Executive Editor: Chris Colton

Authors: Mariusz Bonczar, Daniel Rikli, David Ring

Distal humerus - Complete articular, simple articular, fragmentary metaphyseal

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Glossary

General considerations

Nonoperative treatment is not indicated for intraarticular fractures of the distal humerus, unless there is a general contraindication to surgery.

All adult articular fractures of the distal humerus require open anatomical reduction and stable fixation.

Because adult elbows are notorious for becoming stiff after injury, the goal of operative treatment is anatomical reduction and stable fixation, especially of any joint fragments, so that active motion can be started within a few days of surgery.

Pediatric fractures are considered in Pediatric trauma of Surgery Reference.

ORIF - Perpendicular plating
Indication summary Skill Equipment
Surgeon’s preference - biomechanically more stable Highly experienced and skilled surgeon Full specialized surgical and imaging resources

The use of two plates on the distal humerus for complete articular fractures greatly assists the reconstruction of the triangle of stability.

When one plate lies on the crest of the medial column, and the other lies on the posterior aspect of the lateral column, which is nonarticular, the two plates lie in planes that are at 90 degrees to each other – perpendicular, or biplanar plating.

Such a construct is considered to confer good biomechanical stability in good quality bone, but this has not been proven experimentally.

Contraindications for surgery

  • Noncompliant patient
  • Unacceptable surgical risk
  • Extreme osteoporosis

Advantages of open reduction and internal fixation

  • Anatomical reduction 
  • Articular congruity 
  • Early functional aftertreatment 
  • Reduced risk of degenerate joint disease

Disadvantages of open reduction and internal fixation

  • Risk of infection
  • Requires high level of surgical expertise
  • Requirement for anesthesia
  • Cost
  • The transolecranon osteotomy fixation wires can cause irritation and often need later removal.
ORIF - Parallel plating
Indication summary Skill Equipment
Surgeon’s preference Highly experienced and skilled surgeon Full specialized surgical and imaging resources

There may be times when it is not possible, because of the specific anatomy of a fracture complex, to place the lateral plate posteriorly, and it has to lie on the crest of the lateral column. In such a scenario, the planes of the two plates will be parallel.

Some surgeons use parallel plating as the preferred method on the basis that a posterolateral plate permits only short unicortical screws distally, whereas a lateral plate allows the use of longer distal screws.

The choice of method will be determined by the bone quality, the fracture anatomy, the availability of locking plates and individual surgical philosophy.

Contraindications for surgery

  • Noncompliant patient
  • Unacceptable surgical risk
  • Extreme osteoporosis

Advantages of open reduction and internal fixation

  • Anatomical reduction 
  • Articular congruity 
  • Early functional aftertreatment 
  • Reduced risk of degenerate joint disease

Disadvantages of open reduction and internal fixation

  • Risk of infection
  • Requires high level of surgical expertise
  • Requirement for anesthesia
  • Cost
  • The transolecranon osteotomy fixation wires can cause irritation and often need later removal.
*Skill
Basic surgical experience, no specialized skills Basic surgical experience, no specialized skills
Some specialized surgical experience Some specialized surgical experience
Highly experienced and skilled surgeon Highly experienced and skilled surgeon
*Equipment
Basic equipment only Basic equipment only
Simple surgical and imaging resources Simple surgical and imaging resources
Full specialized surgical and imaging resources Full specialized surgical and imaging resources

v1.0 2007-06-21