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 login to view 4 more bullets mechanism login to view 2 more bullets pathoanatomy login to view 6 more bullets Associated injuries elbow dislocation terrible triad injury floating elbow Volkmann contracture login to view 1 more bullet Anatomy Osteology elbow is a hinged joint articular surface is in login to view 3 more bullets trochlea login to view 2 more bullets capitellum login to view 2 more bullets Muscles common flexors (originate from medial epicondyle) login to view 5 more bullets common extensors (originate from lateral epicondyle) login to view 6 more bullets Ligaments medial collateral ligament login to view 4 more bullets lateral collateral ligament login to view 4 more bullets Nerves ulnar nerve login to view 1 more bullet radial nerve login to view 8 more bullets Blood supply intraosseous and extraosseous blood supplies that may be compromised by the injury Classification Anatomic Classification supracondylar fractures single column fractures login to view 3 more bullets bicolumnar fractures login to view 7 more bullets 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 login to view 1 more bullet neurovascular exam login to view 4 more bullets monitor carefully for forearm compartment syndrome Imaging Radiographs recommended views login to view 3 more bullets additional views login to view 7 more bullets CT indications login to view 2 more bullets MRI indications login to view 1 more bullet Treatment Nonoperative cast immobilization login to view 4 more bullets short period of immobilization and followed by early range of motion ("bag of bones" technique) login to view 4 more bullets Operative closed reduction percutaneous pinning (CRPP) login to view 2 more bullets open reduction internal fixation (ORIF) login to view 7 more bullets total elbow arthroplasty login to view 3 more bullets Techniques Cast Immobilization technique login to view 2 more bullets Open reduction internal fixation (ORIF) approach login to view 1 more bullet exposures login to view 37 more bullets fixation login to view 13 more bullets postoperative login to view 10 more bullets Total Elbow Arthroplasty indications login to view 2 more bullets techniques login to view 1 more bullet TEA complications login to view 4 more bullets 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 login to view 1 more bullet Heterotopic ossification seen in 8% routine prophylaxis is not warranted due to increased rate of nonunion in patients treated with indomethacin risk factors login to view 4 more bullets Nonunion low incidence (0-11%) risk factors login to view 4 more bullets treatment login to view 1 more bullet Malunion avoided by proper surgical technique login to view 2 more bullets 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 login to view 1 more bullet 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 login to view 1 more bullet "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 login to view 4 more bullets