample size and selection bias, however, confounds the interpretation of the results because eight patients in the arthroplasty group had RA and none had RA in the ORIF group. McKee et al.132 conducted a randomized prospective study comparing ORIF to elbow arthroplasty in elderly patients with comminuted distal humerus fractures. Outcomes were assessed with the MEPS and DASH score. Twenty-one patients were initially randomized into the two treatment groups; however, five patients randomized to ORIF were intraoperatively converted to arthroplasty. At 2 years follow-up, the MEPS was significantly better in the TEA group; however, the DASH score was not significantly different between groups. The reoperation rate between the arthroplasty and the ORIF groups was also not significantly different. 
At the present time, there are no mid-term or long-term studies comparing the outcomes and complications of ORIF to TEA for the treatment of complex distal humerus fractures in the elderly. It is probable that the revision surgery rate would increase over time in patients treated with elbow arthroplasty, when compared to patients undergoing ORIF, because of polyethylene wear, aseptic loosening, periprosthetic fracture, and infection. 

Hemiarthroplasty for Distal Humerus Fractures

Hemiarthroplasty is another surgical option for unreconstructible distal humerus fractures. This procedure has been described in the past137,201,211 and has recently experienced a renewed interest.2,28,83,212 Two commercially available elbow arthroplasty systems have humerus implants that replicate the distal humeral articular surface, the Sorbie-Questor (Wright Medical Technology, Arlington, TN) and the Latitude (Tornier, Stafford, TX), and therefore can be used for hemiarthroplasty (Fig. 35-33). The added benefit of the Latitude hemiarthroplasty is that it can be converted to a linked or unlinked TEA. This is beneficial if intraoperative hemiarthroplasty stability cannot be achieved necessitating conversion to TEA. Other systems that have nonanatomic humeral components, such as the Kudo2,3 (Biomet Inc., Warsaw, IN, USA), have also been used for hemiarthroplasty. The use of nonanatomic components, however, is not recommended. 
Figure 35-33
 
The Sorbie-Questor (Wright Medical Technology, Arlington, TN) (A) and the Latitude (Tornier, Stafford, TX) total elbow system (B) are two commercially available arthroplasty systems that have humeral implants that replicate the distal humeral articular anatomy, and therefore can be used for hemiarthroplasty.
The Sorbie-Questor (Wright Medical Technology, Arlington, TN) (A) and the Latitude (Tornier, Stafford, TX) total elbow system (B) are two commercially available arthroplasty systems that have humeral implants that replicate the distal humeral articular anatomy, and therefore can be used for hemiarthroplasty.
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Figure 35-33
The Sorbie-Questor (Wright Medical Technology, Arlington, TN) (A) and the Latitude (Tornier, Stafford, TX) total elbow system (B) are two commercially available arthroplasty systems that have humeral implants that replicate the distal humeral articular anatomy, and therefore can be used for hemiarthroplasty.
The Sorbie-Questor (Wright Medical Technology, Arlington, TN) (A) and the Latitude (Tornier, Stafford, TX) total elbow system (B) are two commercially available arthroplasty systems that have humeral implants that replicate the distal humeral articular anatomy, and therefore can be used for hemiarthroplasty.
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Indications/Contraindicaitons.
The indications for distal humerus hemiarthroplasty are virtually identical to TEA. The theoretical advantage of a hemiarthroplasty is the absence of polyethylene wear debris and the associated osteolysis and aseptic loosening which are common modes of failure with total elbow arthroplasties. Hemiarthroplasty, therefore, may function as an “in between” in those patients with unreconstructible distal humerus fractures who are deemed too young or too active for TEA. It should be noted, however, that the believed benefits of hemiarthroplasty are completely speculative and no literature exists to support its use over TEA. 
Hemiarthroplasty of the distal humerus resurfaces the articular segments of the trochlea and capitellum. For it to function optimally to allow elbow stability and range of motion, it relies on the integrity of the primary and secondary elbow stabilizers.83,153 Therefore, when considering hemiarthroplasty, the medial and lateral columns must be reconstructible (Fig. 35-34), the radial head and coronoid must be intact, and the MCLs and LCLs must be repairable or intact on their respective condyles.14,83 
Figure 35-34
A distal humerus fracture (A) treated with hemiarthroplasty and plate fixation of the medial column and suture fixation of the lateral epicondyle (B).
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The contraindications to distal humerus hemiarthroplasty are similar to those for TEA. Additional contraindications include deficient medial or lateral column bone, deficient MCLs or LCLs, or fractures of the radial head or coronoid that cannot be rigidly stabilized. Chondral damage to the greater sigmoid notch or radial head are also relative contraindications as patients may experience postoperative arthritic pain and limited motion. In the above circumstances with deficient bone or soft tissue, linked TEA should be considered. 
Preoperative Planning.
As with TEA, hemiarthroplasty is a technically demanding procedure and should only be conducted by surgeons experienced in upper limb arthroplasty or complex trauma. Standard elbow radiographs are usually sufficient for assessing the fracture pattern and for implant templating. CT will confirm the articular fragmentation, will identify occult fractures (such as fractures of the coronoid and radial head), and may assist with ORIF of the columns. 
Positioning and Surgical Approaches.
Patients can be positioned supine or in the lateral decubitus fashion. A sterile tourniquet is used and the approach starts with a longitudinal posterior skin incision. The ulnar nerve is identified, released, and prepared for anterior subcutaneous transposition. The options available for exposure of the elbow for hemiarthroplasty include olecranon osteotomy, paratricipital approach, triceps split, triceps reflection, and triceps dividing approaches (please see section on surgical approaches). The most commonly used approaches for hemiarthroplasty are the olecranon osteotomy and the paratricipital approach. The olecranon osteotomy allows the best visualization of the joint; however, has a higher rate of complications if intraoperative conversion to a TEA is required. The paratricipital approach maintains integrity of the extensor mechanism, however, affords less visualization of the articular surfaces. For hemiarthroplasty, the paratricipital approach can be modified by maintaining the collateral ligament attachments on the epicondyles and working through the fracture interval. 
Technique.
Once the fracture is visualized, it should be carefully inspected to ensure ORIF is not possible. If hemiarthroplasty is deemed appropriate, sizing of the implant should be done next. The determination of correct humeral component size can be done in three ways, preoperative templating of contralateral elbow radiographs, piecing together the fractured trochlea and capitellum and comparing with the available trial implants, and by placing trial implants into the greater sigmoid notch to select which one best aligns with the coronoid and radial head. The humeral canal is then entered by resecting the superior aspect of the olecranon fossa. The canal is reamed and broached to accept the chosen trial implant. The trial implant must be inserted to the correct depth to recreate the joint line. Local landmarks, such as the collateral ligament origins and the condyles, are used to gauge correct implant length. Provisional fixation of one or both of the fractured columns with K-wires may also assist with determination of the correct implant length. Conservative bone cuts are then made using the available cutting blocks. If use of the cutting blocks is not feasible, conservative free-hand cuts are made and revised as necessary. The trial implant is then inserted into the humerus and the elbow is reduced and taken through a range of motion to ensure there is no restriction or impingement. 
Once the appropriate orientation, length, and size of trial implant have been determined, the next step involves cementation of the true prosthesis and definitive fixation of the columnar fractures. This step can be done in one of several different orders: (1) the fractured columns can be definitively fixated in anatomic position with contoured plates/screws or with K-wires/tension bands augmented with sutures (Fig. 35-35) and then the implant cemented; (2) the implant can be cemented first in anatomic position followed by columnar fracture fixation; (3) the less comminuted column is definitively fixated first to allow easier fracture reduction and to assist with correct implant orientation and length. The implant is inserted and once the cement has hardened, the other column undergoes ORIF to the humeral shaft and stable implant. When conducting this procedure through an olecranon osteotomy, all the above methods are feasible; however, if using a paratricipital approach only the latter two are possible. 
Figure 35-35
Medial and lateral column fixation in hemiarthroplasty for distal humerus fractures may be accomplished by plates and screws, sutures, and tension band constructs.
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Prior to definitive implant insertion, a humeral cement restrictor is inserted and the canal is lavaged and dried. Antibiotic cement is inserted via a thin nozzled pressurization gun. All excess cement is removed, especially around the medial and lateral column fracture surfaces. Once the implant has been cemented and columnar ORIF is complete, the elbow is placed through a range of motion and stability is checked. Postoperatively, the elbow is splinted for 2 to 3 days and then early active assisted range of motion is initiated. 
Potential Pitfalls and Preventative.
Hemiarthroplasty for distal humerus fractures is a technically challenging procedure. It is recommended that only experienced surgeons undertake this procedure. Potential pitfalls include nonanatomic epicondylar reduction with poor collateral ligament tension, nonrigid fixation of condyles, humeral component malrotation, incorrect humeral component length relationship, and incorrect articular sizing. All of the aforementioned pitfalls are technique-dependent and will likely adversely affect patient outcomes. This procedure, therefore, should only be conducted by experienced surgeons. 
Treatment-specific Outcomes.
There is little information in the literature pertaining to the outcomes of distal humerus hemiarthroplasty for trauma.2,3,28,83,166,201 Adolfsson and Nestorson reported on eight cases using the nonanatomic Kudo (Biomet Inc., Warsaw, IN, USA) humeral prosthesis.2,3 At a mean of 4 years follow-up, the MEPSs were good or excellent in all patients. The mean elbow range of motion was 31 to 126 degrees and all patients described having no pain. Radiographic signs of ulnar erosion were present in three patients, but did not correlate to functional outcomes. Parsons et al.166 also reported on four patients undergoing hemiarthroplasty for acute fractures using the anatomic Sorbie-Questor implant (Wright Medical Technology, Arlington, TN). At early follow-up, they reported a mean ASES score of 83.5 and a mean elbow flexion of 130 degrees and an extension of 16 degrees. Unfortunately, these two short-term follow-up studies are all that is available in the literature; therefore, further studies are required to determine if distal humeral hemiarthroplasty for acute trauma is feasible in the long term. 

Special Circumstances and Management of Expected Adverse Outcomes and Unexpected Complications of Distal Humerus Fractures

Open Distal Humerus Fractures

Approximately 7% of distal humerus fracture are open189 and they are classified according to the system of Gustilo and Anderson.70 The principles of open fracture treatment have remained unchanged for the last 3 decades. The priorities are wound irrigation and debridement, intravenous antibiotics, tetanus coverage, fracture stabilization, and appropriate soft tissue management.70,158 The common complications associated with open fractures include infection, nonunion, hardware failure, and wound problems. 
The grade of open fracture varies with the mechanism of injury. Most blunt mechanisms of injury lead to grade I punctures while blast or gun shots lead to grade III wounds.189 Typically, most grade I puncture wounds are located posteriorly or posterolaterally on the elbow and are commonly associated with lacerations of the triceps tendon or muscle.133,189 In cases of an intra-articular fracture with a triceps tendon laceration, the Van Gorder (triceps tongue) or triceps splitting approaches are preferred as they prevent a second disruption of the extensor mechanism with an olecranon osteotomy. 
Typically, in open injuries contaminated or devascularized bone and soft tissues are excised. This rule, however, does not hold absolutely true when dealing with large segments of articular surface. The risk of infection with retaining the fragments must be weighed against the risk of post-traumatic arthritis and the potential need for secondary bone grafting or allograft reconstruction if the fragments are removed. Generally, an attempt should be made to preserve all articular segments with thorough cleansing and meticulous removal of all foreign material and contamination. 
McKee et al.133 reviewed 26 patients who underwent ORIF of open distal humerus fractures. According to the system of Gustilo and Anderson, 50% were grade I, 35% were grade II, and 15% were grade III. At follow-up, 15 patients (57%) had good to excellent outcomes based on the MEPS and the mean DASH score was 24 indicating minimal to moderate disability. The mean elbow arc of flexion–extension motion was 97 degrees (range, 55 to 140 degrees). The overall infection rate was 11% (three patients) with only one patient sustaining a deep infection requiring operative debridement. Four patients (15%) were diagnosed with delayed union (>16 weeks) with two patients going on to require bone grafting. Min et al.,140 in a case-controlled study, compared closed to open AO/OTA type C fractures in 28 patients. At final follow-up, patients with open fractures were found to have significantly worse functional outcomes. 

Nonunion of Distal Humerus Fractures

Nonunions occur in approximately 6% (range, 0% to 25%) of distal humerus fractures treated by modern doubling plating techniques.6,13,47,57,64,67,69,82,106,130,133,160,161,190,193,205,216 Nonunions typically occur at the supracondylar level, are rarely intra-articular, and are usually related to inadequate fixation.5,76,128,164,184,203,204 Other risk factors for nonunion include “low” fracture types with limited distal bone for screw purchase, extensive comminution, and severe osteopenia. Patients typically present with pain, stiffness, and functional limitation. If there is associated failure of fixation, patient may also present with abnormal motion caused by a mobile nonunion. 
In patients presenting with nonunion after ORIF of distal humerus fractures, it is important to establish the cause of the nonunion. All patients should undergo infection screening blood work (complete blood count with differential, erythrocyte sedimentation rate, and C-reactive protein levels). Injury and postoperative radiographs should be examined critically to determine the initial fracture pattern and the adequacy of initial ORIF. Examining postoperative radiographs in a serial fashion may reveal the cause of failure. 
Treatment options for distal humerus nonunions include splinting, revision ORIF, and elbow arthroplasty. Splinting with externally applied bone stimulators, such as ultrasound, may be effective if fixation failure has not occurred. If surgical treatment is deemed necessary, a CT scan may be beneficial in examining the quality and quantity of the remaining distal humerus bone. 
Revision ORIF should be the procedure of choice in healthy active patients. Revision procedures are technically demanding because of the altered anatomy, presence of failed hardware, excessive scarring, and generally poor bone quality. Because of these issues, an olecranon osteotomy is the preferred approach to allow the best access to the joint.5,76,128,184 The goals of surgery are to obtain an anatomic articular reduction, rigid bicolumn fixation, and to stimulate bone healing with autologous bone graft. Additional procedures that are usually required with revision ORIF of distal humerus fractures are anterior and posterior capsulectomy to address elbow stiffness and ulnar nerve neurolysis and transposition.76,128,184 The outcomes of revision ORIF are generally satisfactory5,76,128,184 with bony union occurring in greater than 90% of patients. 
In some nonunions, revision ORIF is not feasible, whether it is because of extensive bone loss or post-traumatic arthrosis. In these cases, TEA is a reliable treatment option.51,129,141,142 Patients who have a healed prior olecranon osteotomy can be approached via a paratricipital approach, Bryan-Morrey (triceps reflecting) approach, or by a triceps split. Patients with a nonunion of an olecranon osteotomy are approached through the osteotomy site. After elbow arthroplasty, the olecranon is fixated with a K-wire/tension band construct, plate/screws, or with excision of the fragment and triceps advancement.122 Other treatment options for distal humerus nonunions include arthrodesis,177 resection arthroplasty, allograft distal humerus replacement,1,37,217,218 vascularized bone grafting,19 and Ilizarov methods.23 

Elbow Stiffness and Heterotopic Ossification of Distal Humerus Fractures

Patients typically achieve functional range of motion after ORIF of distal humerus fractures. Risk factors for elbow stiffness and HO are head injury, polytrauma, severe soft tissue injury, delay to surgical intervention, prolonged postoperative immobilization, and open fractures.61,86,96,124,165,182,183,193 
The reported incidence of HO after surgical treatment of distal humerus fractures varies from 0% to 49%.6,13,47,67,69,160,193,205 The majority of patients with HO do not experience any significant functional deficits; therefore, resection is not always necessary. HO about the elbow can be classified by the system of Hastings and Graham73 (Table 35-8). The incidence of elbow stiffness and contracture is difficult to determine as almost all patients who undergo ORIF have some limitation in motion. The distinction between an elbow contracture and a normal postoperative outcome is dependent on several variables, including patient’s expectations, activity level, age, and occupation. Morrey,146,148 in an effort to identify the etiology of elbow contractures, has classified them as intrinsic, extrinsic, and combined. Intrinsic causes involve the articular surface while extrinsic causes include capsular contracture and HO. 
 
Table 35-8
The Hastings Classification of Heterotopic Ossification
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Table 35-8
The Hastings Classification of Heterotopic Ossification
Class Sub-type Description
I Radiographic heterotopic ossification without functional limitation
II A Limitation of flexion/extension
B Limitation of forearm pronation/supination
C Limitation in both planes
III Bony ankylosis of either the elbow or forearm
X
Primary prevention should be used by all surgeons to limit post-traumatic elbow contracture. For patients at high risk of HO, such as those with head injuries, postoperative indomethacin and/or radiation is recommended. For the treatment of elbow contractures, initial management should be nonoperative with physiotherapy, splints, and braces. Static progressive splinting under the direction of a physiotherapist has been reported as an effective method of regaining elbow range of motion.40 
When splints and braces fail to obtain functional range of motion, the elbow may be treated surgically using either open or arthroscopic techniques. Generally, arthroscopy has a limited role in the treatment of contractures after distal humerus ORIF because of the often extensive internal fixation hardware that requires open removal. Open contracture releases may be done via a medial “over-the-top” exposure, a lateral column procedure, or a combined approach.146,148,214 The preoperative assessment of patients includes identification of prior surgical incisions, examination of the ulnar nerve, and clear localization of the pathology to determine the most appropriate surgical approach. The procedure typically involves ulnar nerve release, capsulectomy, debridement of the olecranon, coronoid and radial fossae, excision of symptomatic HO, and finally removal of internal fixation hardware. Postoperatively, patients are managed with continuous passive motion devices and static progressive splints. The routine use of indomethacin for HO prophylaxis after contracture release remains controversial. 
The surgical excision of symptomatic HO should be delayed until its growth has ceased and it has become corticated. Preoperative or early postoperative single dose radiation treatment has been recommended to decrease HO recurrence; however, there is little literature to support its use. The excision of HO is associated with significantly better gains in range of motion than release of soft tissue-only contractures.165 

Wound Complications and Infection in Distal Humerus Fractures

Superficial wound infections are relatively common after ORIF of distal humerus fractures. Elbows should be examined to ensure there are no deep fluid collections which may indicate infected hematomas or seromas. The management of superficial infections consists of oral antibiotics, dressing changes, and close observation. 
Deep infections after ORIF of distal humerus fractures have a reported rate between 0% and 10%.6,13,47,57,64,67,69,82,106,108,130,133,160,161,183,193,205,216 Management consists of surgical debridement and organism-specific intravenous antibiotics. Intraoperatively, fracture fixation is assessed to ensure it is stable. If stable, the patient is managed serial surgical debridements as required and intravenous antibiotics until healing. If fracture stability is lost, staged revision ORIF is required along with intravenous antibiotics until healing. 
Wound necrosis is also a complication that can occur after ORIF of distal humerus fractures. This is managed with surgical debridement to viable tissue. The remaining soft tissue defect is assessed to determine whether primary closure is possible or if coverage is required. Coverage options depend on several variables, including size and depth of the defect, exposed hardware or vital structures, patient comorbidities, and potential donor site morbidity.33,91 Consultation with a plastic or soft tissue reconstructive surgeon is recommended. 

Ulnar Neuropathy in Distal Humerus Fractures

The ulnar nerve is the most commonly affected nerve in patients with distal humerus fractures. Injury can occur at the time of fracture, intraoperatively, or postoperatively. At the time of fracture, the nerve may be injured by a direct impact or indirectly by traction caused by wide displacement of the fracture fragments. Intraoperatively, injury may occur by traction, manipulation of the nerve, or by injury to its blood supply causing ischemia. Postoperatively, neuritis may occur by nerve “kinking” in flexion or extension, exuberant scarring, or by irritation against fixation hardware. 
Patients with preoperative neuropathy should undergo ulnar nerve exploration during the surgical procedure. The nerve should be decompressed and examined with loop magnification to ensure it is intact. If partially or completely lacerated, the nerve should undergo immediate microsurgical repair. If the nerve is intact, a complete neurolysis should be done. The decision whether or not to transpose the nerve remains controversial. 
In a retrospective study of 107 patients to determine the incidence and predisposing factors for the onset of postoperative ulnar neuropathy, Wiggers et al.224 identified neuropathy in 17 (16%) patients with the only risk factor being the type of fracture. The authors found that columnar fractures had a greater risk of postoperative ulnar neuropathy than capitellar or trochlear fractures, and this effect was independent of whether or not the nerve was transposed at the time of surgery. Chen et al.32 in a multicenter retrospective study compared the rate of ulnar neuropathy in patients with and without ulnar nerve transposition during ORIF of distal humerus fractures. The authors found that patients who underwent intraoperative ulnar nerve transposition had almost four times the incidence of post-operative ulnar neuropathy. The authors, therefore, recommended against ulnar nerve transposition. 
Ulnar neuropathy that presents postoperatively, in a transposed nerve, can be managed with initial observation. The management of postoperative neuropathy in a nerve left in situ remains controversial; anecdotally, some recommend observation while others recommend acute decompression with anterior transposition. It is the author’s practice to conduct a complete release and anterior subcutaneous transposition in all surgically treated distal humerus fractures. 
The outcome of ulnar neuropathy with an intact nerve is good; patients have a high rate of satisfaction, good return of intrinsic muscle strength, and a return of hand functionality.127 Although the prognosis is generally good after ulnar neuropathy, patients do not return to completely normal.18,127 

Olecranon Osteotomy Complications in Distal Humerus Fractures

An olecranon osteotomy affords the best visualization of the articular surface of the distal humerus, and therefore is a valuable approach for comminuted articular fractures. An olecranon osteotomy should be conducted in a systematic way to avoid complications such as inadvertent fracture propagation, incorrect osteotomy location, and malreduction. Complications associated with olecranon osteotomies have been reported to occur in 0% to 31% of cases.6,13,36,57,64,69,78,205,229 
Nonunion or delayed union of olecranon osteotomies have been reported in up to 10% of cases.6,13,36,57,64,78,190,205,229 In many cases, the olecranon osteotomy requires more time to heal than the distal humerus fracture58, perhaps because of the ulna’s unique blood supply.226 The theorized risk factors for nonunion include use of a tension band technique, a transverse osteotomy, and single screw fixation, although, the literature does not support this. Three recent studies36,78,180 on the outcomes of olecranon osteotomy looked at a total of 129 patients. All patients underwent an apex distal chevron osteotomy, although, the types of fixation varied (plates, single medullary screws, and tension band constructs). There were no nonunions, one delayed union, three patients who had early hardware failure required revision ORIF, and 18 patients (14%) had hardware removal specifically for irritation. 
The management of olecranon nonunions includes ruling out infective causes and then revision plate ORIF with autologous bone grafting. In some cases when revision ORIF is not feasible because of the small size of the fragment or associated poor bone quality, the fragment may be excised with advancement of the triceps insertion.122,220 Delayed unions of the olecranon are managed expectantly with consideration given to external bone stimulation devices. 
Prominent symptomatic hardware is common after fixation of olecranon osteotomies. Patients may experience local pain, tenderness, or an inability to rest the elbow hard surfaces. These symptoms can be addressed by hardware removal after the olecranon is completely healed. 

Total Elbow Arthroplasty Complications in Distal Humerus Fractures

Complications of TEA include infection and wound healing, neuropathies, triceps insufficiency, instability, osteolysis and loosening, mechanical failure, periprosthetic fracture, and stiffness. 
The rate of deep infection in TEA ranges from 2% to 5%. The rate has been noted to be declining over time.2,11,35,59,60,98,112,144,171,178 The rate of infection can be minimized by meticulous surgical technique, use of perioperative antibiotics, sterile tourniquets, and antibiotic laden cement. The consequences of deep infection can be devastating. The treatment will often include organism-specific intravenous antibiotics and surgical debridements with possible staged reconstruction. Organisms such as Staphylococcus epidermidis are particularly difficult to eradicate, and resection arthroplasty may be the consequence. 
Ulnar neuropathy is common in traumatic conditions of the elbow. The probability of persistent ulnar neuropathy after TEA for trauma is high and is reported to occur in up to 28% of patients, with permanent dysfunction in up to 10%.11,17,35,59,74,97,98,173,178,187 Ulnar nerve exposure, complete neurolysis, and anterior transposition is recommended, although, transposition also has risks, such as devascularization. The surgical approach used for elbow arthroplasty is also influential as the extended Kocher approach has a higher risk of postoperative ulnar nerve palsy.79,116 
Triceps insufficiency is a common problem after TEA performed via an extensor mechanism disrupting approach, and is reported in up to 11% of patients.143,168,174,178,223 Surgical exposures that utilize a triceps-on approach such as the paratricipital approach, although more technically challenging, may avoid this complication. When using a triceps disrupting approach this complication can be minimized by solid anatomic repair of the triceps insertion and postoperative protection of the repair by avoiding active extension for 6 weeks. Many patients, such as those that use ambulatory aids or self-propelled wheelchairs, require a strong intact triceps mechanism. These patients may be best suited for the paratricipital approach. Patients who develop extensor mechanism insufficiency and who rely on active extension may benefit from extensor mechanism revision repair or reconstruction with auto- or allograft. 
Instability after TEA is a problem associated with unlinked designs. These designs rely on correct implant positioning, preserved bony architecture, and intact soft tissue stabilizers. Typically, unlinked designs are not used for distal humerus fracture because of disrupted bony and soft tissue stabilizers; however, they may be used if these structures are anatomically repaired. Newer unlinked designs have several advantages, they have greater contact surface area in the ulnohumeral articulation providing increased constraint, some have the option of a radial head arthroplasty which provides additional stability, and others have the ability to convert to a linked implant. If intraoperative instability exists in an unlinked arthroplasty after repair of the bony structures and soft tissues, then conversion to a linked prosthesis should be performed. 
Bearing wear in a TEA is inevitable. Many implants allow for change of the bearing surface without revision of the components. Accelerated wear rates have been found in younger patients, in patients with post-traumatic conditions, and in cases with persistent postoperative malalignment or deformity.85,111,121,141 The problem with polyethylene wear is the host reaction that causes osteolysis, which can lead to aseptic loosening and loss of bone stock. 
TEA implants can also undergo fatigue fracture.17 Metal fatigue most commonly affects titanium implants because of their notch sensitivity. Implants at risk are those with insufficient bony support of their metaphyseal segments because of fractured or resected condyles or osteolysis. These at-risk implants experience high cantilever bending forces at the junction of the poorly supported metaphyseal segment and the well-fixed diaphyseal segment. 
Periprosthetic fractures can occur intraoperatively and postoperatively. Risk factors for intraoperative fractures include osteopenic bone, excessive diaphyseal bowing with use of long stem implants, overly aggressive reaming and revision cases. Fixation of condylar fractures when using a linked system is not required; however, shaft fractures require reduction and stabilization with some combination of long stem components with cerlage wires, allograft struts, or plate and screw fixation. Postoperative periprosthetic fractures can occur secondary to trauma or through pathologic bone weakened by osteolysis. Periprosthetic fractures with unstable components will likely require revision arthroplasty in the medically fit patient. Periprosthetic fractures with stable components may be managed with immobilization or ORIF. Allograft strut grafts are useful adjuncts in these situations especially in those with bone loss. 

Author’s Preferred Treatment for Distal Humerus Fractures (Fig. 35-36)

Figure 35-36
Authors Preferred Treatment Algorithm for Distal Humerus Fractures.
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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.

Controversies/Future Directions in Distal Humerus Fractures

Several implant-related advancements have been made over the last few years. The use of precontoured and locking plates has become ubiquitous; however, no clinical advantages have been reported. Further study is required to determine if their additional cost leads to improved patient outcomes, especially in today’s fiscally responsible health care environment. 
TEA has certainly demonstrated predictably good outcomes in short- to medium-term follow-up; however, as with all total joints the survivorship decreases over time. The role of hemiarthroplasty, therefore, requires further investigation to determine if it effectively functions as an intermediate to total joint replacement. 

Acknowledgments

I would like to thank Drs. C. Michael Robinson, Graham J.W. King, Marc Prud’homme-Foster, and Kenneth J. Faber for their assistance with the preparation of this chapter. 

References

1.
Ackerman G, Jupiter JB. Non-union of fractures of the distal end of the humerus. J Bone Joint Surg Am. 1988;70(1):75–83.
2.
Adolfsson L, Hammer R. Elbow hemiarthroplasty for acute reconstruction of intraarticular distal humerus fractures: a preliminary report involving 4 patients. Acta Orthop. 2006;77(5):785–787.
3.
Adolfsson L, Nestorson J. The Kudo humeral component as primary hemiarthroplasty in distal humeral fractures. J Shoulder Elbow Surg. 2012;21(4):451–455.
4.
Aitken GK, Rorabeck CH. Distal humeral fractures in the adult. Clin Orthop Relat Res. 1986;(207):191–197.
5.
Ali A, Douglas H, Stanley D. Revision surgery for nonunion after early failure of fixation of fractures of the distal humerus. J Bone Joint Surg Br. 2005;87(8):1107–1110.
6.
Allende CA, Allende BT, Allende BL, et al. Intercondylar distal humerus fractures–surgical treatment and results. Chir Main. 2004;23(2):85–95.
7.
Alonso-Llames M. Bilaterotricipital approach to the elbow. Its application in the osteosynthesis of supracondylar fractures of the humerus in children. Acta Orthop Scand. 1972;43(6):479–490.
8.
Anglen J. Distal humerus fractures. J Am Acad Orthop Surg. 2005;13(5):291–297.
9.
Antuna SA, Laakso RB, Barrera JL, et al. Linked total elbow arthroplasty as treatment of distal humerus fractures. Acta Orthop Belg. 2012;78(4):465–472.
10.
Armstrong AD, Dunning CE, Faber KJ, et al. Single-strand ligament reconstruction of the medial collateral ligament restores valgus elbow stability. J Shoulder Elbow Surg. 2002;11(1):65–71.
11.
Armstrong AD, Yamaguchi K. Total elbow anthroplasty and distal humerus elbow fractures. Hand Clin. 2004;20(4):475–483.
12.
Arnander MW, Reeves A, MacLeod IA, et al. A biomechanical comparison of plate configuration in distal humerus fractures. J Orthop Trauma. 2008;22(5):332–336.
13.
Aslam N, Willett K. Functional outcome following internal fixation of intraarticular fractures of the distal humerus (AO type C). Acta Orthop Belg. 2004;70(2):118–122.
14.
Athwal GS, Goetz TJ, Pollock JW, et al. Prosthetic replacement for distal humerus fractures. Orthop Clin North Am. 2008;39(2):201–212.
15.
Athwal GS, Hoxie SC, Rispoli DM, et al. Precontoured parallel plate fixation of AO/OTA type C distal humerus fractures. J Orthop Trauma. 2009;23(8):575–580.
16.
Athwal GS, Morrey BF. Revision total elbow arthroplasty for prosthetic fractures. J Bone Joint Surg Am. 2006;88(9):2017–2026.
17.
Athwal GS, Rispoli DM, Steinmann SP. The anconeus flap transolecranon approach to the distal humerus. J Orthop Trauma. 2006;20(4):282–285.
18.
Bartels RH, Grotenhuis JA. Anterior submuscular transposition of the ulnar nerve. For post-operative focal neuropathy at the elbow. J Bone Joint Surg Br. 2004;86(7):998–1001.
19.
Beredjiklian PK, Hotchkiss RN, Athanasian EA, et al. Recalcitrant nonunion of the distal humerus: treatment with free vascularized bone grafting. Clin Orthop Relat Res. 2005;(435):134–139.
20.
Bilic R, Kolundzic R, Anticevic D. Absorbable implants in surgical correction of a capitellar malunion in an 11-year-old: a case report. J Orthop Trauma. 2006;20(1):66–69.
21.
Black DM, Steinbuch M, Palermo L, et al. An assessment tool for predicting fracture risk in postmenopausal women. Osteoporos Int. 2001;12(7):519–528.
22.
Boody AR, Wongworawat MD. Accuracy in the measurement of compartment pressures: a comparison of three commonly used devices. J Bone Joint Surg Am. 2005;87(11):2415–2422.
23.
Brinker MR, O’Connor DP, Crouch CC, et al. Ilizarov treatment of infected nonunions of the distal humerus after failure of internal fixation: an outcomes study. J Orthop Trauma. 2007;21(3):178–184.
24.
Brouwer KM, Lindenhovius AL, Dyer GS, et al. Diagnostic accuracy of 2- and 3-dimensional imaging and modeling of distal humerus fractures. J Shoulder Elbow Surg. 2012;21(6):772–776.
25.
Brown RF, Morgan RG. Intercondylar T-shaped fractures of the humerus. Results in ten cases treated by early mobilisation. J Bone Joint Surg Br. 1971;53(3):425–428.
26.
Bryan RS, Morrey BF. Extensive posterior exposure of the elbow. A triceps-sparing approach. Clin Orthop Relat Res. 1982;(166):188–192.
27.
Bryan RS, Morrey BF. Fractures of the distal humerus. In: Morrey BF, ed. The Elbow and its Disorders. Philadelphia, PA: WB Saunders; 1985:302–339.
28.
Burkhart KJ, Nijs S, Mattyasovszky SG, et al. Distal humerus hemiarthroplasty of the elbow for comminuted distal humeral fractures in the elderly patient. J Trauma. 2011;71(3):635–642.
29.
Campbell WC. Incision for exposure of the elbow joint. Am J Surg. 1932;15:65–67.
30.
Cassebaum WH. Open reduction of T & Y fractures of the lower end of the humerus. J Trauma. 1969;9(11):915–925.
31.
Chalidis B, Dimitriou C, Papadopoulos P, et al. Total elbow arthroplasty for the treatment of insufficient distal humeral fractures. A retrospective clinical study and review of the literature. Injury. 2009;40(6):582–590.
32.
Chen RC, Harris DJ, Leduc S, et al. Is ulnar nerve transposition beneficial during open reduction internal fixation of distal humerus fractures? J Orthop Trauma. 2010;24(7):391–394.
33.
Choudry UH, Moran SL, Li S, et al. Soft-tissue coverage of the elbow: an outcome analysis and reconstructive algorithm. Plast Reconstr Surg. 2007;119(6):1852–1857.
34.
Clough TM, Jago ER, Sidhu DP, et al. Fractures of the capitellum: a new method of fixation using a maxillofacial plate. Clin Orthop Relat Res. 2001;(384):232–236.
35.
Cobb TK, Morrey BF. Total elbow arthroplasty as primary treatment for distal humeral fractures in elderly patients. J Bone Joint Surg Am. 1997;79(6):826–832.
36.
Coles CP, Barei DP, Nork SE, et al. The olecranon osteotomy: a six-year experience in the treatment of intraarticular fractures of the distal humerus. J Orthop Trauma. 2006;20(3):164–171.
37.
Dean GS, Holliger EH 4th, Urbaniak JR. Elbow allograft for reconstruction of the elbow with massive bone loss. Long term results. Clin Orthop Relat Res. 1997(341):12–22.
38.
Diliberti T, Botte MJ, Abrams RA. Anatomical considerations regarding the posterior interosseous nerve during posterolateral approaches to the proximal part of the radius. J Bone Joint Surg Am. 2000;82(6):809–813.
39.
Doornberg J, Lindenhovius A, Kloen P, et al. Two- and three-dimensional computed tomography for the classification and management of distal humeral fractures. Evaluation of reliability and diagnostic accuracy. J Bone Joint Surg Am. 2006;88(8):1795–1801.
40.
Doornberg JN, Ring D, Jupiter JB. Static progressive splinting for posttraumatic elbow stiffness. J Orthop Trauma. 2006;20(6):400–404.
41.
Doornberg JN, van Duijn PJ, Linzel D, et al. Surgical treatment of intra-articular fractures of the distal part of the humerus. Functional outcome after twelve to thirty years. J Bone Joint Surg Am. 2007;89(7):1524–1532.
42.
Dowdy PA, Bain GI, King GJ, et al. The midline posterior elbow incision. An anatomical appraisal. J Bone Joint Surg Br. 1995;77(5):696–699.
43.
Dubberley JH, Faber KJ, Macdermid JC, et al. Outcome after open reduction and internal fixation of capitellar and trochlear fractures. J Bone Joint Surg Am. 2006;88(1):46–54.
44.
Duggal N, Dunning CE, Johnson JA, et al. The flat spot of the proximal ulna: a useful anatomic landmark in total elbow arthroplasty. J Shoulder Elbow Surg. 2004;13(2):206–207.
45.
Dunning CE, Zarzour ZD, Patterson SD, et al. Ligamentous stabilizers against posterolateral rotatory instability of the elbow. J Bone Joint Surg Am. 2001;83-A(12):1823–1828.
46.
Eastwood WJ. The T-shaped fracture of the lower end of the humerus. J Bone Joint Surg Am. 1937;19:364–369.
47.
Ek ET, Goldwasser M, Bonomo AL. Functional outcome of complex intercondylar fractures of the distal humerus treated through a triceps-sparing approach. J Shoulder Elbow Surg. 2008;17(3):441–446.
48.
Elkowitz SJ, Polatsch DB, Egol KA, et al. Capitellum fractures: a biomechanical evaluation of three fixation methods. J Orthop Trauma. 2002;16(7):503–506.
49.
Ergunes K, Yilik L, Ozsoyler I, et al. Traumatic brachial artery injuries. Tex Heart Inst J. 2006;33(1):31–34.
50.
Erpelding JM, Mailander A, High R, et al. Outcomes following distal humeral fracture fixation with an extensor mechanism-on approach. J Bone Joint Surg Am. 2012;94(6):548–553.
51.
Espiga X, Antuna SA, Ferreres A. Linked total elbow arthroplasty as treatment of distal humerus nonunions in patients older than 70 years. Acta Orthop Belg. 2011;77(3):304–310.
52.
Evans EM. Supracondylar-Y fractures of the humerus. J Bone Joint Surg Br. 1953;35-B(3):371–375.
53.
Faber KJ, Cordy ME, Milne AD, et al. Advanced cement technique improves fixation in elbow arthroplasty. Clin Orthop Relat Res. 1997;(334):150–156.
54.
Faber KJ. Coronal shear fractures of the distal humerus: the capitellum and trochlea. Hand Clin. 2004;20(4):455–464.
55.
Foulk DA, Robertson PA, Timmerman LA. Fracture of the trochlea. J Orthop Trauma. 1995;9(6):530–532.
56.
Fracture and dislocation compendium. Orthopaedic trauma association committee for coding and classification. J Orthop Trauma. 1996;10(Suppl 1):1–154.
57.
Frankle MA, Herscovici D Jr, DiPasquale TG, et al. A comparison of open reduction and internal fixation and primary total elbow arthroplasty in the treatment of intraarticular distal humerus fractures in women older than age 65. J Orthop Trauma. 2003;17(7):473–480.
58.
Gainor BJ, Moussa F, Schott T. Healing rate of transverse osteotomies of the olecranon used in reconstruction of distal humerus fractures. J South Orthop Assoc. 1995;4(4):263–268.
59.
Gambirasio R, Riand N, Stern R, et al. Total elbow replacement for complex fractures of the distal humerus. An option for the elderly patient. J Bone Joint Surg Br. 2001;83(7):974–978.
60.
Garcia JA, Mykula R, Stanley D. Complex fractures of the distal humerus in the elderly. The role of total elbow replacement as primary treatment. J Bone Joint Surg Br. 2002;84(6):812–816.
61.
Garland DE, O’Hollaren RM. Fractures and dislocations about the elbow in the head-injured adult. Clin Orthop Relat Res. 1982(168):38–41.
62.
Gerwin M, Hotchkiss RN, Weiland AJ. Alternative operative exposures of the posterior aspect of the humeral diaphysis with reference to the radial nerve. J Bone Joint Surg Am. 1996;78(11):1690–1695.
63.
Glanville EV. Perforation of the coronoid-olecranon septum. Humero-ulnar relationships in Netherlands and African populations. Am J Phys Anthropol. 1967;26(1):85–92.
64.
Gofton WT, Macdermid JC, Patterson SD, et al. Functional outcome of AO type C distal humeral fractures. J Hand Surg Am. 2003;28(2):294–308.
65.
Grantham SA, Norris TR, Bush DC. Isolated fracture of the humeral capitellum. Clin Orthop Relat Res. 1981;(161):262–269.
66.
Grechenig W, Clement H, Pichler W, et al. The influence of lateral and anterior angulation of the proximal ulna on the treatment of a Monteggia fracture: an anatomical cadaver study. J Bone Joint Surg Br. 2007;89(6):836–838.
67.
Greiner S, Haas NP, Bail HJ. Outcome after open reduction and angular stable internal fixation for supra-intercondylar fractures of the distal humerus: preliminary results with the LCP distal humerus system. Arch Orthop Trauma Surg. 2008;128(7):723–729.
68.
Gschwend N, Simmen BR, Matejovsky Z. Late complications in elbow arthroplasty. J Shoulder Elbow Surg. 1996;5(2 Pt 1):86–96.
69.
Gupta R, Khanchandani P. Intercondylar fractures of the distal humerus in adults: a critical analysis of 55 cases. Injury. 2002;33(6):511–515.
70.
Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976;58(4):453–458.
71.
Hahn NF. Fall von einer besonderes varietat der frakturen des ellenbogens. Zeitsch Wundartze Geburtshlefer. 1853;6:185.
72.
Hardy P, Menguy F, Guillot S. Arthroscopic treatment of capitellum fracture of the humerus. Arthroscopy. 2002;18(4):422–426.
73.
Hastings H 2nd, Graham TJ. The classification and treatment of heterotopic ossification about the elbow and forearm. Hand Clin. 1994;10(3):417–437.
74.
Hastings H 2nd, Theng CS. Total elbow replacement for distal humerus fractures and traumatic deformity: results and complications of semiconstrained implants and design rationale for the Discovery Elbow System. Am J Orthop. 2003;32(9 Suppl):20–28.
75.
Helfet DL, Hotchkiss RN. Internal fixation of the distal humerus: a biomechanical comparison of methods. J Orthop Trauma. 1990;4(3):260–264.
76.
Helfet DL, Kloen P, Anand N, et al. Open reduction and internal fixation of delayed unions and nonunions of fractures of the distal part of the humerus. J Bone Joint Surg Am. 2003;85-A(1):33–40.
77.
Helfet DL, Schmeling GJ. Bicondylar intraarticular fractures of the distal humerus in adults. Clin Orthop Relat Res. 1993;(292):26–36.
78.
Hewins EA, Gofton WT, Dubberly J, et al. Plate fixation of olecranon osteotomies. J Orthop Trauma. 2007;21(1):58–62.
79.
Hodgson SP, Parkinson RW, Noble J. Capitellocondylar total elbow replacement for rheumatoid arthritis. J R Coll Surg Edinb. 1991;36(2):133–135.
80.
Holdsworth BJ, Mossad MM. Fractures of the adult distal humerus. Elbow function after internal fixation. J Bone Joint Surg Br. 1990;72(3):362–365.
81.
Hotchkiss RN. Elbow contractures. In: Green DP, Hotchkiss RN, Pederson WC, eds. Green’s Operative Hand Surgery. Vol 1. Philadelphia, PA: Churchill Livingstone; 1999:673–674.
82.
Huang TL, Chiu FY, Chuang TY, et al. The results of open reduction and internal fixation in elderly patients with severe fractures of the distal humerus: a critical analysis of the results. J Trauma. 2005;58(1):62–69.
83.
Hughes JS. Distal humeral hemiarthroplasty. In: Yamaguchi K, King GJ, McKee MD, O’Driscoll SW, eds. Advanced Reconstruction Elbow. Rosemont: American Academy of Orthopaedic Surgeons; 2006:219–228.
84.
Hunsaker FG, Cioffi DA, Amadio PC, et al. The American academy of orthopaedic surgeons outcomes instruments: normative values from the general population. J Bone Joint Surg Am. 2002;84-A(2):208–215.
85.
Ikavalko M, Belt EA, Kautiainen H, et al. Souter arthroplasty for elbows with severe destruction. Clin Orthop Relat Res. 2004(421):126–133.
86.
Ilahi OA, Strausser DW, Gabel GT. Post-traumatic heterotopic ossification about the elbow. Orthopedics. 1998;21(3):265–268.
87.
Imatani J, Morito Y, Hashizume H, et al. Internal fixation for coronal shear fracture of the distal end of the humerus by the anterolateral approach. J Shoulder Elbow Surg. 2001;10(6):554–556.
88.
Imatani J, Ogura T, Morito Y, et al. Anatomic and histologic studies of lateral collateral ligament complex of the elbow joint. J Shoulder Elbow Surg. 1999;8(6):625–627.
89.
Jacobson SR, Glisson RR, Urbaniak JR. Comparison of distal humerus fracture fixation: a biomechanical study. J South Orthop Assoc. 1997;6(4):241–249.
90.
Jarvinen TL, Sievanen H, Khan KM, et al. Shifting the focus in fracture prevention from osteoporosis to falls. BMJ. 2008;336(7636):124–126.
91.
Jensen M, Moran SL. Soft tissue coverage of the elbow: a reconstructive algorithm. Orthop Clin North Am. 2008;39(2):251–264.
92.
Jones KG. Percutaneous pin fixation of fractures of the lower end of the humerus. Clin Orthop Relat Res. 1967;50:53–69.
93.
Jupiter JB, Mehne DK. Fractures of the distal humerus. Orthopedics. 1992;15(7):825–833.
94.
Jupiter JB, Neff U, Holzach P, et al. Intercondylar fractures of the humerus. An operative approach. J Bone Joint Surg Am. 1985;67(2):226–239.
95.
Jupiter JB, Neff U, Regazzoni P, et al. Unicondylar fractures of the distal humerus: an operative approach. J Orthop Trauma. 1988;2(2):102–109.
96.
Jupiter JB, O’Driscoll SW, Cohen MS. The assessment and management of the stiff elbow. Instr Course Lect. 2003;52:93–111.
97.
Kalogrianitis S, Sinopidis C, El Meligy M, et al. Unlinked elbow arthroplasty as primary treatment for fractures of the distal humerus. J Shoulder Elbow Surg. 2008;17(2):287–292.
98.
Kamineni S, Morrey BF. Distal humeral fractures treated with noncustom total elbow replacement. J Bone Joint Surg Am. 2004;86-A(5):940–947.
99.
Kamineni S, Morrey BF. Distal humeral fractures treated with noncustom total elbow replacement. Surgical technique. J Bone Joint Surg Am. 2005;87(Suppl 1Pt 1):41–50.
100.
Kannus P, Niemi S, Parkkari J, et al. Why is the age-standardized incidence of low-trauma fractures rising in many elderly populations? J Bone Miner Res. 2002;17(8):1363–1367.
101.
Kannus P. Preventing osteoporosis, falls, and fractures among elderly people. Promotion of lifelong physical activity is essential. BMJ. 1999;318(7178):205–206.
102.
Kaplan EB. Surgical approaches to the proximal end of the radius and its use in fractures of the head and neck of the radius. J Bone Joint Surg Am. 1941;23:86.
103.
Keon-Cohen BT. Fractures at the elbow. J Bone Joint Surg Am. 1966;48A:1623–1639.
104.
Kocher T. Beitrage zur kenntniss einger praktisch wishctiger fraktur formen. Mitheil a Klin u Med Inst and Schweiz Basal, reihe. 1896:767.
105.
Kocher T. Textbook of Operative Surgery. 3rd ed. London: Adam and Charles Black; 1911.
106.
Korner J, Lill H, Muller LP, et al. Distal humerus fractures in elderly patients: results after open reduction and internal fixation. Osteoporos Int. 2005;16(Suppl 2):S73–S79.
107.
Kuhn JE, Louis DS, Loder RT. Divergent single-column fractures of the distal part of the humerus. J Bone Joint Surg Am. 1995;77(4):538–542.
108.
Kundel K, Braun W, Wieberneit J, et al. Intraarticular distal humerus fractures. Factors affecting functional outcome. Clin Orthop Relat Res. 1996;(332):200–208.
109.
Kuriyama K, Kawanishi Y, Yamamoto K. Arthroscopic-assisted reduction and percutaneous fixation for coronal shear fractures of the distal humerus: report of two cases. J Hand Surg Am. 2010;35(9):1506–1509.
110.
Lambotte A. Chirurgie Operatoire des Fractures. Paris: Masson et Cie; 1913.
111.
Lee BP, Adams RA, Morrey BF. Polyethylene wear after total elbow arthroplasty. J Bone Joint Surg Am. 2005;87(5):1080–1087.
112.
Lee KT, Lai CH, Singh S. Results of total elbow arthroplasty in the treatment of distal humerus fractures in elderly Asian patients. J Trauma. 2006;61(4):889–892.
113.
Li SH, Li ZH, Cai ZD, et al. Bilateral plate fixation for type C distal humerus fractures: experience at a single institution. Int Orthop. 2011;35(3):433–438.
114.
Liberman N, Katz T, Howard CB, et al. Fixation of capitellar fractures with the Herbert screw. Arch Orthop Trauma Surg. 1991;110(3):155–157.
115.
Liu JJ, Ruan HJ, Wang JG, et al. Double-column fixation for type C fractures of the distal humerus in the elderly. J Shoulder Elbow Surg. 2009;18(4):646–651.
116.
Ljung P, Jonsson K, Rydholm U. Short-term complications of the lateral approach for non-constrained elbow replacement. Follow-up of 50 rheumatoid elbows. J Bone Joint Surg Br. 1995;77(6):937–942.
117.
Lorenz H. Zur kenntnis der fractural capitulum humeri (Eminentiae Capitatae). Dtsche Ztrschr f Chir. 1905;78:531–545.
118.
MacAusland WR. Ankylosis of the elbow: with report of four cases treated by arthroplasty. JAMA. 1915;64:312–318.
119.
MacDermid JC. Outcome evaluation in patients with elbow pathology: issues in instrument development and evaluation. J Hand Ther. 2001;14(2):105–114.
120.
Mahirogullari M, Kiral A, Solakoglu C, et al. Treatment of fractures of the humeral capitellum using Herbert screws. J Hand Surg Br. 2006;31(3):320–325.
121.
Mansat P, Morrey BF. Semiconstrained total elbow arthroplasty for ankylosed and stiff elbows. J Bone Joint Surg Am. 2000;82(9):1260–1268.
122.
Marra G, Morrey BF, Gallay SH, et al. Fracture and nonunion of the olecranon in total elbow arthroplasty. J Shoulder Elbow Surg. 2006;15(4):486–494.
123.
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(10 Suppl):S1–S133.
124.
McCarty LP, Ring D, Jupiter JB. Management of distal humerus fractures. Am J Orthop. 2005;34(9):430–438.
125.
McKee M, Jupiter J, Toh CL, et al. Reconstruction after malunion and nonunion of intra-articular fractures of the distal humerus. Methods and results in 13 adults. J Bone Joint Surg Br. 1994;76(4):614–621.
126.
McKee MD, Jupiter JB, Bamberger HB. Coronal shear fractures of the distal end of the humerus. J Bone Joint Surg Am. 1996;78(1):49–54.
127.
McKee MD, Jupiter JB, Bosse G, et al. Outcome of ulnar neurolysis during post-traumatic reconstruction of the elbow. J Bone Joint Surg Br. 1998;80(1):100–105.
128.
McKee MD, Jupiter JB. A contemporary approach to the management of complex fractures of the distal humerus and their sequelae. Hand Clin. 1994;10(3):479–494.
129.
McKee MD, Jupiter JB. Semiconstrained elbow replacement for distal humeral nonunion. J Bone Joint Surg Br. 1995;77(4):665–666.
130.
McKee MD, Kim J, Kebaish K, et al. Functional outcome after open supracondylar fractures of the humerus. The effect of the surgical approach. J Bone Joint Surg Br. 2000;82(5):646–651.
131.
McKee MD, Pugh DM, Richards RR, et al. Effect of humeral condylar resection on strength and functional outcome after semiconstrained total elbow arthroplasty. J Bone Joint Surg Am. 2003;85-A(5):802–807.
132.
McKee MD, Veillette CJ, Hall JA, et al. A multicenter, prospective, randomized, controlled trial of open reduction–internal fixation versus total elbow arthroplasty for displaced intra-articular distal humeral fractures in elderly patients. J Shoulder Elbow Surg. 2009;18(1):3–12.
133.
McKee MD, Wilson TL, Winston L, et al. Functional outcome following surgical treatment of intra-articular distal humeral fractures through a posterior approach. J Bone Joint Surg Am. 2000;82-A(12):1701–1707.
134.
McKee MD. Randomized Trial of ORIF versus Total Elbow Arthroplasty for Distal Humerus Fractures. AAOS San Diego; 2007.
135.
McQueen MM, Gaston P, Court-Brown CM. Acute compartment syndrome. Who is at risk? J Bone Joint Surg Br. 2000;82(2):200–203.
136.
Meissner M, Paun M, Johansen K. Duplex scanning for arterial trauma. Am J Surg. 1991;161(5):552–555.
137.
Mellen RH, Phalen GS. Arthroplasty of the elbow by replacement of the distal portion of the humerus with an acrylic prosthesis. J Bone Joint Surg Am. 1947;29:348–353.
138.
Mighell M, Virani NA, Shannon R, et al. Large coronal shear fractures of the capitellum and trochlea treated with headless compression screws. J Shoulder Elbow Surg. 2010;19(1):38–45.
139.
Milch H. Fractures and fracture dislocations of the humeral condyles. J Trauma. 1964;4:592–607.
140.
Min W, Ding BC, Tejwani NC. Comparative functional outcome of AO/OTA type C distal humerus fractures: open injuries do worse than closed fractures. J Trauma Acute Care Surg. 2012;72(2):E27–E32.
141.
Moro JK, King GJ. Total elbow arthroplasty in the treatment of posttraumatic conditions of the elbow. Clin Orthop Relat Res. 2000;(370):102–114.
142.
Morrey BF, Adams RA. Semiconstrained elbow replacement for distal humeral nonunion. J Bone Joint Surg Br. 1995;77(1):67–72.
143.
Morrey BF, Bryan RS. Complications of total elbow arthroplasty. Clin Orthop Relat Res. 1982;(170):204–212.
144.
Morrey BF, Bryan RS. Infection after total elbow arthroplasty. J Bone Joint Surg Am. 1983;65(3):330–338.
145.
Morrey BF. Fractures of the distal humerus: role of elbow replacement. Orthop Clin North Am. 2000;31(1):145–154.
146.
Morrey BF. Post-traumatic contracture of the elbow. Operative treatment, including distraction arthroplasty. J Bone Joint Surg Am. 1990;72(4):601–618.
147.
Morrey BF. Surgical treatment of extraarticular elbow contracture. Clin Orthop Relat Res. 2000;(370):57–64.
148.
Morrey BF. The posttraumatic stiff elbow. Clin Orthop Relat Res. 2005;(431):26–35.
149.
Muller LP, Kamineni S, Rommens PM, et al. Primary total elbow replacement for fractures of the distal humerus. Oper Orthop Traumatol. 2005;17(2):119–142.
150.
Muller M. The Comprehensive Classification of Fractures of Long Bones. Berlin: Springer-Verlag; 1990.
151.
O’Driscoll SW, Morrey BF, Korinek S, et al. Elbow subluxation and dislocation. A spectrum of instability. Clin Orthop Relat Res. 1992;(280):186–197.
152.
O’Driscoll SW, Sanchez-Sotelo J, Torchia ME. Management of the smashed distal humerus. Orthop Clin North Am. 2002;33(1):19–33.
153.
O’Driscoll SW. Elbow instability. Hand Clin. 1994;10(3):405–415.
154.
O’Driscoll SW. Optimizing stability in distal humeral fracture fixation. J Shoulder Elbow Surg. 2005;14(1 Suppl S):186S–194S.
155.
O’Driscoll SW. Supracondylar fractures of the elbow: open reduction, internal fixation. Hand Clin. 2004;20(4):465–474.
156.
O’Driscoll SW. The triceps-reflecting anconeus pedicle (TRAP) approach for distal humeral fractures and nonunions. Orthop Clin North Am. 2000;31(1):91–101.
157.
Ochner RS, Bloom H, Palumbo RC, et al. Closed reduction of coronal fractures of the capitellum. J Trauma. 1996;40(2):199–203.
158.
Olson SA, Rhorer AS. Orthopaedic trauma for the general orthopaedist: avoiding problems and pitfalls in treatment. Clin Orthop Relat Res. 2005;(433):30–37.
159.
Ozdemir H, Urguden M, Soyuncu Y, et al. [Long-term functional results of adult intra-articular distal humeral fractures treated by open reduction and plate osteosynthesis]. Acta Orthop Traumatol Turc. 2002;36(4):328–335.
160.
Ozer H, Solak S, Turanli S, et al. Intercondylar fractures of the distal humerus treated with the triceps-reflecting anconeus pedicle approach. Arch Orthop Trauma Surg. 2005;125(7):469–474.
161.
Pajarinen J, Bjorkenheim JM. Operative treatment of type C intercondylar fractures of the distal humerus: results after a mean follow-up of 2 years in a series of 18 patients. J Shoulder Elbow Surg. 2002;11(1):48–52.
162.
Palvanen M, Kannus P, Niemi S, et al. Secular trends in the osteoporotic fractures of the distal humerus in elderly women. Eur J Epidemiol. 1998;14(2):159–164.
163.
Palvanen M, Kannus P, Parkkari J, et al. The injury mechanisms of osteoporotic upper extremity fractures among older adults: a controlled study of 287 consecutive patients and their 108 controls. Osteoporos Int. 2000;11(10):822–831.
164.
Papaioannou N, Babis GC, Kalavritinos J, et al. Operative treatment of type C intra-articular fractures of the distal humerus: the role of stability achieved at surgery on final outcome. Injury. 1995;26(3):169–173.
165.
Park MJ, Kim HG, Lee JY. Surgical treatment of post-traumatic stiffness of the elbow. J Bone Joint Surg Br. 2004;86(8):1158–1162.
166.
Parsons M, O’Brien, RJ, Hughes JS. Elbow hemiarthroplasty for acute and salvage reconstruction of intra-articular distal humerus fractures. Techniques in Shoulder and Elbow Surgery. 2005;6(2):87–97.
167.
Patterson SD, Bain GI, Mehta JA. Surgical approaches to the elbow. Clin Orthop Relat Res. 2000;(370):19–33.
168.
Pierce TD, Herndon JH. The triceps preserving approach to total elbow arthroplasty. Clin Orthop Relat Res. 1998;(354):144–152.
169.
Pollock JW, Athwal GS, Steinmann SP. Surgical exposures for distal humerus fractures: a review. Clin Anat. 2008;21(8):757–768.
170.
Pollock JW, Faber KJ, Athwal GS. Distal humerus fractures. Orthop Clin North Am. 2008;39(2):187–200.
171.
Potter D, Claydon P, Stanley D. Total elbow replacement using the Kudo prosthesis. Clinical and radiological review with five- to seven-year follow-up. J Bone Joint Surg Br. 2003;85(3):354–357.
172.
Poynton AR, Kelly IP, O’Rourke SK. Fractures of the capitellum–a comparison of two fixation methods. Injury. 1998;29(5):341–343.
173.
Prasad N, Dent C. Outcome of total elbow replacement for distal humeral fractures in the elderly: a comparison of primary surgery and surgery after failed internal fixation or conservative treatment. J Bone Joint Surg Br. 2008;90(3):343–348.
174.
Prokopis PM, Weiland AJ. The triceps-preserving approach for semiconstrained total elbow arthroplasty. J Shoulder Elbow Surg. 2008;17(3):454–458.
175.
Puchwein P, Wildburger R, Archan S, et al. Outcome of type C (AO) distal humeral fractures: follow-up of 22 patients with bicolumnar plating osteosynthesis. J Shoulder Elbow Surg. 2011;20(4):631–636.
176.
Puloski S, Kemp K, Sheps D, et al. Closed reduction and early mobilization in fractures of the humeral capitellum. J Orthop Trauma. 2012;26(1):62–65.
177.
Rashkoff E, Burkhalter WE. Arthrodesis of the salvage elbow. Orthopedics. 1986;9(5):733–738.
178.
Ray PS, Kakarlapudi K, Rajsekhar C, et al. Total elbow arthroplasty as primary treatment for distal humeral fractures in elderly patients. Injury. 2000;31(9):687–692.
179.
Richards RR, Khoury GW, Burke FD, et al. Internal fixation of capitellar fractures using Herbert screws: a report of four cases. Can J Surg. 1987;30(3):188–191.
180.
Ring D, Gulotta L, Chin K, et al. Olecranon osteotomy for exposure of fractures and nonunions of the distal humerus. J Orthop Trauma. 2004;18(7):446–449.
181.
Ring D, Gulotta L, Jupiter JB. Unstable nonunions of the distal part of the humerus. J Bone Joint Surg Am. 2003;85-A(6):1040–1046.
182.
Ring D, Jupiter JB, Gulotta L. Articular fractures of the distal part of the humerus. J Bone Joint Surg Am. 2003;85-A(2):232–238.
183.
Ring D, Jupiter JB. Complex fractures of the distal humerus and their complications. J Shoulder Elbow Surg. 1999;8(1):85–97.
184.
Ring D, Jupiter JB. Operative release of complete ankylosis of the elbow due to heterotopic bone in patients without severe injury of the central nervous system. J Bone Joint Surg Am. 2003;85-A(5):849–857.
185.
Ring D, Jupiter JB. Operative treatment of osteochondral nonunion of the distal humerus. J Orthop Trauma. 2006;20(1):56–59.
186.
Riseborough EJ, Radin EL. Intercondylar T fractures of the humerus in the adult. A comparison of operative and non-operative treatment in twenty-nine cases. J Bone Joint Surg Am. 1969;51(1):130–141.
187.
Rispoli DM, Athwal GS, Morrey BF. Neurolysis of the ulnar nerve for neuropathy following total elbow replacement. J Bone Joint Surg Br. 2008;90(10):1348–1351.
188.
Roberts RM, String ST. Arterial injuries in extremity shotgun wounds: requisite factors for successful management. Surgery. 1984;96(5):902–908.
189.
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.
190.
Robinson CM. Fractures of the distal humerus. In: Bucholz RW, HJ, Court-Brown C, Tornetta P, Koval KJ, eds. Rockwood and Green’s Fractures in Adults. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005:1051–1116.
191.
Rose SH, Melton LJ 3rd, Morrey BF, et al. Epidemiologic features of humeral fractures. Clin Orthop Relat Res. 1982;(168):24–30.
192.
Sabo MT, Athwal GS, King GJ. Landmarks for rotational alignment of the humeral component during elbow arthroplasty. J Bone Joint Surg Am. 2012;94(19):1794–1800.
193.
Sanchez-Sotelo J, Torchia ME, O’Driscoll SW. Complex distal humeral fractures: internal fixation with a principle-based parallel-plate technique. J Bone Joint Surg Am. 2007;89(5):961–969.
194.
Sanchez-Sotelo J, Torchia ME, O’Driscoll SW. Complex distal humeral fractures: internal fixation with a principle-based parallel-plate technique. Surgical technique. J Bone Joint Surg Am. 2008;90(Suppl 2):31–46.
195.
Sanders RA, Raney EM, Pipkin S. Operative treatment of bicondylar intraarticular fractures of the distal humerus. Orthopedics. 1992;15(2):159–163.
196.
Sano S, Rokkaku T, Saito S, et al. Herbert screw fixation of capitellar fractures. J Shoulder Elbow Surg. 2005;14(3):307–311.
197.
Schemitsch EH, Tencer AF, Henley MB. Biomechanical evaluation of methods of internal fixation of the distal humerus. J Orthop Trauma. 1994;8(6):468–475.
198.
Schildhauer TA, Nork SE, Mills WJ, et al. Extensor mechanism-sparing paratricipital posterior approach to the distal humerus. J Orthop Trauma. 2003;17(5):374–378.
199.
Schuster I, Korner J, Arzdorf M, et al. Mechanical comparison in cadaver specimens of three different 90-degree double-plate osteosyntheses for simulated C2-type distal humerus fractures with varying bone densities. J Orthop Trauma. 2008;22(2):113–120.
200.
Self J, Viegas SF, Buford WL Jr, et al. A comparison of double-plate fixation methods for complex distal humerus fractures. J Shoulder Elbow Surg. 1995;4(1 Pt 1):10–16.
201.
Shifrin PG, Johnson DP. Elbow hemiarthroplasty with 20-year follow-up study. A case report and literature review. Clin Orthop Relat Res. 1990;(254):128–133.
202.
Singh AP, Vaishya R, Jain A, et al. Fractures of capitellum: a review of 14 cases treated by open reduction and internal fixation with Herbert screws. Int Orthop. 2010;34(6):897–901.
203.
Sodergard J, Sandelin J, Bostman O. Mechanical failures of internal fixation in T and Y fractures of the distal humerus. J Trauma. 1992;33(5):687–690.
204.
Sodergard J, Sandelin J, Bostman O. Postoperative complications of distal humeral fractures. 27/96 adults followed up for 6 (2-10) years. Acta Orthop Scand. 1992;63(1):85–89.
205.
Soon JL, Chan BK, Low CO. Surgical fixation of intra-articular fractures of the distal humerus in adults. Injury. 2004;35(1):44–54.
206.
Spinner M, Kaplan EB. The relationship of the ulnar nerve to the medial intermuscular septum in the arm and its clinical significance. Hand. 1976;8(3):239–242.
207.
Spinner RJ, Morgenlander JC, Nunley JA. Ulnar nerve function following total elbow arthroplasty: a prospective study comparing preoperative and postoperative clinical and electrophysiologic evaluation in patients with rheumatoid arthritis. J Hand Surg Am. 2000;25(2):360–364.
208.
Stamatis E, Paxinos O. The treatment and functional outcome of type IV coronal shear fractures of the distal humerus: a retrospective review of five cases. J Orthop Trauma. 2003;17(4):279–284.
209.
Steinthal D. Die isolirte fraktur der eminenthia capetala in ellenbogengelenk. Zentralb Chir. 1898;15:17.
210.
Stoffel K, Cunneen S, Morgan R, et al. Comparative stability of perpendicular versus parallel double-locking plating systems in osteoporotic comminuted distal humerus fractures. J Orthop Res. 2008;26(6):778–784.
211.
Street DM, Stevens PS. A humeral replacement prosthesis for the elbow: results in ten elbows. J Bone Joint Surg Am. 1974;56(6):1147–1158.
212.
Swoboda B, Scott RD. Humeral hemiarthroplasty of the elbow joint in young patients with rheumatoid arthritis: a report on 7 arthroplasties. J Arthroplasty. 1999;14(5):553–559.
213.
Tachihara A, Nakamura H, Yoshioka T, et al. Postoperative results and complications of total elbow arthroplasty in patients with rheumatoid arthritis: three types of nonconstrained arthroplasty. Mod Rheumatol. 2008;18(5):465–471.
214.
Tan V, Daluiski A, Simic P, et al. Outcome of open release for post-traumatic elbow stiffness. J Trauma. 2006;61(3):673–678.
215.
Taylor TK, Scham SM. A posteromedial approach to the proximal end of the ulna for the internal fixation of olecranon fractures. J Trauma. 1969;9(7):594–602.
216.
Tyllianakis M, Panagopoulos A, Papadopoulos AX, et al. Functional evaluation of comminuted intra-articular fractures of the distal humerus (AO type C). Long term results in twenty-six patients. Acta Orthop Belg. 2004;70(2):123–130.
217.
Urbaniak JR, Aitken M. Clinical use of bone allografts in the elbow. Orthop Clin North Am. 1987;18(2):311–321.
218.
Urbaniak JR, Black KE Jr. Cadaveric elbow allografts. A six-year experience. Clin Orthop Relat Res. 1985;(197):131–140.
219.
Van Gorder GW. Surgical approach in supracondylar “T” fractures of the humerus requiring open reduction. J Bone Joint Surg Am. 1940;22:278.
220.
Veillette CJ, Steinmann SP. Olecranon fractures. Orthop Clin North Am. 2008;39(2):229–236.
221.
Ward WG, Nunley JA. Concomitant fractures of the capitellum and radial head. J Orthop Trauma. 1988;2(2):110–116.
222.
Watts AC, Morris A, Robinson CM. Fractures of the distal humeral articular surface. J Bone Joint Surg Br. 2007;89(4):510–515.
223.
Weiland AJ, Weiss AP, Wills RP, et al. Capitellocondylar total elbow replacement. A long-term follow-up study. J Bone Joint Surg Am. 1989;71(2):217–222.
224.
Wiggers JK, Brouwer KM, Helmerhorst GT, et al. Predictors of diagnosis of ulnar neuropathy after surgically treated distal humerus fractures. J Hand Surg Am. 2012;37(6):1168–1172.
225.
Wilkinson JM, Stanley D. Posterior surgical approaches to the elbow: a comparative anatomic study. J Shoulder Elbow Surg. 2001;10(4):380–382.
226.
Wright TW, Glowczewskie F. Vascular anatomy of the ulna. J Hand Surg Am. 1998;23(5):800–804.
227.
Yamaguchi K, Adams RA, Morrey BF. Infection after total elbow arthroplasty. J Bone Joint Surg Am. 1998;80(4):481–491.
228.
Yamaguchi K, Sweet FA, Bindra R, et al. The extraosseous and intraosseous arterial anatomy of the adult elbow. J Bone Joint Surg Am. 1997;79(11):1653–1662.
229.
Yang KH, Park HW, Park SJ, et al. Lateral J-plate fixation in comminuted intercondylar fracture of the humerus. Arch Orthop Trauma Surg. 2003;123(5):234–238.