DISTAL HUMERUS FRACTURE

1. Introduction
- This is a relatively uncommon injury, comprising approximately 2% of all fractures and one-
third of all humerus fractures.
- Incidence of distal humerus fractures in adults is 5.7 per 100,000 per year.
- Distal humerus fractures have a bimodal age distribution, with peak incidences occurring
between the ages of 12 and 19 years in men and 80 years and older in women.
- Greater than 60% of distal humerus fractures in the elderly occur from low-energy injuries,
such as a fall from standing height.
- Extra-articular fractures (40%) and bicondylar intra-articular fractures of the distal humerus
(37%) are the most common fracture patterns.
- Extension-type supracondylar fractures of the distal humerus account for >80% of all
supracondylar fractures in children.
2. Anatomy
- Distal humerus may be conceptualized as medial and lateral “columns,” each of which is
roughly triangular in shape and composed of an epicondyle, or the nonarticulating terminal
of the supracondylar ridge, and a condyle, which is the articulating unit of the distal
humerus (Fig. 17.1).
- Articulating surface of the capitellum and trochlea projects distal and anterior at a 40- to
45degree angle. The center of the arc of rotation of each condyle’s articular surface lies on
the same horizontal axis; thus, malalignment of the relationships of the condyles to each
other changes their arc of rotation, thus limiting flexion and extension (Fig. 17.2).
- The trochlear axis compared with the longitudinal axis of the humerus is 4 to 8 degrees of
valgus.
- The trochlear axis is 3 to 8 degrees internally rotated.
- The intramedullary canal of the humerus ends 2 to 3 cm above the olecranon fossa.
3. Mechanism of Injury
- Most low-energy distal humeral fractures result from a simple fall in middle-aged and
elderly women in which the elbow is either struck directly or is axially loaded in a fall onto
the outstretched hand.
- Motor vehicle and sporting accidents are more common causes of injury in younger
individuals.
4. Diagnosis
CLINICAL EVALUATION
- Signs and symptoms vary with degree of swelling and displacement; considerable swelling
frequently occurs, rendering landmarks difficult to palpate. However, the normal
relationship of the olecranon, medial, and lateral condyles should be maintained, roughly
delineating an equilateral triangle.
- Crepitus with range of motion and gross instability may be present; although this is highly
suggestive of fracture, no attempt should be made to elicit it because neurovascular
compromise may result.
 - A careful neurovascular evaluation is essential because the sharp, fractured end of the
proximal fragment may impale or contuse the brachial artery, median nerve, or radial nerve.
- Serial neurovascular examinations with compartment pressure monitoring may be
necessary with massive swelling; cubital fossa swelling may result in vascular impairment or
the development of a volar compartment syndrome resulting in Volkmann ischemia.
RADIOGRAPHIC EVALUATION
- Standard anteroposterior (AP) and lateral views of the elbow should be obtained. Oblique
radiographs may be helpful for further fracture definition.
- Traction radiographs may better delineate the fracture pattern and may be useful for
preoperative planning.
- In nondisplaced fractures, an anterior or posterior “fat pad sign” may be present on the
lateral radiograph, representing displacement of the adipose layer overlying the joint
capsule in the presence of effusion or hemarthrosis.
- Minimally displaced fractures may result in a decrease in the normal condylar shaft angle of
40 degrees seen on the lateral radiograph.
- Because intercondylar fractures are almost as common as supracondylar fractures in adults,
the AP (or oblique) radiograph should be scrutinized for evidence of a vertical split in the
intercondylar region of the distal humerus.
- Computed tomography is often used to delineate the fracture pattern, amount of
comminution, and intra-articular extension.
5. Classification
Descriptive
- Supracondylar fractures
o Extension type
o Flexion type
- Transcondylar fractures
- Intercondylar fractures
- Condylar fractures
- Capitellum fractures
- Trochlea fractures
- Lateral epicondylar fractures
- Medial epicondylar fractures
- Fractures of the supracondylar process

Orthopaedic Trauma Association Classification of Fractures of the Distal Humerus

6. Treatment
GENERAL TREATMENT PRINCIPLES
- Anatomic articular reduction
- Stable internal fixation of the articular surface
- Restoration of articular axial alignment
- Stable internal fixation of the articular segment to the metaphysis and diaphysis
- Early range of elbow motion
SPECIFIC FRACTURE TYPES
Extra-Articular Supracondylar Fracture
- This results from a fall onto an outstretched hand with or without an abduction or adduction
force.
- The majority are extension patterns with a minority being flexion types.

Nonoperative
- This is reserved for nondisplaced or minimally displaced fractures, as well as for severely
comminuted fractures in elderly patients with limited functional ability.
- A posterior long arm splint is placed in at least 90 degrees of elbow flexion if swelling and
neurovascular status permit, with the forearm in neutral.
- Posterior splint immobilization is continued for 1 to 2 weeks, after which range-of-motion
exercises are initiated in a hinged brace. The splint or brace may be discontinued after
approximately 6 weeks, when radiographic evidence of healing is present.
- Frequent radiographic evaluation is necessary to detect loss of fracture reduction.
Operative
- Indications
- Displaced fractures
- Vascular injury
- Open fracture
- Inability to maintain acceptable reduction
Patient positioning
- Supine on a radiolucent table with arm over chest
- Quick and easy setup
- Good for multiply injured patients with multiple extremity involvement
- Requires assistant to hold arm during procedure
- Lateral
- Allows good access to posterior arm and elbow without need for additional assistant
- Prone
- Allows good access to posterior arm and elbow without need for additional assistant
Image positioning
- Image intensifier can be placed on same or opposite side of the injured extremity Surgical
approaches:
- Triceps splitting approach
o Easy to perform
o Enables intact trochlear notch of proximal ulna to act as template to assist fracture
reduction
o No need for additional hardware to reattach olecranon
o Can be converted to exposure necessary for total elbow replacement or olecranon
osteotomy for increased articular exposure
o Affords limited articular exposure—usually used for extra-articular fractures
- Paratricipital approach
o Easy to perform
o Uses windows on either side of the triceps to assess fracture reduction
o Can be converted to exposure necessary for total elbow replacement or olecranon
osteotomy for increased articular exposure
 o Has limited articular exposure compared to olecranon osteotomy
o Usually used for extra-articular fractures or if chance of conversion to elbow
arthroplasty during surgery
- Triceps reflecting anconeus pedicle (TRAP) approach
o Uses a proximally based triceps–anconeus flap
o Medial portion of flap is created by subperiosteal dissection from the subcutaneous
border of the ulna
o Kocher interval is used to raise the anconeus muscle and develop the lateral portion of
the flap
o Anconeus flap elevated and reflected proximally to expose the triceps insertion, which is
also released
o Advantage is preservation of the neurovascular supply to the anconeus
o Soft tissue repair required to reattach the extensor mechanism
- Bryan-Morrey approach
o Involves subperiosteal reflection of the triceps insertion from medial to lateral in
continuity with the forearm fascia and anconeus muscle
o Although the triceps tendon insertion is detached, the extensor mechanism maintains
its continuity as a single sleeve through its soft tissue attachments
o Extensor sleeve is repaired using drill holes or osseous anchors
o Used primarily for arthroplasty
- Van Gorder approach (triceps tongue)
o Transection of triceps at musculotendinous junction (V–Y incision)
o Used for arthroplasty or fractures with complete/high-grade triceps tendon laceration
- Olecranon osteotomy
o Most extensile approach
o Uses a transverse or apex distal, chevron-type osteotomy of the olecranon which exits in
the socalled bare area of the trochlear groove
o Osteotomy is initiated with an oscillating saw and completed with an osteotome
o Osteotomy requires fixation using a tension band construct, an intramedullary
screw/nail, or a plate.
Implant options
- Plate fixation
o Plate fixation is used on each column, either in parallel or 90 degrees from one another.
o Use of locked plates has gained in popularity and affords much better metaphyseal
fixation than conventional nonlocked plates.
o Parallel plating has been shown to be biomechanically superior to orthogonal plating for
distal fractures. Use of parallel plating allows for longer length screws directed from
lateral to medial than a posterolateral plate in which screw length is limited by the
anterior articular surface.
- Total elbow replacement
o Indicated in elderly patients with a severely comminuted fracture of the distal humerus
deemed unreconstructable
o Use of elbow arthroplasty requires lifelong restriction of 5 lb weight bearing in that arm
 o Medial, triceps-sparing approach should be utilized, rather than an olecranon
osteotomy, for exposure of the elbow joint.
- Range-of-motion exercises should be initiated as soon as the patient is able to tolerate
therapy.
7. Complication
- Volkmann ischemic contracture (rare): This may result from unrecognized compartment
syndrome with subsequent neurovascular compromise. A high index of suspicion
accompanied by aggressive elevation and serial neurovascular examinations with or without
compartment pressure monitoring must be maintained.
- Loss of elbow range of motion: This is generally the rule following any fracture about the
elbow.
o Loss of extension due to callus formation in the olecranon fossa
o Loss of flexion due to capsular contracture and/or H.O.
- Heterotopic bone formation may occur.