Distal Humerus Fractures

There are several posterior approaches and they can be
classified into five general types: olecranon osteotomy, paratricipital
(triceps-on), triceps splitting, triceps reflecting, and triceps
dividing. 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); any
associated injuries (i.e., triceps laceration or olecranon fracture)
that may make one approach more favorable.

Olecranon Osteotomy. The olecranon osteotomy was first described by MacAusland¹⁰⁶ and has undergone several modifications.²⁶,⁴⁹,¹⁶²
When compared with other posterior approaches, osteotomy of the
olecranon provides the best visualization of the distal humerus
articular surface,²⁰⁴ 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 total elbow arthroplasty 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 (Figure 33-10B).
It remains unclear whether the ulnar nerve should be transposed or
replaced in the cubital tunnel 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 (Figure 33-10C). 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 Kirchner wire
(K-wire). Two osteotomes, placed into each arm of the chevron, apply
controlled leverage of the olecranon fragment causing fracture of the
remaining third (Figure 33-10D). 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.¹⁵¹ A transverse olecranon osteotomy is also an option as it is technically simpler and can be performed more rapidly.⁴⁹,⁷⁰
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 (Figure 33-10E). Typically, the anconeus muscle must be divided to reflect the triceps posteriorly which causes its denervation.¹³⁸
Anconeus muscle denervation can be avoided by reflecting the anconeus
muscle posteriorly along with the olecranon fragment and triceps.¹⁵ Once the osteotomy (Figure 33-10F,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,¹¹¹ screw/tension band constructs, or compression plating.⁵⁵ The author’s preferred method of fixation is compression plating.⁶⁸
When using this method the plate is prefixed 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.⁵⁷

Paratricipital Approach (Triceps-On). The paratricipital
(bilaterotricipital, triceps sparing, or triceps-on) approach was first
reported by Alonso-Llames in 1972 for the management of pediatric
supracondylar fractures.⁷ 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.¹⁷⁹

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 (Figure 33-11A) and the triceps is elevated off the posterior aspect of the humerus (Figure 33-11B).
Laterally, the triceps is elevated off the lateral intermuscular septum
and the posterior humerus in conjunction with the anconeus muscle (Figure 33-11).⁷,¹⁷⁹
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.¹³ The third surgical window allows improved visualization of the distal humerus articular surface.

The paratricipital approach has several advantages,
including, avoidance of an olecranon osteotomy, therefore the risks of
nonunion and symptomatic olecranon hardware are avoided. Additionally,
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,¹⁷⁹
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.⁵³ 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.¹¹¹,¹⁵⁴,¹⁷⁹

In distal humerus fractures deemed unrepairable, in
which the intent is to proceed directly to total elbow arthroplasty,
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 in which an
initial attempt at ORIF is planned and there is a possibility of an
intraoperative convertion to total elbow arthroplasty should fixation
be deemed unsuccessful.

Triceps
Splitting Approach. The triceps splitting approach described by
Campbell involves a midline split through the triceps tendon.²⁵ The medial and lateral columns are exposed with subperiosteal dissection starting from the midline and moving outwards (Figure 33-12).
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 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.

The advantages of the triceps splitting approach are its
relative technical ease and the ability to convert from open reduction
and internal fixation to total elbow arthroplasty with few
consequences. The disadvantages of the approach include limited
visibility of the articular surface, disruption of the extensor
mechanism requiring postoperative protection and the risk of triceps
dehiscence. In order to improve triceps healing, Gschwend et al.⁵⁹ modified the approach to incorporate a flake

of olecranon bone. McKee et al.¹¹⁸
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.

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.⁹⁶
This interval can be identified by a thin fat stripe or by the
perforating branches of the recurrent posterior interosseous artery (Figure 33-15A).
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) (Figure 33-15B,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 (Figure 33-15D).
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.

An easier, and some believe safer, approach to the
radiocapitellar joint is the extensor digitorum communis (EDC) split.
This approach involves creation of a lateral elbow arthrotomy at the
equator of the radiocapitellar joint (Figure 33-16). The site of the arthrotomy is chosen by palpating the capitellum

and radial head to determine the midequator. 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 midequator is avoided, as it may disrupt the LUCL.

The Kaplan approach uses the interval between ECRL and EDC to access the radiocapitellar joint.⁹²
The approach provides good exposure of the radial head and capitellum
and remains anterior to the lateral collateral ligament insertion. The
forearm should be pronated during distal extension of the approach to
maximize the distance to the posterior interosseous nerve.³²

Medial approaches to the elbow can be accessed by a
direct medial skin incision or 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.⁷¹,¹⁵¹
The medial supracondylar ridge is identified and the flexor-pronator
origin is release 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 medial
collateral ligament.

The medial coronoid, the anterior bundle of the medial
collateral ligament (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 flexor carpi ulnaris, 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 Scham¹⁹⁵
described a similar approach with the only difference being that the
ulnar head of FCU is elevated anteriorly with the other flexors.

The anterior approach to the elbow is rarely used for the internal fixation of adult distal humerus fractures⁹³,¹⁵¹
because it provides little access to the medial and lateral columns for
the application of internal fixation. This approach may be used if
access to the brachial artery or median nerve is required for repair or
in release of posttraumatic elbow contractures.

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 (Figure 33-17).
Other circumstances are elderly patients with unrepairable distal
humerus fractures in which arthroplasty is the most reasonable option,
however, 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.

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.

In 1969, Riseborough and Radin¹⁶⁸
compared operative with 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 Morgan²²
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, whereas three complained of elbow aches in cold
and damp weather.

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 in which
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 Type A2 and A3). Closed reduction and percutaneous K-wire
fixation has been described for treatment of these injuries in adults.⁸²
The technique in adults is similar to the technique used 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. 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.

Open reduction and internal fixation is the preferred
fixation technique for these fractures (Transcolumn, 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
highdensity screw insertion into the distal articular segment. In
certain low transcolumn fractures in elderly patients with severe
osteopenia or pre-existing arthritis, total elbow arthroplasty may be
the most appropriate form of treatment. Elbow arthroplasty is 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.

Surgical fixation of distal humerus fractures requires
preoperative planning, specialized implants, instruments, and surgical
expertise. Medically fit and stabilized patients with uncompromised
soft tissues may be best managed with early surgery within 48 to 72
hours.⁷⁶ Early surgery may lead to
decreases complications such as heterotopic ossification and stiffness.
Polytrauma patients that 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
owing to partial healing and callous, increased bleeding, and the
increased risk of heterotopic ossification.

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.

Surgical Approach. The principles of 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 total elbow arthroplasty. 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 that allows visualization

of
the posterior aspects of both columns and the posterior aspect of the
articular surface. In cases in which 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 (Figure 33-18).

AO/OTA Type A and C Fractures.
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.
Once the fractured articular fragments are reduced and interdigitated,
a large tenaculum can be used to hold the reduction until provisional
transfixion with K-wires. Definitive fixation of the articular segment
can be done with one or two centrally placed screws along the
capitellar-trochlear axis (Figure 33-19) or by screws placed through plates that are applied in a parallel fashion (Figure 33-20).
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 (non-overdrilled) position screws rather than lag screws
should be used to stabilize the articular segment.

Small articular fracture segments that cannot be
incorporated into the greater fixation construct should be
independently fixated. Supplementary implants should be available to
address these small osteochondral fragments, such as minifragment
plates, headless compression screws, countersunk small diameter screws,
threaded K-wires, and 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,⁶⁷,⁸⁴,¹⁸¹ parallel,^13b,¹⁷⁴,¹⁷⁵ or triple⁵⁵,¹¹¹ plating. No clinical superiority of either method has been reported when comparing orthogonal with parallel plating techniques.

Orthogonal plating involves the placement of plates on both columns at 90-degree angles (Figure 33-21).
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 on 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 used.

Parallel plating also uses two plates; however, the
plates are placed parallel to each other on their respective
supracondylar ridges (Figure 33-22). 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 engage fragments
that are secured to the opposite column.^13b,¹³⁶,¹³⁷,¹⁷⁴
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.

Before definitive plate fixation, the elbow should be placed

through a range of motion to ensure there is no hardware impingement.
Also, an attempt should be made to dynamically compress the
supracondylar level fracture with eccentrically placed screws through
the medial and lateral plates.¹³⁶,¹³⁷
If possible, the plates should end at different levels on the humeral
shaft to minimize the stress riser effect and each plate should have at
least three bicortical screws proximal to the metaphyseal comminution.¹¹¹,¹³⁷

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.¹⁴⁰
If absolute rigid fixation cannot be achieved to allow early range of
motion, triple plating should be considered as recommended by Gofton⁵⁵ and Jupiter.⁸³ Triple plating can also be useful for fixation of coronal plane fractures (Figure 33-19).

Fracture specific precontoured plates are now 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.

AO/OTA Type 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.⁸⁵ Single
column plating has the advantage of providing an antiglide construct at
the proximal fracture line between the column and humeral shaft (Figure 33-18).
In certain highly comminuted partial-articular fractures in elderly
patients with osteopenia, total elbow arthroplasty may also be an
appropriate treatment option. Elbow arthroplasty is discussed later in
this chapter.

Controversy exists on which implant designs and plate
configurations confer the greatest amount of stability when treating
distal humerus fractures. Jacobson et al.⁷⁹
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 with
other constructs which included parallel and triple plating.

Helfet and Hotchkiss⁶⁵
also found that orthogonal plating provided greater rigidity and
fatigue resistance when compared with a single Y plate or crossed
screws.

In contrast, Schemitsch et al.¹⁷⁸
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.¹⁸¹
found that parallel plating trended towards having greater rigidity and
load to failure than orthogonal plating, however, the differences did
not reach statistical significance. Arnander et al.,¹¹
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 with 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.¹⁸⁰
demonstrated that locking 3.5-mm reconstruction plates applied
orthogonally had superior cyclic failure properties when compared with
conventional nonlocked plates applied in a similar fashion in cadavers
with low bone mineral density. Stoffel et al.¹⁹⁰
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 be 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 one third tubular plates, which have been shown to have insufficient

strength and are susceptible to breakage.⁷⁰,¹³⁶,¹³⁷,¹⁹⁶ These plates should not be used in the primary two-plate construct; however, they may be used as a supplementary third plate.

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^* When averaging the outcomes of 17 series published between 2002 and 2009 (Table 33-4), 85% of patients experienced good to excellent outcomes at a mean follow-up of 50 months. Doornberg et al.³⁵
have shown that the rate of good to excellent outcomes is durable in
the long-term (12 to 30 years). Patients that 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.

Gofton et al.⁵⁵
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 with
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 with unaffected limb. The mean score on the Disabilities
of the Arm, Shoulder and Hand (DASH) questionnaire was 12, which is
very close to the overall normative score of 10.1.⁷⁴
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 and colleagues¹²⁰
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 among age-matched controls.

Approximately 7% of distal humerus fracture are open,¹⁷² and they are classified according to the system of Gustilo and Anderson.⁶¹
The principles of open fracture treatment have remained unchanged for
the last three decades. The priorities are wound irrigation and
débridement, intravenous antibiotics, tetanus coverage, fracture
stabilization and appropriate soft tissue management.⁶¹,¹⁴² 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,
whereas blast or gun shots lead to grade III wounds.¹⁷²
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.¹¹⁸,¹⁷²
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 posttraumatic arthritis and
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.¹¹⁸
reviewed 26 patients who underwent open reduction and internal fixation
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 Mayo Elbow Performance score, 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 débridement. Four
patients (15%) were diagnosed with delayed union (>16 weeks), with
two patients going on to require revision surgery with bone grafting.

Intra-articular distal humerus fractures are among the
most challenging fractures to manage. Nonoperative treatment, 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 rheumatoid arthritis (Figure 33-25).
In cases in which rigid internal fixation cannot be achieved to allow
early range of motion, resultant prolonged immobilization often leads
to poor outcomes.⁴ Total elbow arthroplasty for such factures is a reliable treatment option with good outcomes^*

Absolute contraindications to total elbow arthroplasty
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 open reduction and internal fixation. 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 débridement followed by
splinting and antibiotics until definitive surgery is deemed
appropriate.

Total elbow arthroplasty is a technically demanding
procedure and should be done by an experienced upper limb or trauma
surgeon. Radiographs should be templated preoperatively to ensure
implants of the appropriate size and lengths are available. The
surgical approach starts with an extensile posterior skin incision and
the elevation of medial and lateral fasciocutaneous flaps. The ulnar
nerve requires identification and protection during the surgical
procedure as it is vulnerable to direct injury or indirect traction
injury. Presently, the literature is unclear whether the ulnar nerve
should be anteriorly transposed or returned to the cubital tunnel at
the completion of the procedure.

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, whereas its disadvantage is that it increases the
complexity of the procedure because it provides less visualization of
the elbow joint. 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 total elbow arthroplasty through
an olecranon osteotomy is possible, however, not recommended. 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.

Generally, a linked design of total elbow arthroplasty
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 medial and
lateral collateral ligaments that 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.¹¹⁹
have shown that condylar resection during total elbow arthroplasty does
not affect strength or functional outcome; therefore, through the
medial arthrotomy while protecting the ulnar nerve, the medial
collateral ligament is released and the medial fracture fragments are
excised. Similarly, through the lateral arthrotomy the lateral
collateral ligament 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 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
parallel to the axis of elbow joint rotation, and to examine the
insertions of the medial and lateral intermuscular septa, which are
also parallel to the axis. Reaming and broaching of the humeral canal
are 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 recreated. 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 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 that the axis of rotation bisects the radial head and that the
axis is parallel to the flat surface on the proximal dorsal ulna.³⁸

It is recommend that antibiotic-laden bone cement be used and cement restrictors for the humeral and ulnar canals.⁴⁶
A cement gun with a small diameter injector nozzle is used to ensure
complete filling of the intramedullary canal. The humeral and ulnar
components can be cemented together at the same time or separately.

The outcomes of total elbow arthroplasty for distal
humerus fractures at short-term and mid-term follow-up have been
reproducibly good (Table 33-6).^* Most studies have used the Coonrad-Morrey implant (Zimmer, Warsaw, IN), which is

linked and described as semiconstrained because of its “sloppy” hinge.

In a retrospective study, Frankle et al. compared open
reduction and internal fixation with elbow arthroplasty in 24 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, as 8 of 12 patients in the
arthroplasty group had rheumatoid arthritis (RA) and none had RA in the
ORIF group. McKee and colleagues¹¹³
presented preliminary data from a randomized prospective study
comparing open reduction and internal fixation to elbow arthroplasty in
elderly patients with comminuted distal humerus fractures. Outcomes
were assessed with the Mayo Elbow Performance Score (MEPS) and
Disabilities of the Arm, Shoulder, and Hand (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 total elbow arthroplasty group; however,
the DASH score was not significantly different between groups. The
reoperation rate between the arthroplasty and the open reduction and
internal fixation groups was also not significantly different.

At the present time, there are no midterm or long-term
studies comparing the outcomes and complications of open reduction and
internal fixation with total elbow arthroplasty for the treatment of
complex distal humerus fractures in elderly persons. It is probable
that the revision surgery rate would increase over time in patients
treated with elbow arthroplasty, when compared with patients undergoing
ORIF because of polyethylene wear, aseptic loosening, periprosthetic
fracture, and infection.

The indications for distal humerus hemiarthroplasty are
virtually identical to total elbow arthroplasty. 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 unreconstructable distal humerus fractures who are deemed
too young or too active for total elbow arthroplasty. It should be
noted, however, that the believed benefits of hemiarthroplasty are
completely speculative and no literature exists to support its use over
total elbow arthroplasty.

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.⁷³,¹³⁵ Therefore, when considering hemiarthroplasty, the medial and lateral columns must be reconstructable (Figure 33-27),
the radial head and coronoid must be intact, and the medial and lateral
collateral ligaments must be repairable or intact on their respective
condyles.¹³,⁷³

The contraindications to distal humerus hemiarthroplasty
are similar to those for total elbow arthroplasty. Additional
contraindications include deficient medial or lateral column bone,
deficient medial or lateral collateral ligaments, 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 these circumstances with deficient bone or
soft tissue, linked total elbow arthroplasty should be considered.

As with total elbow arthroplasty, hemiarthroplasty is a
technically demanding procedure and should only be conducted by
surgeons experience in upper limb arthroplasty or complex trauma.
Standard elbow radiographs are usually sufficient for assessing the
fracture pattern and implant templating. Computed tomography (CT) will
confirm the articular fragmentation, will identify occult fractures
(such as fractures of the coronoid and radial head) and may assist with
open reduction and internal fixation of the columns. 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 total elbow arthroplasty 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.

Once the facture is visualized, it should be carefully
inspected to ensure open reduction and internal fixation 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 three ways, preoperatively templating of
contralateral elbow radiographs, piecing together the fractured
trochlea and capitellum and comparing with the available trial
implants, and 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 condyles, are used to gauge correct implant
length. Provisional fixation of one or both of the fractured columns
with Kirschner 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:
(i) the fractured columns can be definitively fixated in anatomic
position with contoured plates/screws, or with K-wires/tension bands
augmented with sutures (Figure 33-28) and then
the implant cemented; (ii) the implant can be cemented first in
anatomic position followed by columnar fracture fixation; (iii) 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
preceding methods are feasible; however, if using a paratricipital
approach only the latter two are possible.

Before 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.

There is little information in the literature pertaining to the outcomes of distal humerus hemiarthroplasty for trauma.³,⁷³,¹⁵⁰,¹⁸² Adolfsson and Hammer reported on four cases using the non-anatomic Kudo (Biomet, Inc., Warsaw, IN) humeral prosthesis.³
At a mean of 10 months follow-up (range, 3 to 14 months), the Mayo
Elbow Performance Scores were excellent in three patients and good in
one. The mean arc of elbow motion was 106 degrees and all patients
described having no pain.

Parsons et al.¹⁵⁰
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
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.

Nonoperative management of articular fracture of the
distal humerus in young patients is rarely recommended and it is
generally reserved for patients deemed medically unfit to undergo

surgery.
Nonoperative management techniques include above-elbow casting, and
collar and cuff treatment with early mobilization, the so-called “bag
of bones” method.

Closed reduction and casting is a described method for the treatment of displaced capitellar fractures.¹⁴¹
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.

Anatomic reduction and rigid internal fixation is
considered the gold standard for most displaced articular fractures of
the distal humerus. Rigid internal fixation allows fracture healing to
occur anatomically while permitting early range of motion to maximize
function. In cases in which 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.

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 decreases the risk of
cutaneous nerve injury.³⁶ The deep lateral approach is via the Kocher interval⁹⁶
between anconeus and extensor carpi ulnaris. The arthrotomy is made
anterior to the lateral ulnar collateral ligament 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 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 screws placed anterior to posterior
through the articular surface (Figure 33-31), or by screws placed into the capitellum in a retrograde

fashion from the posterior aspect of the lateral column or by a combined method (Figure 33-32).
The placement of posterior to anterior screws has been shown to be
biomechanically more stable and has the added benefit of not violating
the articular surface.⁴² In cases in which rigid internal fixation is obtained, early active range of motion can be initiated.

When there is comminution or impaction of the posterior aspect of the lateral column (Ring et al.,¹⁶⁷ type 3, and Dubberly et al.³⁷
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 2) may be exposed by using the lateral epicondylar
fracture as an osteotomy, reflecting the epicondylar fragment with the
origin of the lateral collateral ligament distally (Figure 33-33).
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.

Rigid internal fixation of the Kocher⁹⁵-Lorenz¹⁰⁵
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.

Isolated trochlear fractures (AO/OTA Type B3.2) are rare
and should be treated with open reduction and internal fixation.
Fixation may be done antegrade through the cartilage or retrograde from
posterior through a medial deep approach.

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 lateral collateral
ligament 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 medial collateral ligament. A similar approach uses
a lateral epicondylar fracture, which may be reflected distally to
hinge open the elbow joint. Medial joint exposure can also 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.

In elderly patients with severe articular comminution
and osteopenia, or in patients with pre-existing conditions of the
elbow such as rheumatoid arthritis, open reduction and internal
fixation may not be feasible. In such cases where rigid internal
fixation cannot be achieved, elbow arthroplasty is a reliable treatment
option. Total elbow arthroplasty can be done through a paratricipital
approach using a linked implant. (Please see prior section on TEA
insertion technique.) Distal humerus hemiarthroplasty is another
surgical option for unreconstructable articular fractures (Figure 33-34).
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 total elbow
arthroplasty. Further studies are required to determine the role of
distal humerus hemiarthroplasty in elbow trauma.

The outcomes after open reduction and internal fixation
of capitellar fractures with or without involvement of the lateral
trochlear

ridge have been shown to be predictably good.^* More complex fracture patterns with involvement of the anterior trochlea also have a relatively good prognosis;³⁷,¹¹⁶,¹⁶⁷,¹⁸⁸ however, Dubberley et al.³⁷ have shown that the outcomes do deteriorate with increasing fracture complexity.

The most common complication after surgical management of distal humerus articular fractures is elbow stiffness.³⁷,¹⁶⁷
This is initially managed with nonoperative techniques, such as
physiotherapy and splints. In refractory cases, open and arthroscopic
contracture releases have proved successful. Other complications
include nonunion,¹⁶⁶ malunion,¹⁸ ulnar neuritis,¹⁶⁷ and avascular necrosis.³⁷,¹⁰³