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Surgical Techniques

Distal Humerus Fractures

Jeffrey Anglen, MD
F ractures of the elbow constitute
about 7% of adult fractures; dis-
tal humerus fractures account for
teopenia and/or comminution of the
joint surface in which stable recon-
struction cannot be achieved, total
less than half of all elbow fractures. elbow arthroplasty using a semi-
There is evidence, however, that in- constrained linked prosthesis may
cidence is increasing. Investigators be preferable to other options.4 For
in Finland performed a retrospective most displaced unstable fractures in
The video that accompanies this article
review of hospital admission records patients with functional arms, open
is “Open Reduction and Internal Fixa-
tion,” available on the Orthopaedic
between 1970 and 1995 and found reduction and internal fixation
Knowledge Online website, at
that the age-adjusted increase in in- (ORIF) is indicated to restore opti-
http://www5.aaos.org/oko/trauma/jaaos. cidence in women older than 60 mal elbow function.
years had more than doubled.1
The Orthopaedic Trauma Associ-
Contraindications
ation (OTA)/AO classification sys-
tem divides distal humerus fractures Contraindications to ORIF of distal
into type A, nonarticular; type B, humerus fractures include inability
partial articular; and type C, com- to tolerate surgery because of health
plete articular2 (Fig. 1). Additional status, inability to benefit from sur-
levels of classification are based on gery because of neurologic impair-
position and orientation of the frac- ment of the limb, and inability to
ture line and degree of comminu- achieve stability because of severe
tion. osteopenia or deficient bone. In addi-
The partial articular fractures can tion, ORIF is contraindicated in pa-
be described as “unicolumnar” frac- tients with excessively high risk for
tures; they are rare in adults (2% to local complications because of in-
3%) and are more common in chil- fected or deficient soft tissues.
dren and adolescents. Fractures of
the lateral column are more com-
Surgical Technique
mon than those of the medial col-
umn. Capitellar fractures are a spe- The surgical approach and implant
cial instance of partial articular strategy for ORIF of a distal humer-
Dr. Anglen is Professor and Chairman,
fractures (OTA/AO B3.1) represent- us fracture are guided by the classi-
Department of Orthopaedics, Indiana
University School of Medicine, Indianap-
ing a shearing injury with very little fication of the fracture.
olis, IN.
soft-tissue attachment to the anteri- Nonarticular fractures (type A):
or fragment. Three types of lateral These usually can be fixed through a
Neither Dr. Anglen nor the department column fractures have been de- triceps-splitting approach (Fig. 2) or
with which he is affiliated has received scribed by Bryan and Morrey.3 triceps-sparing approach (Fig. 3) with
anything of value from or owns stock in a restoration of alignment and bico-
commercial company or institution re- lumnar fixation. Isolated epicondy-
lated directly or indirectly to the subject Indications
lar fractures in many cases can be
of this article.
Nonsurgical treatment is appropri- fixed with lag screws alone.
Reprint requests: Dr. Anglen, Indiana ate for stable, nondisplaced fractures Partial articular fractures (type B):
University School of Medicine, Suite and in patients with neurologic im- In the uncommon adult unicolum-
600, 540 Clinical Drive, Indianapolis IN pairment or otherwise nonfunction- nar fracture, lag screws alone may be
46202. al extremities. Hinged or static ex- adequate fixation when the bone
ternal fixation can be used for either quality is good. Otherwise, a but-
J Am Acad Orthop Surg 2005;13:291-
temporary or definitive treatment in tress or antiglide plate should be
297
patients with severely contaminated used. Some capitellar fractures can
Copyright 2005 by the American open wounds or extensive soft-tissue be fixed through a lateral or posteri-
Academy of Orthopaedic Surgeons. defects. In older patients with os- or approach with lag screws placed

Volume 13, Number 5, September 2005 291
Distal Humerus Fractures

Figure 1 from posterior to anterior, while
small or comminuted capitellar frag-
ments are usually excised.
Complete articular fractures
(type C): ORIF can be performed
through several approaches;5-9 the
most common are the extensile me-
dial approach (Bryan and Morrey),5
the extensile lateral approach
(Kocher), or the posterior transolec-
ranon approach. The plating con-
struct that provides the greatest sag-
ittal plane stiffness without loss of
coronal or torsional stiffness is a me-
dially positioned reconstruction
plate and a small-fragment compres-
sion plate on the posterolateral
surface.10-12
The principles of the procedure
are similar to those of any articular
The OTA/AO classification of fractures of the distal humerus. A, nonarticular.
fracture. Anatomic restoration of the
B, partial articular. C, complete articular. (Reproduced with permission from articular surface is the first priority
Müller ME, Nazareon S, Koch P, Schaftsker J: Comprehensive Classification (and usually, but not always, the first
of Fractures of Long Bones. Berlin, Germany: Springer-Verlag, 1990, p 330.) goal completed). The next goal is res-
toration of joint shaft alignment,
then stable fixation of the joint frag-
ments to the shaft, and finally, early,
Figure 2 active rehabilitation (Fig. 4). As with
any complex fracture procedure,
ORIF of distal humerus fractures is
best undertaken during daylight
hours, after adequate planning, and
with a rested, experienced surgical
team and staff.
The first step is preoperative plan-
ning. Using good traction films of the
distal humerus in two planes, tracings
are made of the injured extremity,
carefully noting fracture lines and
outlining major fragments. Then, lay-
ing this drawing over a tracing of the
intact, uninjured side, the fracture
fragments are pieced back together
and the anatomy of the humerus is re-
constructed, showing on the tracing
the position of the reduced fragments
and fracture lines. Appropriate im-
plants are then traced in position,
The Campbell posterior approach. A, A straight (solid line) or curvilinear (dashed planning the size and location of
line) incision is made over the posterior aspect of the elbow. B, The triceps muscle plates and the number and position
is split distally over the olecranon insertion and peeled subperiosteally. C, The tri- of screws. Finally, the surgical tactic
ceps muscle is split along the central tendon from distal to proximal direction 6 to 8 is written out, detailing the steps of
cm to expose the distal humerus. (Reproduced with permission from Anson BJ, the procedure in order, noting any an-
Maddock WG: Callander’s Surgical Anatomy, ed 4. Philadelphia, PA: W.B. Saun- ticipated difficulties or potential bar-
ders, 1958.) riers and options.

292 Journal of the American Academy of Orthopaedic Surgeons
Jeffrey Anglen, MD

The following list of instruments Figure 3
and implants should be available:
• Small-fragment plates and
screws (including long screws
up to 100 mm length)
• Minifragment plates and
screws
• Malleable reconstruction plates
and plate benders (or anatomi-
cally preshaped plates)
• Herbert screws
• Kirschner wires (K-wires) and,
if desired, bioabsorbable pins
• Small oscillating saw and
osteotomes
• Wire set
• Bone graft harvesting set
C-arm fluoroscopy should be
available, but it is not routinely used
because the reduction and fixation is
primarily performed under direct vi-
sion.
The patient is positioned prone
with the arm at 90° abduction and
the elbow at 90° flexion over a radio-
lucent arm board ( video step 1).
Care is taken to pad and protect all
bony prominence areas. When the
patient cannot be placed prone, the
procedure can be done from the lat-
eral position with the arm supported
across the field. The arm is prepared
and draped proximally at least as far
as the deltoid insertion. For distal
fractures in thinner patients, a pneu-
matic tourniquet may be applied be-
fore preparation and draping; for
more extensive fractures or larger
arms, it is better to have a sterile
tourniquet available and not com-
promise on the size of the prepared
field. The posterior iliac crest should The Bryan approach. A, A straight or curvilinear incision ulnarly directed exposes
the proximal ulna, medial epicondyle, ulnar nerve, and triceps. B, The ulnar nerve is
be prepared and draped.
translocated anteriorly. C, The triceps insertion is elevated subperiosteally ulnar
A midline posterior incision is
to radial off the olecranon. D, With the triceps reflected laterally, the anconeus is re-
made curving around the tip of the leased subperiosteally. One can expose the radial head; the most proximal tip of
olecranon to avoid making a scar di- the olecranon is now removed providing full exposure of the distal humerus. E, For
rectly upon it—usually to the later- full exposure, one can partially release the lateral collateral ligament (LCL) and
al side to avoid having a scar direct- medial collateral ligament (MCL). F, Repair of the triceps aponeurosis is made back
ly over the ulnar nerve ( video to the proximal ulna through drill holes with a heavy no. 3 or no. 5 Mersilene su-
step 2). Prior to incision, the skin ture. (Reproduced with permission from Bryan RS, Morrey BF: Extensive posterior
and subcutaneous tissues can be in- exposure of the elbow: A triceps-sparing approach. Clin Orthop 1982;116:188.)
jected with bupivacaine and epi-
nephrine to decrease bleeding from
this very vascular area. The ulnar merus and proximal to the zone of The cubital tunnel is released and
nerve is identified medial to the hu- injury, and it is carefully exposed. the nerve is freed for anterior trans-

Volume 13, Number 5, September 2005 293
Distal Humerus Fractures

Figure 4 can be retracted by sewing it to the
skin of the upper arm with a stitch
in the undersurface of the triceps
tendon.
Fracture fragments are then gently
cleaned of clot and debris, taking care
to note the orientation and position
of any free fragments before remov-
ing them from the field ( video
step 3-4). The distal humeral articu-
lar surface is reassembled based on
the preoperative plan and tactics, and
stabilized with K-wires (Fig. 4, A-B).
The joint surface is restored first, and
then the joint attached to the shaft,
although occasionally one begins by
attaching one articular condyle to the
appropriate column, building across
the joint and onto the opposite col-
umn. Fragments can be manipulated
by joystick K-wires, reduction
clamps, or instruments. Care is taken
not to damage the articular surface it-
Techniques for internal fixation of the distal humerus. A, T-condylar fracture of the self. The deforming forces of muscles
distal humerus. B, Reduction of both condyles with K-wire fixation. The intra-articular and gravity must be acknowledged
fragments are reduced first. C, Compression screw fixation of the condyles and and converted into helpful forces by
medial and lateral condyle to the distal humerus. Cannulated screws are helpful correct positioning and support. Al-
here. D, Medial and lateral condylar plate fixation of the condyle to the distal shaft though usually the reduction can be
of the humerus. E, Y-plate fixation of the humeral shaft to the condyles of the hu- directly and accurately seen, occa-
merus. (By permission of Mayo Foundation for Medical Education and Research. All sionally C-arm fluoroscopy is helpful.
rights reserved.)
The final construct based on the
preoperative plan is assembled, usu-
position at the end of the case. The way through the bone with a small, ally beginning with the transverse
nerve is protected throughout the handheld oscillating saw. The final lag screws (Fig. 4, C) or position
duration of the procedure, but it is cut into the joint surface is made with screws when there is intercondylar
handled gently and should never be a sharp, narrow osteotome, to avoid comminution or bone loss. When
forcefully retracted. taking a curf (the width of the saw bone is missing from the trochlea,
A chevron-shaped (apex distal) os- blade) of the joint surface. Patience, care should be taken not to narrow
teotomy is made in the olecranon gentleness, and control are important it; this may require placement of a
(Fig. 5, G). Soft tissue is dissected in making the osteotomy to avoid piece of structural graft, usually ob-
along both sides of the proximal ole- surface damage or fracture. tained from the iliac crest. Plates are
cranon to identify the joint surface. The olecranon is then reflected applied (Figs. 4, D and E, and 6), usu-
A Kelly or right-angle clamp is gen- proximally by dividing the joint cap- ally beginning with one in the poste-
tly passed around the articular surface sule. The triceps is split loose medi- rolateral position along the straight
of the olecranon between the ulna ally and laterally parallel to the hu- lateral column. This is usually a
and the humerus and is used to pass merus, taking care to protect the small fragment (3.5-mm) compres-
a wide Penrose drain, which will ulnar nerve medially and the radial sion plate or congruent elbow plate.
show the level of the joint as well as nerve laterally. The radial nerve lies The medial plate is frequently a 3.5-
protect the humeral surface. The against the lateral humerus about 14 mm pelvic reconstruction plate con-
V-shaped cut or similar cut (Fig. 5D/ cm from the joint surface; however, toured to lie directly medial over the
5G) should be located about 3 cm the position is variable, so vigilance medial epicondyle. Anatomically
from the tip, to enter the joint at the is required. The triceps is lifted off precontoured plates are available
bottom of the curve, and should be the posterior surface of the bone. and may be helpful, particularly on
marked in the soft tissues with elec- The olecranon tip is wrapped in a the medial side. One should have
trocautery. It is then cut most of the wet sponge, and the reflected triceps available minifragment plates, 2.7-

294 Journal of the American Academy of Orthopaedic Surgeons
Jeffrey Anglen, MD

mm reconstruction plates, and Her- Figure 5
bert screws or bioabsorbable pins for
the smaller articular fragments.
The olecranon osteotomy should
be repaired with a tension band con-
struct (Fig. 6) ( video step 5-6) or
compression screw (Fig. 5, F). Two
1.6- or 2.0-mm K-wires are inserted
into the olecranon tip and advanced
to the osteotomy site. The osteoto-
my is then closed and the wires driv-
en in. Engagement of the anterior
cortex is not required or especially
desirable. The wires should be in-
serted at least 1 cm deeper than nec-
essary and then backed out that
amount, to allow complete seating
of the wires later. A figure-of-8 loop
of 1.5-mm wire is positioned
through a drill hole located distally
at approximately the same distance
from the osteotomy apex as is the tip
of the olecranon. It is then passed be-
hind the K-wires directly on the
bone. This may be facilitated with a
14-gauge angiocatheter. The wire is
tightened by twisting in two places
on opposite arms of the “X” portion
of the figure-of-8. The K-wires are
bent over 180° and cut off (they
should be bent before cutting) and
seated firmly in the bone using an
impactor.
The ulnar nerve is transposed to
an anterior subcutaneous position
and secured in place with a stitch be-
tween the fascia and subcutaneous
tissue that restrains the position of
the nerve. Care should be taken to
ensure that there is no tethering or
pressure on the nerve in its new
home. Subcutaneous tissue and skin
are closed in layers.
Stability and range-of-motion test-
ing is done intraoperatively. Portable
radiographs are obtained with the pa-
tient in the operating room and still
in the prone position. Then the pa-
tient can be turned and awakened. Osteotomy of the olecranon. Three different types of olecranon osteotomy can be
Gentle active-assisted and passive used. A and B, Intra-articular transverse. C through F, Extra-articular oblique. G,
motion is started early, within the Intra-articular chevron. The chevron enhances stability and union. (Panels A-F repro-
first few days. The patient can be in- duced with permission from Müller ME, et al: Manual of Internal Fixation: Tech-
nique Recommended by the AO-Group. New York, NY: Springer-Verlag, 1970.
structed to support the wrist with
Panel G by permission of Mayo Foundation for Medical Education and Research.
the opposite hand and gently flex All rights reserved.).
and extend the elbow, gradually in-

Volume 13, Number 5, September 2005 295
Distal Humerus Fractures

Figure 6 • Inadequate reduction of the
joint surface:
– residual step or gap
– unrecognized bone loss with
resultant narrowing of the
trochlea
– malrotation between the
condyles
• Inadequate stability of
fixation:
– reliance on smooth or thread-
ed pins rather than screw fix-
ation
– reliance on a single plate in-
stead of two-column plate fix-
ation
– using plates that are too short
– using plates of inadequate
stiffness (one-third tubular)
– plating in distraction at the
diaphysis or diaphysis-
metaphysis junction
• Poor hardware placement:
– avoid placing screws in the
thin bone above the trochlea
or into the olecranon fossa
– posterior-to-anterior screws
may penetrate the capitellum
A, A distal humerus, intra-articular T-bicondylar fracture with comminution. B, Expo- and damage the joint
sure by an olecranon osteotomy repaired later with tension band wire technique. – screws or wires in the
Internal fixation with transcondylar screws and medial and lateral contoured condy- epicondyles or olecranon can
lar plates. (By permission of Mayo Foundation for Medical Education and Re- be quite prominent under the
search. All rights reserved.).
skin and annoying
– excessive retraction or rough
handling of the ulnar nerve,
creasing the range of motion. When ing it afterward.
poor transposition technique
a sling is used, the patient should be • Prepare the posterior iliac crest
(kinking or tethering the
instructed to take the arm out sever- for bone graft. Again, mention
nerve)
al times daily for these exercises and the possibility to the patient
• Tension band problems:
to let gravity work on extending the before the operation.
– failure to drive the K-wires in
elbow. Active motion against resis- • Provide good support of the arm
and then back them out, so
tance should be delayed until some so that gravity is not constant-
that at the final seating they
healing has occurred, usually at 6 to ly fighting your reduction.
will not advance with the
8 weeks. When stability of fixation • Preoperative planning can save
impactor and stay prominent
is marginal, a hinged fracture brace great amounts of time. A sterile
or back out early
may be used to provide additional tourniquet can be helpful.
– drilling the transverse
support. • Intraoperative radiographs at the
distal hole in the ulna too
end of the procedure are essen-
shallow, leading to cutout
tial; make sure the lateral view
Pearls of the wire
is adequate. Repeat if necessary.
– not getting the wire behind
• Despite careful handling, tran- the K-wires right down on the
sient postoperative ulnar nerve Pitfalls bone, leading to loosening and
palsy is not rare. Telling pa- loss of function
tients about the possibility be- Common mistakes include the fol- – leaving knots or twists prom-
forehand is easier than explain- lowing: inent under thin skin

296 Journal of the American Academy of Orthopaedic Surgeons
Jeffrey Anglen, MD

Outcomes References approach to the humeral shaft: An al-
1. Palvanen M, Kannus P, Niemi S, ternative approach for fracture treat-
An outcome scale for distal hu- Parkkari J: Secular trends in the os- ment. J Orthop Trauma 1996;10:81-86.
merus fractures was presented by teoporotic fractures of the distal hu- 8. Olson SA, Hertel R, Jakob RP: The
Bickel and Perry.13 An excellent re- merus in elderly women. Eur J Epide- trans-tricipital approach for intra-
miol 1998;14:159-164. articular fractures of the distal humer-
sult is considered a stable, pain-free 2. Fracture and dislocation compendi- us: A report of two cases. Injury 1994;
elbow with nearly normal range of um: Orthopaedic Trauma Association 25:193-198.
motion of 120° or more. A good re- Committee for Coding and Classifica- 9. Moran MC: Modified lateral approach
sult is a stable fracture with no de- tion. J Orthop Trauma 1996;10(suppl to the distal humerus for internal fix-
1):1-154. ation. Clin Orthop 1997;340:190-197.
formity, 60° or more of flexion-ex- 3. Bryan RS, Morrey BF: Fractures of the 10. Helfet DL, Hotchkiss RN: Internal
tension in a usable range, and distal humerus, in Morrey BF (ed): The fixation of the distal humerus: A bio-
rotation 50% of normal. A fair result Elbow and Its Disorders, ed 2. Phila- mechanical comparison of methods.
is a stable fracture construct with delphia, PA: WB Saunders, 1993, pp J Orthop Trauma 1990;4:260-264.
mild pain with normal use and <60° 328-366. 11. Schemitsch EH, Tencer AF, Henley
4. Cobb TK, Morrey BF: Total elbow ar- MB: Biomechanical evaluation of
of motion associated with moderate throplasty as primary treatment for methods of internal fixation of the
deformity. A poor result is defined as distal humeral fractures in elderly pa- distal humerus. J Orthop Trauma
pain, deformity, and greatly re- tients. J Bone Joint Surg Am 1997;79: 1994;8:468-475.
stricted range of motion.3 O’Driscoll 826-832. 12. Jacobson SR, Glisson RR, Urbaniak
et al14 reported that elbow flexion 5. Bryan RS, Morrey BF: Extensive poste- JR: Comparison of distal humerus
rior exposure of the elbow: A triceps- fracture fixation: A biomechanical
and extension strength are de- sparing approach. Clin Orthop 1982; study. J South Orthop Assoc 1997;6:
creased to about 75% of contralat- 166:188-192. 241-249.
eral strength following apparently 6. Gerwin M, Hotchkiss RN, Weiland 13. Bickel WE, Perry RE: Comminuted
successful treatment of commi- AJ: Alternative operative exposures of fractures of the distal humerus. JAMA
the posterior aspect of the humeral di- 1963;184:553-557.
nuted distal humerus fractures, al-
aphysis with reference to the radial 14. O’Driscoll SW, Jupiter JB, Cohen MS,
though the average patient will have nerve. J Bone Joint Surg Am 1996;78: Ring D, McKee MD: Difficult elbow
a functional and relatively pain-free 1690-1695. fractures: Pearls and pitfalls. Instr
arc of motion of 105°. 7. Mills WJ, Hanel DP, Smith DG: Lateral Course Lect 2003;52:113-134.

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