Distal Humerus Fractures

EpidemiologyDistal Humeral Fracture


2 groups

- young patient with high velocity injury

- older patient with comminuted, osteoporotic fracture


In the second group fixation can be very difficult




Hinged Joint

- trochlea axis is centre of rotation

- 40o anterior angulation in sagittal plane

- trochlea 3-8o externally rotated

- 4 - 8o valgus

- medial and lateral columns


Elbow Lateral NormalElbow Lateral Normal 40 degree anterior angulation


Elbow AP NormalElbow Normal AP 4 degrees valgus


CT scan


Aids preoperative planning

- identify capitellar fracture

- identify if trochlea deficiencies which might need bone grafting

- aid diagnosis / reconstruction intr-articular extension


Muller's Classification


Type A: Extra-articular fracture


Distal Humerus Fracture


Type B: Uni-condylar fracture

- lateral /  medial


Elbow Medial Condyle FractureElbow Lateral Condyle Fracture


Type C: Bi-condylar fracture


Distal Humeral Fracture APDistal Humeral Fracture BicondylarDistal Humeral Fracture


Operative Management




Within 24 hours or at 5 - 7 days

- minimises inflammation

- minimises risk HO




1.  ORIF


2.  Distal humeral replacement / osteoporotic and highly comminuted fractures


Kalogrianitis et al J Should Elbow Surg 2008

- 9 patients mean age 37

- highly comminuted, osteoporotic, non reconstructable fractures

- no deep infections

- ROM 15 - 120o


McKee et al JSES 2009

- RCT 42 patients > 65 years of age


- 5 ORIF patients converted to TEA intraop

- better outcomes and decreased reoperation rate with TEA



- good treatment if unable to ORIF

- high level of skills required

- can replace distal humerus only if ligaments and proximal ulna preserved

- otherwise must replace ulna +/- linked prosthesis


3.  "Bag of bones" treatment

- patient elderly and not operative candidate

- intial rest in plaster

- then mobilisation

- surprisingly good ROM and function


Distal Humerus Non Operative




Extra-articular fracture


Distal Humerus Extraarticular ORIF


1.  Mobilise triceps either side of humerus 

- reduce distal fragment and hold with K wires

- application 2 x perpendicular plates


2.  Bryan - Morrey Triceps sparing posteromedial approach

- find and protect ulna nerve

- elevate triceps aponeurosis medial to lateral off ulna

- leave one side of periosteum intact


3.  Split triceps

- feather with osteotome off ulna medial and laterally


Intra-articular fracture


Need to visualise distal humerus to get anatomical reduction

- olecraonon blocks visualisation

- Chevron Osteotomy


Technique for Intra-articular fracture


Distal Humerus ORIF APDistal Humerus ORIF Lateral



- lateral decubitus with bolsters

- arm over bolster

- tourniquet

- may need to prep and drape iliac crest for bone graft


Elbow Lateral Decubitus


Posterior approach

- midline posterior incision is used

- deviate radial side of olecranon (prevents painful incision)

- ulnar nerve identified / mobilised / vessiloops / protected


Chevron Olecranon Osteotomy


Chevron Osteotomy



- predrill proximal ulna with 3.2 mm bit 

- partially tapped for 6.5 mm cancellous screw

- cut with oscillating saw, apex distal

- homan retractors each side to protect structures

- attempt to make in bare area of central olecranon

- 3 cm from tip olecranon

- complete with osteotome so can interdigitate fracture and not saw away segment of articular cartilage

- take fragment and retract proximally, taking triceps with it to expose distal humerus

- radial nerve 14 cm proximal to lateral epicondyle

- wrap in wet sponge, clip with artery to drapes


Restoration of Articular Anatomy

- Anatomic reduction of the condyles / distal articular surface

- ORIF with cannulated 4.0 mm partially threaded screws

- reduce fragment onto distal humerus

- fix with K wires in medial and lateral columns

- check with II


Pre-contoured locking plates

- posterolateral and medial

- ensure not of equal length to decrease stress risers proximally

- can get variants of posteriorlateral plate to fix coronal plane fracture of capitellum (AP screws in PL plate)

- fix with locking screws

- ensure not in olecranon or coronoid fossa  


Assess ROM

- no block to motion

- good stability


Check II


Assess ulna nerve 

- ensure not impinging on medial plate   

- may need to consider anterior transposition  


ORIF olecranon

- 6.5 mm screw + washer, then wire tension band

- may need plate if screw does not get good bite

- can use K wires and TBW


Post op 


POP backslab 2/52 for wound healing

Range if stable with physio / active assist

- avoid PROM (HO)




G/E 75%





- loss of 10 - 20o extension common


Humeral non union


Olecranon osteotomy non union

- 5%

- bone graft and plate


Ulna nerve palsy

- keep in mind the need to perform anterior transposition in original OT

- treat with neurolysis + transposition


Painful Hardware

- most common

- re-fracture risk if remove both plates


Adult Lateral Condyle Fracture


Elbow Lateral Condyle FractureElbow Lateral Condyle Fracture 2




Fracture of lateral condyle

- involve capitulum alone

- may extend medially to involve the lateral portion of trochlea


Management Options


These fractures are typically displaced and require surgical treatment

- Kocher approach and ORIF with compression screws

- Posterior approach and posterolateral plate


Adult Medial Condyle Fracture


Elbow Medial Condyle Fracture




Medial epicondyle is common origin of several flexor muscles of hand and wrist

When medial epicondyle is fractured, flexor muscles pull fragment distally




1.  Medial approach

- find and protect ulna nerve

- ORIF with screws


2.  Posterior approach

- find and protect ulna nerve

- application of medial plate / ORIF with screws

- ensure at end no encroachment of  plate on nerve or might need anterior transposition


Transcondylar Fracture




Type of supracondylar fractures that occurs within joint capsule

- very distal / often very comminuted

- most commonly occurs with osteoporotic bone




Non-displaced fractures are treated with splinting or percutaneous pinning


Displaced fracture

- consider ORIF

- may need to consider primary hemiarthroplasty / elbow replacement