DISTAL HUMERUS FRACTURES - SURGICAL RECONSTRUCTION
Bicolumnar Concept | Anatomic Reduction Essential | ORIF vs TEA
AO/OTA CLASSIFICATION
Critical Must-Knows
- Bicolumnar anatomy - triangular architecture must be reconstructed
- Anatomic articular reduction is critical for good outcomes
- Dual plate fixation (90-90 or parallel) is standard for Type C fractures
- Olecranon osteotomy provides best articular visualization
- Total elbow arthroplasty is an option in elderly, low-demand patients with comminution
Examiner's Pearls
- "Columns form an inverted triangle - both must be stabilized
- "Articular step more than 2mm increases arthritis risk significantly
- "Ulnar nerve transposition is routine with medial plating
- "TEA contraindicated in young active patients - reserved for elderly
Clinical Imaging
Imaging Gallery
Critical Distal Humerus Fracture Exam Points
Bicolumnar Concept
Distal humerus forms an inverted triangle with medial and lateral columns supporting the trochlea. Both columns must be stabilized to restore the triangular arch for stable elbow function.
Surgical Approaches
Olecranon osteotomy provides best visualization of articular surface. Alternatives: triceps-splitting, paratricipital (Bryan-Morrey), TRAP. Choice depends on fracture pattern and soft tissue.
Plate Configuration
90-90 plating (posterolateral and medial) or parallel plating (both posterior). Both biomechanically sound. 90-90 may reduce hardware conflict. Minimum 2 screws per column.
TEA Option
Total Elbow Arthroplasty indicated in elderly (age 65 plus), low-demand patients with significant comminution. Contraindicated in young, active patients. Lifetime lifting restriction 5kg.
Distal Humerus Fractures: Quick Reference
| Category | Key Points |
|---|---|
| 2-6% of all fractures, 30% intra-articular | Bimodal: young males (high energy) and elderly females (low energy) |
| AO/OTA: Type A (extra-articular), Type B (partial articular), Type C (complete articular bicolumnar) | C3 most challenging: comminuted articular and metaphyseal |
| Inverted triangular architecture with medial and lateral columns | Both columns must be fixed to shaft for stability |
| Olecranon osteotomy: gold standard for articular visualization | Alternatives: triceps-splitting, paratricipital, TRAP |
| Dual plating: 90-90 (medial plus posterolateral) or parallel (both posterior) | Minimum 2 screws per column into shaft, interdigitate distally |
| Age 65 plus, low demand, severe comminution (C3) | Lifetime 5kg lifting restriction - contraindicated in young active patients |
| Stiffness (15-50%) most common - goal: 30-130 degrees functional arc | Ulnar neuropathy (10-15%), heterotopic ossification (5-15%), nonunion (2-10%) |
| ORIF: 90-95% good/excellent in young patients | TEA: similar outcomes to ORIF in elderly but with activity restrictions |
COLUMNS - Bicolumnar Fixation Principles
Memory Hook:COLUMNS reminds you to stabilize both columns for stable elbow reconstruction
TRAP - Triceps-Reflecting Approach
Memory Hook:TRAP approach reflects triceps with anconeus - continuous sleeve, avoids osteotomy
13-ABCAO Distal Humerus Classification
Memory Hook:13-ABC: A=Away, B=Bit, C=Complete - simple way to remember AO classification!
TEA - Arthroplasty Indications
Memory Hook:TEA for elderly patients, extensive damage, with low activity
90-90 vs PARALLEL
Memory Hook:Both configurations work - 90-90 reduces hardware conflict, parallel may be stronger distally
Overview and Epidemiology
Distal humerus fractures are challenging injuries requiring meticulous surgical technique for optimal outcomes. They represent a significant proportion of elbow fractures and have complex anatomy requiring reconstruction.
Bimodal distribution:
- Young males (20-40): High-energy trauma (MVA, falls from height, sports)
- Elderly females (age 65 plus): Low-energy falls, osteoporotic bone
Mechanism of injury:
- Fall directly onto elbow (most common)
- Fall on outstretched hand with elbow flexed
- High-energy direct trauma
- Sports injuries (football, rugby)
Osteoporotic Considerations
In elderly patients with osteoporotic bone, achieving stable fixation is challenging. The "bag of bones" concept of conservative treatment has largely been replaced by ORIF or primary TEA for better functional outcomes.
Anatomy and Pathophysiology
Bicolumnar anatomy:
The distal humerus forms an inverted triangle:
- Medial column: Supports medial trochlear ridge
- Lateral column: Supports capitellum and lateral trochlea
- Apex: Confluence of columns at metaphysis
- Base: Articular surface (trochlea plus capitellum)
Triangular Architecture
The medial and lateral columns form a triangular arch that supports the articular surface. Surgical reconstruction must restore this architecture. Both columns must be independently fixed to the shaft for stability.
Articular anatomy:
- Trochlea: Articulates with ulna, spool-shaped
- Capitellum: Articulates with radial head, hemispherical
- Coronoid fossa: Accommodates coronoid in flexion
- Olecranon fossa: Accommodates olecranon in extension
- Thin central bone: Very thin bone between fossae
Normal angles:
- Carrying angle: 10-15 degrees valgus (arm extended, palm forward)
- Baumann angle: 70-80 degrees (angle of capitellum to humeral shaft)
- Anterior humeral line: Passes through middle third of capitellum
Neurovascular considerations:
Ulnar Nerve
The ulnar nerve passes posterior to the medial epicondyle in the cubital tunnel. It is at risk during surgical exposure and with medial plate placement. Most surgeons perform anterior subcutaneous transposition as part of medial plating.
Other structures:
- Radial nerve: Travels in spiral groove, passes anterior at lateral column level
- Brachial artery: Anterior to joint, at risk with anterior approaches
- Median nerve: Travels with brachial artery
Classification Systems
AO/OTA Classification (standard)
| Type | Description | Pattern |
|---|---|---|
| A | Extra-articular | Supracondylar |
| A1 | Apophyseal avulsion | Epicondyle fracture |
| A2 | Simple metaphyseal | Transverse or oblique |
| A3 | Multifragmentary metaphyseal | Comminuted supracondylar |
| B | Partial articular | Unicondylar |
| B1 | Lateral sagittal | Lateral condyle |
| B2 | Medial sagittal | Medial condyle |
| B3 | Coronal (capitellar/trochlear) | Shear fractures |
| C | Complete articular | Bicolumnar |
| C1 | Simple articular, simple metaphyseal | T or Y pattern |
| C2 | Simple articular, comminuted metaphyseal | Articular simple, column comminution |
| C3 | Comminuted articular and metaphyseal | Most complex |
C-Type Significance
Type C fractures are the most common pattern requiring surgical reconstruction. The articular block is separated from both columns, requiring reconstruction of the joint and stable fixation to the shaft.
Clinical Presentation and Assessment
History:
- Mechanism (fall, direct trauma, high vs low energy)
- Age and activity level
- Hand dominance
- Pre-injury function and comorbidities
- Occupation (implications for TEA consideration)
Physical examination:
Physical Examination Findings
| Finding | Significance | Action |
|---|---|---|
| Gross swelling, deformity | Fracture confirmed | Splint, ice, elevate |
| Skin compromise/tenting | Impending open fracture | Urgent reduction, consider early surgery |
| Open wound | Open fracture | Antibiotics, debridement, staged treatment |
| Ulnar nerve dysfunction | Nerve injury (15-20%) | Document, monitor, consider early exploration |
| Absent pulse | Vascular injury | Urgent reduction, angiography |
| Compartment syndrome signs | Impending compartment syndrome | Urgent fasciotomies |
Neurovascular examination:
- Ulnar nerve: sensation little finger, FDI strength, Froment sign
- Radial nerve: wrist/finger extension, sensation dorsal first web
- Median nerve: sensation thumb/index, thenar strength
- Brachial artery pulse, capillary refill
Ulnar Nerve Injury
Pre-operative ulnar nerve injury occurs in 15-20% of distal humerus fractures. Document carefully before surgery. Most are neurapraxia and recover. Persistent or worsening symptoms may require exploration.
Associated injuries:
- Ipsilateral forearm fractures (floating elbow)
- Olecranon fractures
- Proximal ulna fractures
Investigations
Radiographic assessment:
Standard views:
- AP elbow - Assess column involvement, carrying angle
- Lateral elbow - Assess anterior/posterior displacement, articular involvement
- Oblique views - May help delineate fracture pattern
Traction views:
- AP and lateral with longitudinal traction
- Reduces overlap, better defines fracture pattern
- Useful for surgical planning
CT Imaging
CT with 3D reconstruction is essential for surgical planning in all Type C fractures. It defines articular involvement, identifies small fragments, and helps plan fixation strategy. Do not operate without adequate imaging.
CT indications:
- All intra-articular fractures (Type B and C)
- Surgical planning for ORIF
- Coronal shear fractures (capitellar/trochlear)
- Comminuted patterns
MRI:
- Rarely indicated acutely
- May be useful for soft tissue assessment in delayed presentations
Management Algorithm
Treatment Decision Guide
| Fracture Pattern | Patient Factors | Treatment |
|---|---|---|
| Type A (extra-articular) | Any age | Posterior plating, no osteotomy needed |
| Type B (unicondylar) | Any age | Lag screws plus or minus buttress plate |
| Type C (bicolumnar) | Young, active, good bone | Dual plate ORIF via olecranon osteotomy |
| Type C comminuted | Young patient | Dual plate ORIF - accept some complexity |
| Type C comminuted | Elderly (age 65 plus), low demand | Consider primary TEA |
| Open fracture | Any patient | Staged: debridement, spanning ex-fix, then definitive |
Surgical Technique
Olecranon Osteotomy - gold standard for Type C fractures
Technique:
- Posterior midline incision
- Identify and protect ulnar nerve
- Chevron or transverse osteotomy 2cm from tip
- Predrill for later tension band or plate fixation
- Reflect olecranon proximally with triceps attached
- Provides excellent articular visualization
Alternative approaches:
Triceps-Splitting: Direct posterior split - adequate for Type A, limited articular view.
Bryan-Morrey (Paratricipital): Elevate triceps off columns - maintains continuity, limited articular view.
TRAP: Triceps-anconeus pedicle flap - maintains blood supply, avoids osteotomy.
Osteotomy Fixation
The osteotomy is typically fixed with tension band wire or plate fixation. Plate fixation may have lower hardware removal rates. Pre-drilling before osteotomy ensures accurate reduction.
Complications
Complications of Distal Humerus Fracture Treatment
| Complication | Incidence | Prevention/Management |
|---|---|---|
| Elbow stiffness | 15-50% | Early motion, stable fixation, CPM |
| Ulnar neuropathy | 10-15% | Anterior transposition, careful handling |
| Heterotopic ossification | 5-15% | Prophylaxis (indomethacin or XRT), early motion |
| Nonunion | 2-10% | Stable fixation, bone graft if needed |
| Hardware failure | 3-5% | Adequate fixation, protected loading |
| Infection | 1-3% | Prophylactic antibiotics, good soft tissue handling |
| Osteotomy nonunion | 5-10% | Adequate fixation, consider plate over TBW |
| Post-traumatic arthritis | 10-20% | Anatomic reduction, minimize step-off |
Stiffness:
- Most common complication
- Goal: functional arc 30-130 degrees
- Prevention: stable fixation allowing early motion
- Treatment: physiotherapy, dynamic splinting, arthroscopic or open release
Functional Arc
The functional arc for most activities of daily living is 30-130 degrees flexion and 50 degrees pronation-supination. This is the minimum acceptable outcome. Patients should be counseled that some stiffness is expected.
Ulnar nerve complications:
- Transposition is routine with medial plating
- New symptoms may develop post-operatively
- Most neurapraxias recover over 6-12 months
- Persistent symptoms may require revision transposition
Heterotopic ossification:
- More common with delayed surgery, head injury, severe trauma
- Prophylaxis: indomethacin 75mg/day for 2 weeks or single-dose XRT
- May require excision if limiting motion (wait 12 plus months)
Postoperative Care and Rehabilitation
Post-ORIF protocol:
- Posterior splint at 90 degrees
- Elevation, ice
- Wound check at 48 hours
- Gentle finger motion
- Remove splint for supervised motion
- Begin active assisted ROM
- Focus on flexion-extension first
- Continue finger and wrist motion
- Progressive active ROM
- Night splinting if developing flexion contracture
- Dynamic splinting if significant stiffness
- No resistive exercises
- Begin gentle strengthening
- Progressive loading as tolerated
- Continue ROM exercises
- Full strengthening
- Return to most activities
- Heavy lifting/sport when healed
Key rehabilitation principles:
- Stable fixation is essential for early motion
- Continuous passive motion (CPM) may be helpful
- Balance between motion and healing
- Patient education about expected stiffness
- Long-term therapy often required
Motion Priority
The goal is early motion to prevent stiffness. Stable fixation that allows early ROM produces better outcomes than rigid immobilization. If fixation is not stable enough for motion, it is not adequate.
Outcomes and Prognosis
Expected outcomes by treatment:
| Treatment | Good/Excellent Outcomes | Key Points |
|---|---|---|
| ORIF (young) | 90-95% | Anatomic reduction, early motion |
| ORIF (elderly) | 75-85% | More stiffness, higher complication rate |
| TEA | 85-90% | Reliable pain relief, restrictions required |
| Conservative | 50-60% | Stiffness, malunion, poor function |
Prognostic factors:
- Patient age and bone quality
- Fracture complexity (C3 worse than C1)
- Quality of reduction (articular step-off)
- Adequacy of fixation
- Associated injuries
- Compliance with rehabilitation
ORIF vs TEA Outcomes
In comparable elderly populations, ORIF and TEA produce similar functional outcomes at 2 years. ORIF has higher re-operation rates for hardware issues. TEA has lifetime restrictions but reliable pain relief. Patient selection is key.
Evidence Base
- RCT comparing ORIF to TEA in patients age 65 plus with AO Type C fractures
- TEA had better MEPS scores at 2 years (86 vs 73)
- TEA group had fewer re-operations compared to ORIF group
- Both groups achieved similar functional outcomes overall
- Biomechanical study showing parallel plating (both plates posterior) may provide stronger fixation than 90-90 configuration
- Screws interdigitating in articular block create fixed-angle construct
- Both configurations demonstrated adequate biomechanical stability
- Key factor is adequate screw purchase in articular block
- Chevron osteotomy provides excellent articular visualization
- Nonunion rate 5-10% with tension band wiring
- Plate fixation may reduce hardware-related complications compared to tension band wiring
- Pre-drilling before osteotomy improves reduction accuracy
- Coronal shear fractures (capitellar/trochlear) require anterior approach
- Headless compression screws from anterior provide stable fixation
- Countersunk screws avoid articular prominence
- Important to recognize as distinct fracture pattern
- Modern ORIF techniques produce 85-95% good/excellent outcomes in Type C fractures
- Key factors: anatomic reduction, stable fixation, early motion
- Quality of articular reduction is most critical determinant
- Early motion protocol improves functional outcomes
Viva Scenarios
Practice these scenarios to excel in your viva examination
Scenario 1: Bicolumnar Fracture Management
"A 45-year-old right-hand dominant carpenter falls from a ladder, landing on his elbow. X-rays show a Type C2 distal humerus fracture (simple articular, comminuted metaphysis). The ulnar nerve is intact. Describe your management."
Thank you. This 45-year-old carpenter has an AO Type C2 distal humerus fracture - this is a bicolumnar intra-articular fracture with a simple articular split but comminuted metaphysis. Given his age, occupation, and the fracture pattern, ORIF is clearly indicated.
Initial Management: I would splint the elbow at 90 degrees, provide adequate analgesia, and document complete neurovascular status including the ulnar nerve. I would order a CT scan with 3D reconstruction for surgical planning to better define the articular and metaphyseal components.
Timing: I would aim for surgery within 24-48 hours before swelling peaks. Operating on a swollen elbow significantly increases complication risk.
Surgical Approach: Through a posterior skin incision, I would perform a chevron olecranon osteotomy - this provides the best visualization of the distal humeral articular surface. The ulnar nerve must be identified early and protected - I would perform anterior subcutaneous transposition to protect it from the medial plate.
Fixation Strategy:
- First, reconstruct the articular block using small lag screws to convert C2 to a supracondylar pattern
- Then apply dual plating - my preference is 90-90 configuration (medial plate plus posterolateral plate)
- Minimum greater than 2 screws per plate into the shaft, with interdigitating screws in the articular block
- Fix the olecranon osteotomy with a plate or tension band construct
Postoperatively: Early motion is essential - once the wound is stable at 7-10 days, begin active assisted ROM. The carpenter can expect return to work at 3-4 months.
Scenario 2: Elderly Patient with Comminuted Fracture
"A 78-year-old woman with osteoporosis and rheumatoid arthritis falls at home. CT shows a Type C3 distal humerus fracture with severe articular comminution. She lives alone but is independent. What are your treatment options?"
Thank you. This is a challenging case requiring careful consideration of patient factors and fracture characteristics to determine optimal management.
Assessment of Key Factors:
- Age 78 - life expectancy considerations
- Osteoporosis - poor bone quality for fixation
- Rheumatoid arthritis - pre-existing joint disease and ligamentous laxity
- Type C3 - severe articular comminution making anatomic reconstruction difficult
- Independent living - but activity demands need clarification
Options: The two main options are ORIF versus primary Total Elbow Arthroplasty (TEA).
Arguments Against ORIF:
- Osteoporotic bone with poor screw purchase
- Articular surface likely unreconstructable
- High risk of fixation failure and nonunion
- May end up requiring delayed TEA anyway (worse outcomes than primary TEA)
Arguments For Primary TEA:
- Predictable pain relief (greater than 95% satisfaction)
- No need to reconstruct comminuted articular surface
- Early mobilization
- Well-established outcomes in RA patients
TEA Considerations:
- Lifetime 5kg lifting restriction - must counsel carefully
- Would use a linked implant given RA and likely ligamentous insufficiency
- Approach via posterior incision, paratricipital or triceps-reflecting approach
My Recommendation: Given the constellation of factors - age, osteoporosis, RA, and unreconstructable C3 pattern - I would recommend primary TEA after thorough counseling about activity restrictions. However, the final decision must involve the patient's informed choice regarding lifestyle implications.
Scenario 3: Open Fracture with Soft Tissue Compromise
"A 35-year-old male motorcyclist has a Type C3 distal humerus fracture with severe soft tissue injury and skin loss posteriorly. The wound is contaminated. The hand is well perfused but he has ulnar nerve palsy. How do you manage this?"
Thank you. This is a complex open fracture requiring a staged approach. The priorities are soft tissue management first, then definitive fracture fixation.
Immediate Management:
- ATLS assessment - ensure no life-threatening injuries
- IV antibiotics - cephalosporin plus aminoglycoside for Gustilo III pattern
- Tetanus prophylaxis
- Thorough documentation of the ulnar nerve palsy - this is likely a primary injury at the time of trauma
- Provisional splinting
Operative Stage 1 (within 6-12 hours):
- Thorough irrigation and debridement of all contaminated and devitalized tissue
- Explore the ulnar nerve - in an open fracture with palsy, the nerve must be visualized
- Apply a spanning external fixator to stabilize the fracture and protect the soft tissues
- Negative pressure wound therapy (NPWT) for soft tissue management
- Early plastic surgery consultation for soft tissue coverage planning
Staged Approach:
- Serial debridements every 48-72 hours until wound is clean
- Definitive soft tissue coverage required before or concurrent with ORIF - typically flap coverage
- ORIF when soft tissues are stable, usually 7-14 days - dual plating through healthy tissue
Critical Points:
- TEA is absolutely contraindicated in this 35-year-old active patient
- The ulnar nerve should be protected and monitored - may need delayed grafting if transected
- Free tissue transfer may be required if local flaps insufficient
Expected Outcome: With staged management, we can achieve fracture union and functional outcome. The ulnar nerve palsy will be monitored with EMG/NCS at 6 weeks.
MCQ Practice Points
Anatomy Question
Q: What is the bicolumnar concept in distal humerus fractures? A: The distal humerus forms an inverted triangular architecture with medial and lateral columns that support the articular surface (trochlea and capitellum). Both columns must be reconstructed and fixed to the shaft for stable elbow function.
Approach Question
Q: Which surgical approach provides the best visualization of the distal humerus articular surface? A: Chevron olecranon osteotomy. This elevates the olecranon with the triceps attached, providing direct visualization of the entire articular surface. Alternative approaches (triceps-splitting, paratricipital) have limited articular visualization.
Fixation Question
Q: In 90-90 plating of the distal humerus, where are the plates positioned? A: Medial plate on the medial column and posterolateral plate on the lateral column, positioned approximately 90 degrees apart. Alternative is parallel plating with both plates on the posterior surface.
TEA Question
Q: What are the indications for primary TEA in distal humerus fractures? A: Age 65 plus years, low-demand patient, severe articular comminution (C3 pattern) that cannot be reconstructed, and pre-existing arthritis (especially rheumatoid). Contraindicated in young, active patients.
Complication Question
Q: What is the most common complication following distal humerus fracture fixation? A: Elbow stiffness (15-50%). The goal is to achieve a functional arc of 30-130 degrees. Prevention includes stable fixation allowing early motion and appropriate physiotherapy.
Australian Context
Epidemiology:
- Bimodal distribution similar to worldwide data
- Increasing elderly population equals more low-energy fractures
- Sports injuries (AFL, rugby, cycling) in younger population
Management considerations:
- Subspecialty referral often required for complex patterns
- May require transfer to major trauma center
TEA considerations in Australia:
- Limited centers performing high volumes
- Implant availability may vary
- Revision surgery capacity important consideration
- National Joint Replacement Registry tracks outcomes
Exam Context
Be prepared to discuss both ORIF and TEA options with their indications, advantages, and disadvantages. Understand the Australian healthcare context including public/private systems and regional variation in expertise.
DISTAL HUMERUS FRACTURES
High-Yield Exam Summary
BICOLUMNAR CONCEPT
- •Inverted triangular architecture
- •Medial column plus lateral column support articular surface
- •Both columns must be fixed to shaft for stability
- •Interdigitating screws in articular block
CLASSIFICATION
- •AO Type A: extra-articular (supracondylar)
- •AO Type B: partial articular (unicondylar)
- •AO Type C: complete articular (bicolumnar)
- •C3 equals comminuted articular and metaphyseal equals most challenging
SURGICAL APPROACHES
- •Olecranon osteotomy: best articular visualization (gold standard)
- •Triceps-splitting: simple patterns, limited view
- •Paratricipital: TEA, some ORIF, no osteotomy
- •TRAP: TEA, preserves triceps blood supply
PLATE CONFIGURATION
- •90-90: medial plus posterolateral plates (90 degrees apart)
- •Parallel: both plates posterior surface
- •Both configurations acceptable
- •Minimum 2 screws per column into shaft
TEA INDICATIONS
- •Age 65 plus (ideally age 75 plus)
- •Low-demand patient
- •Severe articular comminution (C3)
- •Pre-existing arthritis (especially RA)
- •Contraindicated in young, active patients
TRAPS AND PEARLS
- •Always get CT for surgical planning
- •Ulnar nerve transposition is routine with medial plating
- •Early motion is essential to prevent stiffness
- •Functional arc: 30-130 degrees flexion
- •TEA requires lifetime 5kg lifting restriction