Elbow Fractures: Distal Humerus: The American Society For Surgery of The Hand.)

CURRENT CONCEPTS
Elbow Fractures: Distal Humerus

Andrew S. Wong, MD, Mark E. Baratz, MD
A distal humerus fracture can be a debilitating and difficult injury to treat. The anatomy of
the distal humerus is highly complex, as it articulates with both the radius and ulna and
allows for motion in multiple planes. Furthermore, comminution and osteopenia may render
the metaphyseal-diaphyseal junction weak, making adequate stabilization difficult. Various
methods of surgical fixation have been described, with bicolumnar plating being the most
popular. Controversy over fixation techniques and the introduction of recently developed
implants, including precontoured plates and locking plates, have led to renewed focus on
biomechanical testing of various fixation constructs. Failure of adequate reconstruction or
fixation can be addressed with adjunctive measures such as incorporation of structural bone
grafts, external fixation, or, in certain instances, salvage with total elbow arthroplasty. The
articular surface can also be injured from a shear force, resulting in fractures of the
capitellum and trochlea in the coronal plane. This article presents a review of current
literature concerning the diagnosis, classification, treatment, and outcome of distal humerus
fractures. (J Hand Surg 2009;34A:176–190. © 2009 Published by Elsevier Inc. on behalf of
the American Society for Surgery of the Hand.)
Key words Distal humerus, fractures, elbow.
RACTURES OF THE distal humerus are an increas- erative treatment unsuccessful and often makes fracture
F ingly common1 and often difficult injury to treat.

Although the overall incidence of distal humerus
fractures in adults has been reported to be only 5.7 cases
fixation difficult.
Given the challenges in treating these fractures, there
has been controversy regarding treatment. This article
per 100,000,2 these fractures can lead to considerable presents a review of current literature concerning the
long-term impairment. Patients who sustain distal hu- diagnosis, classification, treatment, and outcome of
merus fractures fall into a bimodal distribution of young treatment of distal humerus fractures.
patients, involved in high-energy trauma, and elderly,
osteoporotic patients, typically injured from a low-en- DIAGNOSIS
ergy fall.2 In both instances, fractures may range from a The mainstay in diagnosing distal humerus fractures is
simple extra-articular fracture pattern to a complex pat- conventional radiography, including views of the wrist
tern, involving extensive destruction of the articular and shoulder to rule out concomitant injury. Standard
surface with comminution and bone loss in the metaph- views, including anteroposterior, lateral, and oblique
yseal-diaphyseal junction of the bone. Difficulty is fur- views, can generally confirm the presence of and help
ther compounded by the difficult fracture anatomy. The to characterize distal humerus fractures.3 However, in
distal location and articular involvement makes nonop- fractures with severe comminution and shortening, frac-
ture fragments may overlap, obscuring the area in ques-
From Allegheny General Hospital, Pittsburgh, PA. tion. In the absence of articular comminution, intraop-
Current Concepts
Received for publication October 16, 2008; accepted in revised form October 26, 2008. erative traction views may be helpful in delineating the
No benefits in any form have been received or will be received related directly or indirectly to the major fracture fragments.
subject of this article. In shear fractures of the distal humeral surface, a
Corresponding author: Mark E. Baratz, MD, Allegheny General Hospital, Orthopaedics, 1307 radial head– capitellum view may be helpful. A modi-
Federal Street, 2nd Floor, Pittsburgh, PA 15212; e-mail: [email protected]. fication of a lateral view, the radial head– capitellum
0363-5023/09/34A01-0029$36.00/0 view is shot by angling the beam of the radiograph 45°
doi:10.1016/j.jhsa.2008.10.023
anteriorly to diminish overlap of the humeroradial and
176 䉬 ©  Published by Elsevier, Inc. on behalf of the ASSH.
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ELBOW FRACTURES: DISTAL HUMERUS 177
FIGURE 1: Radial head– capitellum view. A The radiographic beam is angled 45° anteriorly from a standard lateral elbow
radiograph. B Radiographic view of the radial head– capitellum.
FIGURE 2: Evaluation of a distal humerus articular and concomitant olecranon fracture with multiple different modalities. A, B
Anteroposterior and lateral radiographic views. C, D Representative 2-D CT reconstructions. E–G Three-dimensional CT
reconstruction views.
humeroulnar articulations (Fig. 1).4 This allows for anatomy of the distal humerus, confounded by the dis-
better visualization of small fragments of the capitellum tortion caused by comminution and displacement, can
that may be largely composed of articular cartilage. The make accurate assessment difficult. Three-dimensional
Current Concepts
double-arc sign is indicative of a fracture of the capi- (3-D) reconstructions provide a surface view of the
tellum and lateral trochlear ridge.5 The “double-arc” anatomy and the ability to subtract the ulna and hu-
represents the increased radiographic density of the merus from the image (Fig. 2). This technique is be-
subchondral bone of the capitellum and trochlear ridge. lieved by some authors to improve the accuracy of
Computed tomography (CT) is a powerful tool for fracture characterization. In a study by Dornberg et al.,
characterizing fractures of the distal humerus.3 Two- the addition of 3-D reconstructions to plain radiographs
dimensional (2-D) CT allows for accurate assessment and 2-D CT scans of distal humerus fracture improved
of the fracture in multiple planes and is often useful in intraobserver reliability but not the interobserver agree-
surgical planning.6 However, the complexity of the ment.7 These findings support the findings of Vannier et
JHS 䉬 Vol A, January 

178 ELBOW FRACTURES: DISTAL HUMERUS
FIGURE 3: Schematic of the AO classification system of distal humerus fractures. Group A includes extra-articular fractures.
Group B includes intra-articular fractures involving 1 column. Group C fractures are intra-articular and involve both columns.
al., who found 3-D CT to be equivalent to conventional an extra-articular fracture; type B fractures extend into
modalities in the evaluation of complex articular frac- the articular surface; and type C fractures describe com-
tures.8 plete separation of the articular surface from the shaft.
Current Concepts
Numerical attachments, from 1 to 3, are used to further

CLASSIFICATION classify degree of comminution, with 3 being more
Fractures of the distal humerus can be broadly classified highly comminuted.3 Intercondylar fractures can be
into supracondylar, transcondylar, and intercondylar characterized by the Riseborough and Radin classifica-
fractures based on the location of the fracture above the tion scheme, with all types including a supracondylar
olecranon fossa, through the olecranon fossa, or be- component9 (Fig. 4). Type I are nondisplaced fractures
tween the condyles of the distal humerus, respectively.3 between the capitellum and trochlea. Type II fractures
A more comprehensive and commonly used system is have a displaced, nonrotated fracture between the con-
the AO classification system (Fig. 3). Type A describes dyles, whereas type III fractures have a displaced and

FIGURE 4: Schematic of the Riseborough and Radin classification of intercondylar fractures (all types including a supracondylar
component). A Type 1, B type II, C type III, D type IV.
rotated fracture. Type IV describes severe comminution painting the exposed articular surfaces with methylene
of the articular surface of one or both condyles. blue, the authors determined that the olecranon osteot-
omy provided better exposure of the articular surface
NONSURGICAL TREATMENT than did the triceps-splitting and the triceps-reflecting
In nondisplaced fractures of the distal humerus, the techniques, but this difference did not reach statistical
literature supports nonoperative treatment. This consists significance in the case of triceps-reflecting exposure.11
of a period of immobilization, followed by bracing.3 It is our experience that the triceps-splitting and triceps-
However, given the proximity of the many fractures to reflecting exposures allow visualization of the posterior
the joint, it may be difficult or impossible to control portion of the trochlea, and only the olecranon osteot-
distal fractures with functional braces. Further, immo- omy provides access to the anterior aspect of the troch-
bilization of patients in a long-arm cast counters the lea and capitellum.
goal of early movement of the elbow to prevent stiff- The triceps-splitting posterior approach exploits the
ness. Our experience suggests that rigid surgical fixa- proximal innervation of the muscle, which allows for
tion is preferable. There is less morbidity of operative splitting of the tendon and distal muscle fibers without
intervention in patients with nondisplaced fractures than denervating the muscle (Fig. 6A–C). Most surgeons
in those with more extensive fractures, and a stable will limit the exposure to a split that stops at the tip of
fracture allows for immediate motion and reliable heal- the olecranon. This technique is most commonly used
ing3 (Fig. 5). for fractures without articular comminution, as expo-
The role for nonoperative treatment in displaced sure of the articular surface is limited.3,12 Ziran et al.
distal humerus fractures is limited, especially with intra- reviewed their experience with a true triceps-splitting
articular extension.3 However, in the setting of patients approach in 34 fractures.13 They performed a more
who are unable to have operative intervention due to extensive variation of this approach in which they peeled
medical comorbidities, treatment with the “bag of the triceps off the olecranon and both collateral liga-
bones” method may be the best alternative. This tech- ments off the distal humerus. This allowed them to see
nique consists of immobilizing the elbow in 60° of and fix fractures with extension to the anterior aspect of
flexion for 2 to 3 weeks, followed by gentle motion.3 the distal humerus. They did have 1 case of heterotopic
ossification (HO), 1 transient ulnar nerve palsy, 5 non-
SURGICAL APPROACH unions, and 4 cases of varus or valgus instability.
Surgical intervention is considered the standard treat- We usually stop short of peeling off the triceps
Current Concepts
ment for displaced distal humeral fractures.10 There are tendon when using this approach and have been reluc-
several options for the surgical approach. In general tant to release the collateral ligaments. By mobilizing
terms, complex, comminuted fracture patterns that in- the triceps tendon-muscle unit both medially and later-
volve the articular surface require more extensive ex- ally, 2 additional “windows” are created that allow for
posure than do extra-articular, simple fracture patterns. additional visualization, greater ease in reduction, and
In an attempt to elucidate the most advantageous ap- accuracy of implant placement (Fig. 6D, E). Further,
proach for such complex fractures, Wilkinson and Stan- resection of approximately 1 cm of the tip of the olec-
ley performed a triceps-splitting, triceps-reflecting, and ranon can aid in the view of the trochlea.3 We have used
olecranon osteotomy on cadaveric human elbows. By this approach for fractures with proximal extension,

FIGURE 5: A 67-year-old woman sustains a low-energy elbow injury. A, B Anteroposterior and lateral radiographic views of the
elbow reveal a nondisplaced supracondylar humerus fracture. The patient elected nonoperative treatment despite counseling for
operative intervention. C, D Anteroposterior and lateral views showing progression of fracture to nonunion after 2 months of
nonoperative treatment. E, F Anteroposterior and lateral views showing resultant open reduction and internal fixation of fracture
nonunion.
extra-articular fractures, and simple “T”-type fractures fractures through this approach. Another recent study
in which the articular surface can be reduced by seeing evaluated triceps tendon strength after triceps-sparing
only the posterior aspect of the trochlea. versus triceps-splitting or V-Y approach. The authors
Bryan and Morrey described the posterior “triceps- found all approaches to result in marked weakening of
sparing” approach, initially designed for reconstructive the triceps, but with statistically better strength after the
surgery of the elbow, particularly total elbow arthro- triceps reflecting approach than after approaches that
plasty (Fig. 6F, G). This involves elevating the triceps divided the tendon.16 We have found this approach
tendon from medial to lateral off of the olecranon with adequate for exposing extra-articular fractures without
care to maintain continuity of the triceps tendon with proximal extension and simple articular fractures that
Current Concepts
the proximal ulnar periosteum. At the completion of the can be aligned with indirect reduction. Care must be
procedure, the tendon is repaired to the proximal ulna taken when retracting the muscle on the lateral side. We
using sutures placed through drill holes.14 In a recent have seen 2 cases in which retraction with a Homan
single-surgeon review of functional outcome of AO retractor placed on the lateral cortex resulted in transient
type C fractures through a triceps-sparing approach, 7 radial nerve palsies.
patients were found to have good clinical scores, me- The olecranon osteotomy has been described for all
dian arc of motion of 90°, and no radiographic evidence fractures of the distal humerus, but particularly for
of HO.15 However, the authors noted in their discussion fractures with comminution of the articular surface.
that they had some difficulty fixing lateral condylar Previous authors have described a relatively high inci-

FIGURE 6: Surgical approaches to the distal humerus. A The ulnar nerve is identified, mobilized, and carefully protected. B
Triceps-splitting approach: superficial division of triceps. C Triceps-splitting approach: deep dissection exposing the distal
Current Concepts
humerus. One centimeter of the olecranon tip can be resected to increase visualization. D The medial border of triceps is elevated
to expose medial humerus. E The lateral border of the triceps can also be elevated to exposure of the lateral humerus. Care must
be taken to avoid excessive traction on the radial nerve. F Triceps-reflecting approach: The triceps is elevated from the distal
humerus, and triceps tendon is dissected subperiosteally from the olecranon insertion. G Triceps-reflecting approach: The triceps
tendon is completely reflected laterally taking care to preserve continuity with the ulnar periosteum. The tendon is subsequently
repaired through bone tunnels back to the olecranon. H Olecranon osteotomy: A chevron-shaped osteotomy provides increased
bony healing surface. Completion of the osteotomy through the far-cortex is completed with an osteotome to avoid damage to
articular surface. I Olecranon osteotomy: Extensive exposure of distal humerus, including the articular surface, after elevation of
the triceps off the posterior humerus.

FIGURE 7: A The anatomy of the distal humerus is likened to a hand holding a spool of thread with strong support of the spool
from each finger and a central void. B Likewise, the distal humerus has strong medial and lateral columns, which support the
distal articular segment. The thin central area of the bone, made up of the olecranon and coronoid fossae, provide little bony
support.
dence of nonunion. The risk of nonunion potential reflecting procedure to the transolecranon approach as
complication is lessened with use of a chevron-shaped well.20,21
osteotomy of the olecranon and proper fixation of the
osteotomy.3 After the osteotomy is performed, the dis- ULNAR NERVE
tal humerus is exposed by elevating the entire triceps Regardless of the approach, exposure of distal humerus
unit off the posterior distal humerus. Care should be fractures involves identifying and protecting the ulnar
taken not to dissect proximal to the distal one-fourth of nerve.12 The nerve is at risk during fracture reduction
the humerus to avoid injury to the crossing radial and while placing hardware. At the start of the proce-
nerve.17 The osteotomy is repaired using screws, plates, dure, the ulnar nerve is mobilized, tagged with a vessel
or wires. loop and, in most cases, transposed anteriorly.12,22
Coles et al. conducted a retrospective review of Doornberg et al. reported a 12- to 30-year follow-up of
patients having olecranon osteotomy for complex distal intra-articular distal humerus fractures treated without
humerus fractures.18 Sixty-seven patients had adequate transposition of the ulnar nerve.23 They reported only 1
follow-up to determine healing status of the osteotomy. ulnar nerve complication: a case of painful ulnar neu-
All osteotomies healed; however, 2 osteotomies re- ropathy necessitating subsequent anterior ulnar nerve
quired early revision osteosynthesis to address loss of transposition. Although ulnar nerve transposition may
reduction. In most cases, the osteotomy was stabilized not be required for a safe exposure and acceptable
with a single intramedullary screw, washer, and dorsal- outcome, it makes revision surgery much safer and
ulnar figure-of-8 wire construct. Plate fixation was used easier.
if the initial fixation was deemed inadequate. Implant
irritation appeared to be a major factor for revision STABILIZATION OF BONE
surgery. Eight percent of patients had elective implant The distal humerus is made up of a medial and a lateral
removal for hardware irritation alone. An additional column (Fig. 7). The articular surface is linked to the
Current Concepts
21% of patients had implants removed with coincident shaft of the humerus via medial and lateral metaphyseal
revision procedures. flares. The central area of the supracondylar region is
Recent studies have also described variations on weak because of the thin bone that lies between the
these established techniques. Olecranon osteotomy has coronoid and olecranon fossae.3 This area is particu-
been combined with the triceps-splitting approach for larly thin in patients with osteopenia.24 Diaphyseal-
distal articular fractures with extension to the midshaft metaphyseal contact is essential in creating a stable
of the humerus.19 Concern over denervation of the construct that has a good chance to heal.3
anconeus with olecranon osteotomy led to a description Many techniques have been described in the fixation
of the adaptation of the anconeus flap from the triceps of distal humerus fractures, such as use of specialized

FIGURE 8: A 33-year old man involved in a high-speed motor vehicle accident sustains an open distal humerus fracture. A, B
Anteroposterior and lateral injury films show a high degree of fracture comminution and bone loss, extensive intra-articular
involvement, and displacement of the fractures. C Anteroposterior view after the initial surgical management, which consisted of
thorough debridement of the fracture, provisional fixation, and placement of antibiotic beads. D, E Anteroposterior and lateral
views after definitive treatment. Definitive treatment: the articular surface was reconstructed with multiple, fully threaded screws.
Tricortical iliac crest was harvested and applied to the lateral column to reconstruct the areas of extensive bone loss. Stable
fixation was achieved with bicolumnar plating. The patient went on to unite the fracture.
Y-shaped plates or minifragment fixation.24,25 How- Plates placed in a parallel orientation were found to
ever, the most popular approach involves placing 1 have statistically significantly greater strength and stiff-
plate on the medial column and a second on the lateral ness than did those in a perpendicular orientation (p ⬍
column (Fig. 8). Authors have recommended orthogo- .05).
nal plating of the medial and posterolateral columns Placing a plate on the lateral aspect of the distal
(90-90 technique or perpendicular plating) of the distal humerus can be technically difficult and requires strip-
Current Concepts
humerus as well as parallel placement of plates on the ping soft tissues off of the lateral supracondylar ridge.31
medial and lateral aspects of the distal humerus.26 –30 A recent anatomic study evaluating the intraosseous
Proponents of parallel plating submit that a laterally blood supply of the distal humerus showed that the
based plate allows for a long screw to be placed from distal humerus diaphysis is consistently supplied by a
the lateral to medial cortex, whereas a screw placed in single nutrient artery. Distal to this point, blood flow
a plate positioned on the posterolateral cortex must be consists of watershed supply via multiple perforating
substantially shorter.24 Arnander et al. studied the stiff- vessels. The lateral column is perfused by segmental
ness of the perpendicular and parallel constructs using posterior condylar perforating vessels, which may be
3.5-mm reconstruction plates on epoxy resin humeri.31 stripped away with extensive subperiosteal elevation,

FIGURE 9: Elderly, low-demand woman with a supracondylar humerus fracture nonunion. A Anteroposterior and lateral
radiographs reveal an established nonunion. B Lateral and radiographic view of elbow after treatment with total elbow
arthroplasty.
increasing the risk of delayed union or nonunion.32 tating with screws from the other plate.27 Thus, the
Furthermore, the degree of fixation of both methods surgeon must assess the most judicious use of locked
may be above the threshold necessary for early motion plating to maximize benefit of the fixed-angle construct
and predictable fracture healing, rendering the marginal while limiting unnecessary technical challenges.
strength of parallel plating clinically unimportant. It has Regardless of fixation technique, comminution, bone
been our experience that simple “T-type” distal hu- loss, or poor bone quality may render internal fixation
merus fractures can be adequately treated with nearly inadequate, placing the fracture at risk for nonunion.10
any form of bicolumnar fixation, including “Y” plates, Some reports have identified the primary mode of fail-
dual reconstruction plates, 3.5-mm dynamic compres- ure as loss of fixation of the distal fragment.34,35 Hinged
sion plates, and precontoured plates placed in either a external fixation has been reported to aid in stability of
parallel or orthogonal orientation. We have seen a num- fixation while allowing motion of the elbow. Deuel et
ber of nonunions in “T-condylar” fractures treated with al. biomechanically tested the additional stability af-
one third tubular plates. The most challenging fracture forded by external fixation to various levels of internal
is low distal humerus fracture with articular comminu- fixation in a cadaver model.10 They found that addition
tion. In this injury, we have had our best results using of external fixation to compromised reconstruction
parallel, precontoured plates. plate constructs rendered stability that was similar to or
Adequate fixation in osteopenic bone is a major issue significantly greater than that with optimal internal fix-
in treating distal humerus fractures in the elderly.27 ation alone (p ⬍ .05).
Schuster et al. compared the stiffness of conventional Reconstruction of the articular surface of the distal
reconstruction plates, surgeon-contoured 3.5-mm lock- humerus is important in avoiding joint arthrosis. The
ing compression plates, and precontoured distal hu- articulating segment is commonly reconstructed prior to
merus locking plates in cadaver specimens of varying attempts to reattach it to the shaft of the humerus. With
bone mineral densities.27 Although stiffness in the 3 comminution of the joint surface, care must be taken to
groups was not significantly different (extension, p ⫽ avoid compression of the joint surface, which would
.881; flexion, p ⫽ .547), under cyclic loading the failure alter the width and contour. To achieve this goal, the
rate was lower in the distal humerus plate group than in articular segment is fixed with a fully threaded cortical
the conventional reconstruction plate group (p ⫽ .026). screw.3 In the face of severe destruction of the distal
There was no statistical difference seen between the humerus, the articular segment may not be reconstruct-
locking compression plate group and the conventional ible with standard internal fixation. Tricortical segments
Current Concepts
reconstruction plate group (p ⫽ .619). However, the of iliac crest can be used to rebuild comminuted seg-
authors of this study concluded that in the case of poor ments.36 Several authors have used portions of the
bone mineral density, both the distal humerus plate and radial head to reconstruct lateral trochlear defects.37 In
locking compression plates were superior to conven- rare instances, use of osteochondral allografts may be
tional reconstruction plating. Despite a possible biome- indicated.3
chanical advantage in osteoporotic bone, in the clinical
setting locked plating can be challenging due to the ELBOW ARTHROPLASTY
fixed angle of the screw.33 This can lead to suboptimal Primary total elbow arthroplasty has emerged as a
placement of screws as well as difficulty in interdigi- viable option for managing distal humerus fractures

in the appropriate patient.3 Common indications in- plasty for distal humeral fractures with a mean fol-
clude severely comminuted intra-articular fractures low-up of 56 months.41 Patients were found to have no
in which adequate fixation is not possible, particu- statistically significant difference (p ⬍ .05) in Mayo
larly in low-demand patients under the age of 65. Elbow Performance Score (MEPS). Implant survival
Elbow arthroplasty is also an option in older patients was also similar in the 2 groups, with survivorship of
with pre-existing, symptomatic elbow arthritis. Contra- 93% at 88 months in the early group and 76% in the
indications include pre-existing infection, high demand delayed group. Of note, among the 32 patients in this
and noncompliant patients, nonfunctioning biceps series, 10 were reported to have complications includ-
muscle, and, in the opinion of some authors, open ing aseptic loosening (5 cases), infection (2 cases), HO
fractures.38,39 It is our practice to approach each case (1 case), and ulnar nerve palsy (2 cases). Reported risk
with the plan to fix the distal humerus. However, in factors for implant failure include age of 65 years or
older patients with a severe fracture and poor bone, a less, 2 or more prior surgeries, or prior infection.40
total elbow implant is available in the operating room Although several reports have set forth promising re-
(Fig. 9). sults for this difficult problem, caution should be exer-
Muller et al. reported a series of 43 fractures treated cised in elbow replacements in the setting of fracture.
with primary total elbow arthroplasty with a mean fol- Patients must be appropriately counseled as to the po-
low-up of 7 years.38 These patients achieved an average tential for complications and the importance of adher-
range of motion from 24° to 131°. Thirty-two of 49 ence to restrictions.
patients received no further surgery and did not expe- Several newly described modalities have also been
rience any complications. Five revision arthroplasties recently reported in the treatment of selected distal
were required. humerus fractures. Kalogrianitis et al. examined their
In an extensive review of 92 elbows that received experience with the primary treatment of distal humerus
total elbow arthroplasty as salvage for distal humeral fractures with an unlinked total elbow prosthesis.42
nonunion, Cil et al. reported improvements in the ma- Nine elbows in 9 patients were followed for a mean of
jority of patients. The authors found 74% of patients 4 years. At final evaluation, all 9 elbows were stable and
with no pain or mild pain and 85% with a satisfactory pain relief was satisfactory. Additionally, Adolffson
subjective result.40 In terms of function, 83% reported and Hammer reported on their experience with 4 pa-
that they could use their extremity in 4 or more activ- tients treated with humeral hemiarthroplasty, all of
ities of daily living. Patients in the series had an average whom were found to have good or excellent results with
flexion-extension arc of 113°. However, Cil et al. also short-term follow-up.43 Additional studies and longer
documented a notable complication rate, with 32 reop- follow-up are needed to more fully judge the merits of
erations. Complications included aseptic loosening of these techniques.
the implant in 12 patients, with increased risk for loos-
ening observed in younger patients (under age 65) and OUTCOMES
with the cement technique of precoating the ulnar com- Reported outcomes are difficult to interpret given the
ponent. Five fractures of the implant occurred. Review wide range of injury and treatment. Furthermore, much
of the implant failure revealed that the fractures were of the existing literature consists of relatively small
likely associated with the substantial bone loss from the series.41 However, in recent reports, with appropriate
fracture, as failure occurred at the junction of the fixed rigid fixation, union rates are excellent, reported in the
component with the unsupported segment. Further- range 91% to 100%.2,22 Several reports have rated
more, fractures of the implant all occurred in extrasmall outcomes based on patient-reported outcome scales as
or small titanium implants, leading the authors to rec- well as objective measure of outcome. In a report of
ommend use of the largest implants possible and strict outcome after treatment of complex distal humerus
Current Concepts
adherence to activity restrictions. Additional complica- fractures with parallel plating at a mean of 2 years, good
tions included 4 periprosthetic fractures, 12 soft-tissue to excellent outcomes based on the MEPS were found
and wound complications, 2 transient nerve palsies, 1 in 27 of 34 (79%) patients.24 This is comparable with
C-ring failure, 1 bushing failure, and 1 painful proximal other reports, which range from 84% to 100% good to
radioulnar joint necessitating radial head excision. Im- excellent outcomes.15,22,44 In terms ofobjectively mea-
plant survival was 96% at 2 years, 82% at 5 years, and surable outcomes, mean flexion arc of the elbow after
65% at 10 and 15 years. surgical stabilization is reported in the range 90° mean
Prasad and Dent retrospectively compared patients arc to 106° mean arc,15,22–24 with mean pronation-
who had primary versus delayed total elbow arthro- supination arc of 150° mean arc to 165° mean arc.15,23

In a report of 12- to 30-year outcomes after surgical tures are comminuted fractures of the capitellum.3
treatment of intra-articular fractures, Doornberg et al. McKee et al. described a type IV fracture consisting of
found the short-term reports of success to be durable a coronal shear fracture of the capitellum with extension
based on Disabilities of the Arm, Shoulder, and Hand across much of the trochlea49 (Fig. 10). Ring et al.
score, MEPS, American Shoulder and Elbow Surgeons presented a more descriptive method of classification
score, and visual analog satisfaction scale, with 26 of 30 based on division of the articular surface into 5 regions:
(87%) good to excellent results. However, their findings capitellum and lateral trochlea, lateral epicondyle, pos-
also revealed radiographic evidence of posttraumatic terior aspect of the lateral column, posterior aspect of
arthritis in 80% of patients despite optimal surgical the trochlea, and medial epicondyle. Taking into ac-
treatment.23 count these anatomic regions, they identified 5 patterns
of injury involving various combinations of these 5
COMPLICATIONS regions.50
Various complications are encountered in the treatment Many methods of treatment have been reported since
of distal humerus fractures, with rates reported as high Hahn first described a fracture of the capitellum in 1853
as 48%.45 Apparent risk factors include high-energy based on his findings at autopsy of a palpable promi-
injuries, open fractures, and, in some accounts, nonop- nence at the elbow. These include closed reduction and
erative treatment.2,24,45,46 Although the vast majority of immobilization, excision, open reduction and internal
patients heal, 1 author has reported delayed union in 9% fixation, and replacement. Current literature supports
of patients at 12 weeks, with approximately half of closed treatment of nondisplaced fractures with a brief
these patients healing without further surgery within 24 period of immobilization.3 With nonoperative manage-
weeks.2 Another consistently reported complication is ment, close clinical and radiographic monitoring is nec-
HO. Gofton et al. noted important HO in 13% of essary to ensure maintenance of reduction. Older re-
patients, with a trend toward decreased incidence in ports have shown success with immediate excision of
patients who received postoperative prophylaxis with capitellar fractures, and, in selected patients, this may
indomethacin 100 mg twice per day for 24 hours, fol- still be an acceptable approach.51,52 However, current
lowed by 6 weeks of indomethacin 25 mg 3 times literature favors open reduction and internal fixation
daily.45 Other reports have noted development of HO as whenever possible as this restores the lateral buttress of
the most important complication that limited range of the elbow.
motion.24 Other less common reported complications Regarding surgical approach, some authors favor a
include infection and ulnar nerve neuropathy. posterior skin incision over the more common lateral
incision.53–55 A posterior incision allows for use of
ARTICULAR SHEAR FRACTURES multiple different deeper surgical planes through a sin-
Articular shear fractures merit a separate discus- gle incision. We have used a lateral approach for type I
sion given the challenges unique to this injury. and II fractures: those that involve the capitellum alone
These fractures are rare, making up only 1% of all or the capitellum plus a small portion of the trochlea.
elbow fractures.47 They usually result from low- Described deeper intervals include the Kocher (between
energy trauma, such as a fall from standing height, the extensor carpi ulnaris and anconeus), Boyd (eleva-
but may also result from high-energy trauma. Lee tion of the anconeus and supinator off the ulna), and/or
et al. described a direct mechanism of injury to the Kaplan (between the extensor digitorum communis and
capitellum as loading of the joint with the elbow extensor carpi radialis brevis) intervals. In many in-
partially flexed and the forearm partially pronated, stances, these intervals are used in combination, with
driving the radial head axially across the base of the Kaplan approach used for visualization, reduction,
the capitellum.48 Additionally, the capitellum may and provisional K-wire fixation and the more posterior
Current Concepts
be injured indirectly. In this instance, a subluxed Kocher interval used for definitive fixation. Additional
or dislocated radial head forcefully reduces, apply- exposure can be achieved with release of the lateral
ing a shear force to the capitellum. collateral ligament, necessitating subsequent repair.53,54
Articular shear fractures are separately classified In the event of a fracture extensively involving the
from other distal humeral fractures. Type I fractures, trochlea, the medial extent of the fracture is often dif-
so-called “Hahn-Steinthal fractures,” involve the entire ficult to access. In such instances, it may be necessary to
capitellum and lateral trochlear ridge. Type II (Kocher- perform a medial approach via a flexor-pronator split
Lorenz) fractures involve only the articular surface of or, in some cases, an olecranon osteotomy.50,53,56 It has
the capitellum with subchondral bone. Type III frac- been our practice to start the exposure on the lateral

FIGURE 10: Classification of capitellar fractures. A Type I Hahn–Steinthal, B Type II Kocher–Lorenz.
condylar ridge and split the common extensor in line reflecting the extensive variability in fracture patterns.
with the axis of the radius. If the lateral ulnar collateral Fracture fixation can be accomplished with lag screws,
ligament is intact, in most cases, it can be left alone. An headless compression screws, bioabsorbable screws,
excellent view of the capitellum and lateral half of the plates, and pins, alone or in various combinations (Fig.
trochlea is facilitated by elevating the capsule and the 11). Elkowitz et al. studied the relative biomechanical
origins of the radial wrist extensors off of the antero- strength of anteroposterior (AP) and posteroanterior
lateral aspect of the humerus. We do not hesitate to (PA) cancellous lag screws and AP headless compres-
reflect the lateral ulnar collateral ligament off of the sion screws (Acutrak; Acumed, Beaverton, OR) after
lateral epicondyle with or without a fleck of bone if this stabilizing a type I capitellar fracture.57 Posteroanterior
is necessary to help reduce or fix the fracture. The cancellous lag screws were found to have less displace-
lateral ulnar collateral ligament is repaired through drill ment upon cyclic loading than AP cancellous screws,
Current Concepts
holes in the lateral epicondylar region at the end of the with no statistically significant difference in load to
case. If the fracture involves the entire trochlea, we will failure. In comparison with the AP headless compres-
perform an olecranon osteotomy. Reducing the fracture sion screw, the PA cancellous lag screw was found to
may be complicated by anterior impaction of the pos- be less stable in cyclic loading and weaker in load to
terolateral margin of the lateral epicondyle. Ring et al. failure, although the difference was not statistically
has demonstrated the technique of disimpacting this significant. The authors concluded that this study dem-
bone, allowing it to hinge on its posterior cortex and onstrated superiority of certain constructs, but recog-
bone-grafting into the defect to facilitate reduction.50 nized that surgeon comfort and fracture variation
Various methods of fixation have been described, should dictate choice of fixation.

FIGURE 11: A, B Capitellar shear fracture: A defect from coronal shear fracture and B corresponding articular fragment. C, D
Reduction and compression of capitellar fragment with reduction forceps. Provisional fixation with guide wires for cannulated lag
screws. E, F Intraoperative fluoroscopic verification of anatomic reduction and fixation of fracture.
In recent studies, authors appear to favor use of PA fragment is often composed primarily of articular car-
screws, directed from the posterolateral column anteri- tilage and contains only a thin shell of subchondral
orly into the fragment to avoid articular damage.53,54,56 bone, making fixation difficult with lag techniques. In
However, Sen et al. favor placing screws from lateral to these cases, it may be necessary to use AP directed
anterior to avoid posterior stripping of the lateral con- screws, bioabsorbable screws, or, as a last resort, frag-
dyle in the hopes of diminishing the risk of avascular ment excision.
necrosis of the capitellum.54 Fortunately, the risk of Assessing outcome from current literature is
avascular necrosis seems to be exceptionally low.49,55 difficult as fixation techniques and fracture types
Sen et al. also described an antiglide plate that is used in vary among studies; furthermore, most studies are
conjunction with screw fixation to resist shearing forces retrospective in design and include relatively few
at the capitellum.54 In this technique, a minifragment patients in each series. Dubberley et al. have re-
Current Concepts
plate is bent distally to fit the curvature of the superior cently reported their experience in a relatively
extra-articular portion of the capitellum. The plate is large series of 28 patients after open reduction and
then placed over the anterior surface of the lateral internal fixation of capitellar and trochlear frac-
column and fixed proximally only. More complex fractures.53 Patients had an average flexion-extension
tures involving the trochlea may require additional arc of 119° and supination-pronation arc of 156°.
screws placed from the posteromedial column. In the This is equivalent to that of other studies,
case of posterior comminution, it may be necessary to which report flexion-extension arcs from 96° to
supplement fixation with additional plates, pins, cannu- 131° and pronation-supination arcs from 167° to
lated screws, or bone graft.53 In type II fractures, the 180°.49,50,55,56

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Current Concepts


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CURRENT CONCEPTS

Elbow Fractures: Distal Humerus

F ingly common1 and often difficult injury to treat.

176 䉬 ©  Published by Elsevier, Inc. on behalf of the ASSH.

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Numerical attachments, from 1 to 3, are used to further

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FIGURE 10: Classification of capitellar fractures. A Type I Hahn–Steinthal, B Type II Kocher–Lorenz.

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Reviews of patient-reported outcomes have shown REFERENCES

treatment of intraarticular fractures of the distal humerus. J Orthop

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