Distal humerus fractures: review of literature, tips, and tricks

To examine the epidemiology and results of treatment of fractures of the distal humeral metaphysis. Observational cohort study. An orthopaedic trauma unit, which provides all the fracture care for a well-defined catchment population. A consecutive series of 320 patients with distal humeral fractures admitted to the unit between January 1988 and June 1997. We adopted a protocol of open reduction and fixation of all displaced fractures (greater than 5 mm of displacement in any plane) in patients who were medically fit for anesthesia. Postoperative immobilization was a cylinder cast for 6 weeks. Patients with undisplaced fractures or who were medically unfit were also treated nonoperatively in cylinder casts for 6 weeks. Epidemiological examination of patient subgroups and the incidence of complications of treatment. The overall incidence of distal humeral fractures in adults during this time was 5.7 cases per 100,000 in the population per year with an almost equal male to female ratio. There was a bimodal age distribution, simple falls were the most common overall cause of fracture, and the majority of the fractures were extra-articular (AO/OTA type A) or complete articular fractures (AO/OTA type C). The risk of complications during treatment was generally low in most patients, and the majority healed their fractures uneventfully. Overall, 90.6% of fractures united within 12 weeks and just under half of the remaining 9.4% patients with union complications healed without requiring further operative intervention by 24 weeks. The risk of union complications was higher following high-energy injuries, open fractures, and nonoperative treatment. Although the AO/OTA classification was not predictive of union complications, the "low" transcondylar (type A2.3 and A3) and simple intercondylar fracture (type C1.3) configuration had a greater risk of union complications than the "high" subtype. The rate of infection, myositis ossificans, and other implant-related complications were higher following operative treatment of type C fractures than type A and B fractures. The epidemiology of a consecutive unselected series of adult distal humeral fractures is defined in this study. The majority of these fractures are best treated surgically by rigid open reduction and internal fixation, except for "low" Type A and C fractures, which have a higher risk of union complications. The role of total elbow arthroplasty to treat these more complex injuries requires further evaluation.

Triceps splitting, triceps reflecting, and olecranon osteotomy are the most common posterior surgical approaches to the adult elbow, but no comparative data exist as to the exposure provided by each approach. The aim of this study was to determine which of these approaches provides the greatest exposure of the distal humeral articular surface. Each approach was performed on 4 adult cadaveric elbows. After the completion of each approach, the visible articular surface was painted with methylene blue. The elbow was then disarticulated, and the percentage of articular surface visible was measured. The median exposed articular surface for the triceps splitting, triceps reflecting, and olecranon osteotomy approaches was 35%, 46%, and 57%, respectively. Olecranon osteotomy exposed more articular surface than the triceps splitting approach (Mann-Whitney test, P =.03) but was not significantly greater than the triceps reflecting approach. However, even the olecranon osteotomy approach failed to provide visualization of more than 40% of the distal humeral articular surface.

Distal humeral fractures in adults are relatively uncommon injuries that require operative intervention in the majority of cases. Dual plate fixation, with placement of a separate strong plate on each column and orientation of the plates either at 90° or 180° to each other, is indicated for all adult fractures involving both columns of the distal part of the humerus. Acute total elbow arthroplasty is the preferred treatment for elderly patients with a displaced, comminuted, intra-articular distal humeral fracture that is not amenable to stable internal fixation. Displaced coronal shear fractures of the distal humeral articular surface require operative fixation, most typically via a lateral approach.