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Updated: Sep 21 2024

Distal Humerus Fractures

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  • Summary
    • Distal Humerus Fractures are traumatic injuries to the elbow that comprise of supracondylar fractures, single column fractures, column fractures or coronal shear fractures.
    • Diagnosis is made with plain radiographs of the humerus and elbow. CT scan is helpful for intra-articular assessment and operative planning. 
    • Treatment is usually open reduction and internal fixation. 
  • Epidemiology
    • Incidence
      • accounts for 2% of all fractures
      • accounts for 30% of elbow fractures
      • incidence has been steadily increasing
    • Demographics
      • most common in young males and older females
    • Anatomic location
      • distal intercondylar fractures are the most common fracture pattern
  • Etiology
    • Pathophysiology
      • distal humerus fractures are traumatic injuries that include
        • supracondylar fractures
        • single column (condyle) fractures
        • bicolumnar fractures
        • coronal shear fractures
      • mechanism
        • low energy falls in elderly
        • high energy impact in younger population
      • pathoanatomy
        • elbow position affects fracture type
          • elbow flexed < 90°
            • axial load leads to transcolumnar fracture
            • direct posterior blow leads to olecranon fracture with or without distal humerus involvement
          • elbow flexed > 90°
            • may lead to intercondylar fracture
    • Associated injuries
      • elbow dislocation
      • terrible triad injury
      • floating elbow
      • Volkmann contracture
        • results from missed forearm compartment syndrome
  • Anatomy
    • Osteology
      • elbow is a hinged joint
      • articular surface is in
        • 6 degrees of valgus
        • 5 degrees of external rotation
        • 30 degrees of flexion
      • trochlea
        • articulates with sigmoid notch
        • allows for flexion and extension
      • capitellum
        • articulates with proximal radius
        • allows for forearm rotation
    • Muscles
      • common flexors (originate from medial epicondyle)
        • pronator teres
        • flexor carpi radialis
        • palmaris longus
        • FDS
        • FCU
      • common extensors (originate from lateral epicondyle)
        • anconeus
        • ECRL
        • ECRB
        • extensor digitorum comminus
        • EDM
        • ECU
    • Ligaments
      • medial collateral ligament
        • anterior bundle originates from distal medial epicondyle
        • inserts on sublime tubercle
        • primary restraint to valgus stress at the elbow from 30-120°
        • tight in pronation
      • lateral collateral ligament
        • originates from distal lateral epicondyle
        • inserts on crista supinatorus
        • stabilizer against posterolateral rotational instability
        • tight in supination
    • Nerves
      • ulnar nerve
        • resides in the cubital tunnel in a subcutaneous position posterior to the medial condyle
      • radial nerve
        • anatomic landmarks
          • in the spiral groove 15cm proximal to distal humeral articular surface
          • 10cm from the medial edge of the olecranon
          • 7.5cm from the lateral edge of the olecranon
          • 3.9 cm (two finger-breadths) proximal to the triceps aponeurosis
        • runs between brachioradialis and brachialis proximal to elbow
        • posterior antebrachial cutaneous nerve (PABCN) branches in the posterior arm 
        • divides into PIN and superficial radial nerve at the level of the radial head
    • Blood supply
      • intraosseous and extraosseous blood supplies that may be compromised by the injury
  • Classification
    • Anatomic Classification
      • supracondylar fractures
      • single column fractures 
        • 5% of fractures
        • subclassified using Milch classification system (see table)
        • lateral condyle more common than medial
      • bicolumnar fractures
        • classified using Jupiter classification system (see table)
        • 5 major articular fragments have been identified
          • capitellum/lateral trochlea
          • lateral epicondyle
          • posterolateral epicondyle
          • posterior trochlea
          • medial trochlea/epicondyle
    • Described Classification Systems
      • AO/OTA Classification of Distal Humerus Fractures
      • Type A
      • Extra-articular (supracondylar fracture), 80% are extension type; epicondyle
      • Type B
      • Intraarticular- Single column (partial articular-isolated condylar, coronal shear, epicondyle with articular extension).
      • Type C
      • Intraarticular- Both columns fractured and no portion of the joint is contiguous with the shaft (complete articular)
      • Each type further divided by degree and location of fracture comminution
      • Milch Classification of Single Column Condyle Fractures
      • Milch Type I
      • Lateral trochlear ridge intact
      • Milch Type II
      • Fracture through lateral trochlear ridge
      • Jupiter Classification of Two-Column Distal Humerus Fractures
      • High-T
      • Transverse fx proximal to or at upper olecranon fossa
      • Low-T
      • Transverse fx just proximal to trochlea (common)
      • Y
      • Oblique fx line through both columns with distal vertical fx line
      • H
      • Trochlea is a free fragment (risk of AVN)
      • Medial lambda
      • Proximal fx line exists medially
      • Lateral lambda
      • Proximal fx line exists laterally
      • Multiplane T (not pictured)
      • T type with an additional fracture in coronal plane
  • Presentation
    • Symptoms
      • elbow pain and swelling
    • Physical exam
      • check for open wounds, especially posteriorly
      • gross instability often present
        • avoid ROM due to risk of neurovascular damage
      • neurovascular exam
        • check function of radial, ulnar, and median nerves
        • check distal pulses
          • brachial artery may be injured
          • if pulse decreased, obtain noninvasive vascular studies and consult vascular surgery if abnormal
      • monitor carefully for forearm compartment syndrome
  • Imaging
    • Radiographs
      • recommended views
        • AP
          • ideally taken with 40 deg of flexion
        • lateral
      • additional views
        • humerus and forearm radiographs
        • wrist radiographs
          • obtain if elbow injury present or distal tenderness on exam
        • oblique radiographs 
          • specifically used to evaluate if there is continuity of the trochlear fragment with the medial epicondylar fragment, this can influence hardware choice
        •  traction radiograph
          • may assist with surgical planning
    • CT
      • indications
        • often obtained for surgical planning
          • especially helpful when shear fractures of the capitellum and trochlea are suspected
    • MRI
      • indications
        • usually not indicated in acute injury
  • Treatment
    • Nonoperative
      • cast immobilization
        • indications
          • nondisplaced Milch Type I fractures
        • technique
          • above elbow cast with close follow-up due to risk of displacement
      • short period of immobilization and followed by early range of motion ("bag of bones" technique)
        • indications
          • elderly patients  
            • with significant medical comorbidities precluding surgery
            • unable to comply with postoperative protocol
    • Operative
      • closed reduction percutaneous pinning (CRPP)
        • indications
          • displaced Mich Type I fractures
      • open reduction internal fixation (ORIF)
        • indications
          • supracondylar fractures
          • intercondylar / bicolumnar fractures
          • Milch Type II fractures
        • techniques
          • ulnar nerve transposition
            • no benefit with ORIF
      • total elbow arthroplasty
        • indications
          • distal comminuted bicolumnar fractures in low demand elderly patients
            • must be able to comply with weightbearing restriction
  • Techniques
    • Cast Immobilization
      • technique
        • immobilize in supination for lateral condyle fractures
        • immobilize in pronation for medial condyle fractures
    • Open reduction internal fixation (ORIF)
      • approach
        • posterior superficial approach
      • exposures
        • triceps-splitting (Campbell)
          • technique
            • split triceps tendon in midline down to olecranon
          • for open fractures, approach using the defect leads to better results than an osteotomy
        • triceps-sparing (paratricipital, Alonso-Llames, medial and lateral windows)
          • indications
            • extra-articular fractures
            • fractures with a simple articular split
          • technique
            • elevate triceps from the humerus using medial and lateral windows
            • can be converted to olecranon osteotomy if needed
        • olecranon osteotomy
          • indications
            • complex intra-articular fractures
            • fractures with a coronal split
          • contraindications
            • total elbow arthroplasty is planned/may be required
          • technique
            • perform chevron (apex distal) osteotomy
            • fixation of osteotomy performed using a combination of screws, K wires, tension band or plate
          • complications
            • AIN nerve injury
              • check ability to flex thumb interphalangeal joint in recovery
            • symptomatic hardware (6-30%)
            • osteotomy nonunion (0-9%)
        • triceps-reflecting (Bryan-Morrey)
          • technique
            • reflect triceps tendon, forearm fascia, and periosteum off the olecranon from medial to lateral
            • repair through transosseous drill holes
            • immobilize to protect triceps repair for 4-6 weeks postoperatively
        • triceps-reflecting anconeus pedicle (O'Driscoll)
          • technique
            • elevate anconeous subperiosteally from proximal ulna
        • lateral muscles interval
          • technique
            • elevate the ECRB and part of the ECRL off of the supracondylar ridge
      • fixation
        • perform provisional reduction with k-wires
          • if metaphyseal injury is not comminuted, reducing one column to the metaphysis first may be beneficial
        • perform fixation of articular fragments with countersunk/headless screws
          • consider using positional screws when reducing trochlea to avoid narrowing it with compression
        • perform fixation of condyles and epitrochlear ridge
          • fix the lateral epicondyle using a tension band wire or plate
          • fix the articular segment to the shaft using two plates in orthogonal planes
            • new literature supports parallel plates for increased biomechanics strength
            • no difference in clinical outcomes between 90-90 and parallel plating
          • if the ulnar nerve contacts medial hardware during flexion/extension, can perform an ulnar nerve transposition
            • no difference between rates of post-operative ulnar neuritis with in situ release compared to transposition 
            • no difference in patient-reported outcomes between transposition and in-situ release
        • locking plates are preferred for poor bone quality or comminution 
      • postoperative
        • splint elbow in 70° of flexion
        • remove splint within 7-10 days post-operatively and initiate ROM exercises
          • if osteotomy performed
            • active and active-assisted flexion and extension for 6 weeks
            • no active extension against gravity or resistance
            • no restrictions to rotation
          • if osteotomy not performed
            • active motion against gravity without restrictions
            • no restrictions to rotation
        • start gentle strengthening program at 6 weeks and full strengthening program at 3 months
    • Total Elbow Arthroplasty
      • indications
        • comminuted articular fractures in osteoporotic bone
        • inflammatory conditions (e.g. RA)
      • techniques
        • semi-constrained
      • TEA complications
        • activity restrictions (e.g. can not lift more than 10 pounds)
        • implant loosening
        • polyethylene wear
        • periprosthetic fracture
      • functional outcomes similar to salvage arthroplasty following failed ORIF
  • Complications
    • Elbow stiffness
      • most common (3-42%)
      • mean arc of motion is 90-106 degrees
      • treatment
        • static-progressive splinting
    • Heterotopic ossification
      • seen in 8%
      • routine prophylaxis is not warranted due to increased rate of nonunion in patients treated with indomethacin
      • risk factors
        • head injury
        • floating elbow injury
        • Type A and B fractures
        • delayed surgical fixation
    • Nonunion
      • low incidence (0-11%)
      • risk factors
        • excessive soft-tissue stripping
        • open fractures
        • comminution 
        • low transcondylar or intercondylar fractures
      • treatment
        • revision ORIF with bone graft
    • Malunion
      • avoided by proper surgical technique
        • cubitus valgus (lateral column fractures)
        • cubitus varus (medial column fractures)
    • Anterior interosseous nerve injury
      • can be seen with olecranon osteotomy
    • Ulnar nerve injury (10-38%)
      • Postoperative ulnar nerve palsies are most often secondary due to traction during open reduction and internal fixation
    • Wound complications (up to 16%)
      • due to poor soft tissue envelope over posterior elbow
    • Infection 
      • occurs in 0-14% of patients
    • Posttraumatic Arthritis
  • Prognosis
    • ORIF
      • majority of patients regain 75% of elbow motion and strength
        • goal is to restore elbow ROM 30-130° of flexion
    • Total elbow arthroplasty
      • has rates of implant survival >75% at 10 years if used with appropriate indications 
      • expected ROM is 26-125 degrees
      • in patients > 65 years old functional outcomes were higher with TEA than ORIF at 2-year follow-up
    • "Bag of bones" 
      • goal is a painless pseudoarthrosis
      • only fair functional outcomes
      • high rate of nonunion and later surgery
    • Unsatisfactory outcomes in up to 25%
      • treatment of these fractures is complex due to
        • low fracture line of one or both columns
        • metaphyseal fragmentation of one or both columns
        • articular comminution
        • poor bone quality
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