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Trauma & Fractures

Distal Humerus Fracture

Complex Intra-Articular Elbow Fractures

Dual plating, olecranon osteotomy, and the ORIF vs replacement decision

Understanding Distal Humerus Fractures

Distal humerus fractures account for approximately 2% of all adult fractures but represent some of the most challenging injuries in orthopedic trauma. The goal is to restore a stable, mobile, pain-free elbow.

Anatomy Considerations

  • • Medial Column: Medial epicondyle and medial trochlear ridge
  • • Lateral Column: Lateral epicondyle and capitellum
  • • Articular Surface: Trochlea (articulates with ulna) + Capitellum (articulates with radius)
  • • Ulnar Nerve: Runs in cubital tunnel - must be protected or transposed
  • • Bone is thin and often osteoporotic in elderly

Bimodal Distribution

Young patients: High-energy trauma, more likely to have good bone for fixation.
Elderly patients: Low-energy falls, osteoporotic bone, may be candidates for replacement.

AO/OTA Classification

Type A
Extra-articular

Fracture does not involve articular surface

A1: Apophyseal avulsion

A2: Simple metaphyseal

A3: Comminuted metaphyseal

Type B
Partial Articular

Part of articular surface remains attached to shaft

B1: Lateral sagittal (capitellum)

B2: Medial sagittal (trochlea)

B3: Frontal (coronal shear)

Type C
Complete Articular

Articular surface completely separated from shaft

C1: Simple articular, simple metaphyseal

C2: Simple articular, comminuted metaphyseal

C3: Comminuted articular

Treatment Options

ORIF - Dual Plating (Standard of Care)

Goal: Anatomic reduction, stable fixation, early motion

Surgical Approach

  • • Posterior approach with triceps management
  • • Olecranon osteotomy: Best visualization of articular surface
  • • Triceps-sparing: Paratricipital (Bryan-Morrey) approach
  • • TRAP: Triceps-reflecting anconeus pedicle

Plating Configurations

Parallel Plating

Plates on medial and lateral columns, parallel orientation. Better for distal fixation.

90-90 Plating

Medial plate on medial column, posterolateral plate. Biomechanically similar.

Total Elbow Arthroplasty (TEA)

For elderly patients with unreconstructable fractures

  • • Age typically >65-70 years
  • • Severe comminution with osteoporotic bone
  • • Low physical demands
  • • May have pre-existing arthritis (RA)

McKee et al. (JBJS 2009): RCT showed TEA had better outcomes than ORIF in elderly with comminuted fractures at 2 years. But TEA has lifetime activity restrictions (no >5kg lifting).

Non-Operative (Rare)

Only for patients unfit for any surgery:

  • • Bag of bones technique - accept deformity, aim for painless motion
  • • Early gentle ROM after pain subsides
  • • Results variable - stiffness and malunion common

Evidence & References

• Jupiter JB, Neff U, Holzach P, Allgower M. Intercondylar fractures of the humerus. An operative approach. JBJS Am 1985

• McKee MD, et al. A multicenter, prospective, randomized, controlled trial of open reduction-internal fixation versus total elbow arthroplasty for displaced intra-articular distal humeral fractures in elderly patients. JBJS Am 2009

• Sanchez-Sotelo J, Torchia ME, O'Driscoll SW. Complex distal humeral fractures: internal fixation with a principle-based parallel-plate technique. JBJS Am 2007

• Frankle MA, et al. A comparison of open reduction and internal fixation and primary total elbow arthroplasty in the treatment of intraarticular distal humerus fractures in women older than age 65. J Orthop Trauma 2003

Last Updated: January 2025 | Content reviewed by Dr. Deepthi Nandan Reddy, FRCS (Ortho)

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