Distal humerus fracture
and management
Dr Raffi
Distal humerus fractures account for approximately 2-5% of all
adult fractures.
Bimodal distribution: Young adults (high-energy trauma) and
elderly (low-energy falls, often osteoporotic).
Complex anatomy: Supracondylar region, medial & lateral
epicondyles, capitellum, trochlea, olecranon fossa, coronoid fossa.
Critical neurovascular structures: Ulnar nerve (medial
epicondyle), radial nerve (anterior to capitellum), brachial artery
(anterior).
Intra-articular vs. Extra-articular: Crucial distinction for
management.
Direct Trauma:
• Fall directly onto the elbow.
• Direct blow to the elbow.
Indirect Trauma:
• Fall on outstretched hand (FOOSH): Most common.
◦ Axial compression of the forearm bones against the distal
humerus.
◦ Varies depending on elbow position (flexion/extension) and
forearm rotation.
• Hyperextension or hyperflexion forces.
• Avulsion injuries (e.g., epicondylar fractures from muscle pull).
History:
• Mechanism of injury (critical for understanding fracture pattern).
• Pain, swelling, deformity.
• Previous elbow injuries or surgeries.
• Medical comorbidities, osteoporosis status.
Physical Exam:
• Inspection: Swelling, ecchymosis, gross deformity, open wounds (assess for open
fracture!).
• Palpation: Tenderness, crepitus.
• Neurovascular Assessment: CRITICAL!
◦ Distal pulses (radial, ulnar).
◦ Capillary refill.
◦ Motor and sensory function of median, ulnar, and radial nerves. Document pre-
reduction neurological status meticulously.
• Gentle ROM: If tolerated, assess general stability, but avoid aggressive
Plain Radiographs:
• Standard views: AP and Lateral views of the elbow.
• Oblique views: Medial and lateral obliques often helpful to define fracture lines.
• Traction views: Can help delineate complex intra-articular patterns by
distracting fragments (performed cautiously).
• Assess for joint congruity, fracture lines, displacement, comminution, and
associated dislocations.
Computed Tomography (CT) Scan:
• Highly Recommended for complex intra-articular fractures.
• Provides detailed 3D anatomy, fracture mapping, fragment size, and
displacement.
• Helps with surgical planning (implant size, approach).
• CT Angiography if vascular injury suspected.
A 3d reconstructed
image of a complex
intra -articular distal
humerus fracture
Type A (Extra-articular):
• A1: Avulsion of epicondyle
• A2: Simple supracondylar
• A3: Multifragmentary supracondylar
Type B (Partial Articular): Involves only part of the articular
surface.
• B1: Lateral condyle (capitellum, lateral trochlear ridge)
• B2: Medial condyle (trochlea)
• B3: Coronal shear (Kocher, Hahn-Steinthal)
Type C (Complete Articular): Both columns involved, articular
surface fractured and separated from diaphysis.
• C1: Articular simple, metaphyseal simple
• C2: Articular simple, metaphyseal multifragmentary
Surgical approaches
Posterior Transolecranon Osteotomy:
• Advantages: Excellent exposure of the articular surface, easy reduction.
• Disadvantages: Requires osteotomy fixation, risk of
nonunion/symptomatic hardware at olecranon.
Triceps Sparing/Splitting:
• Triceps Sparing (Paratricipital):
◦ Lateral or medial approaches, or combination.
◦ Often used for simpler patterns or when olecranon osteotomy is
undesirable.
◦ Can be challenging for complex intra-articular fractures.
• Triceps Splitting: Less commonly used now due to triceps weakness.
Medial/Lateral Approaches (for specific column fixation):
• Isolated medial or lateral column fractures.
• Sometimes combined for complex fractures.
Ulnar Nerve Management: Often identified and transposed anteriorly to
Posterior transolecranon osteotomy
Triceps sparing
Medial approach for distal humerus
Lateral approach to distal humerus
Principles of ORIF
Anatomical Reduction: Especially critical for articular fragments.
Reconstruction of the Articular Surface: First priority. Use small K-wires or
screws for provisional fixation.
Columnar Reconstruction:
• Medial and lateral columns should be reconstructed and fixed independently.
• Parallel Plating: Two plates, typically applied 90 degrees to each other (e.g.,
medial plate on medial column, posterior plate on lateral column/supracondylar).
• Orthogonal Plating: Plates at 90 degrees, often a posterior plate and a medial
plate.
• Provides good stability for both axial and rotational forces.
Plate Selection: Locking plates common for comminuted fractures or osteoporotic
bone. Low-profile plates to minimize soft tissue irritation.
Screw Length and Number: Adequate screws in both proximal and distal
Parallel vs Orthogonal plating
Post op Rehabilitation
Phase 1 (Initial Protection):
• Sling for comfort, but begin gentle active-assisted range of motion
(AAROM) within first few days to a week.
• Focus on gentle flexion and extension within pain limits.
Phase 2 (Controlled Mobilization):
• Gradual progression to active range of motion (AROM).
• Gentle strengthening exercises.
Phase 3 (Return to Function):
• Progressive strengthening.
• Sport-specific or activity-specific exercises.
Physical Therapy: Essential for guidance and progression.
Potential complications
Stiffness/Loss of Motion: Most common complication. Prevention
through early, diligent rehab.
Ulnar Neuropathy: Most common nerve injury (iatrogenic during
surgery, or post-operative swelling). May require revision or
decompression.
Nonunion/Malunion: Failure of bone to heal or healing in a deformed
position. Requires revision surgery.
Infection: Risk with any open surgery.
Heterotopic Ossification (HO): Ectopic bone formation around the
joint. Prophylaxis with NSAIDs or radiation in high-risk cases.
Post-traumatic Arthritis: Especially with significant articular damage
or imperfect reduction.
Any questions?
