Executive Editor: Chris Colton

Authors: Mariusz Bonczar, Daniel Rikli, David Ring

Distal humerus - Partial articular, lateral sagittal

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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, such as a noncompliant patient, unacceptable surgical risk or extreme osteoporosis.

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 - Screw fixation
Indication summary Skill Equipment
Single fragment, low demand patient, good bone quality Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Indications

  • Simple fracture configuration
  • Good bone quality

Contraindications

  • Multiple fragments 
  • Osteoporosis
  • Noncompliant patient
  • Unacceptable surgical risk

Advantages

  • Often achievable with minimal invasion in simple fractures
  • Anatomical reduction
  • Articular congruity 
  • Early functional aftertreatment
  • Reduced risk of degenerate joint disease

Disadvantages

  • Risk of infection
  • Requirement for anesthesia
  • Cost
  • If a transolecranon approach is chosen, osteotomy fixation wires can cause irritation and often need later removal.
ORIF - Screw and protection plate
Indication summary Skill Equipment
Large fragment, high demand patient Highly experienced and skilled surgeon Simple surgical and imaging resources

Indications

  • Simple fractures
  • Simple fracture configuration
  • Good bone quality

Contraindications

  • Multiple fragments 
  • Osteoporosis
  • Noncompliant patient
  • Unacceptable surgical risk

Advantages

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

Disadvantages

  • Risk of infection
  • Requirement for anesthesia
  • Cost
  • If a transolecranon approach is chosen, osteotomy fixation wires can cause irritation and often need later removal.
ORIF - Plate fixation
Indication summary Skill Equipment
Large single fragment, high demand patient Highly experienced and skilled surgeon Simple surgical and imaging resources

With larger fragments, muscular patients and questionable compliance, screws alone may not provide sufficiently firm fixation in some cases. The use of a plate, placed on the lateral crest in a buttress mode, incorporating lag screws through the plate, is the treatment of choice in such cases.

 

Indications

  • Large fragments
  • Muscular, or high-demand patient
  • Patient of questionable compliance
  • Poor bone quality

Contraindications

  • Unacceptable surgical risk
  • Noncompliant patient
  • Extreme osteoporosis

Advantages

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

Disadvantages

  • Larger surgical exposure
  • Risk of infection
  • Requirement for anesthesia
  • Cost
  • If a transolecranon approach is chosen, osteotomy fixation wires can cause irritation and often need later removal.
ORIF - Plate and screw fixation (+/- headless screws)
Indication summary Skill Equipment
Multifragmentary fragment +/- associated osteochondral fragment(s) Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Multifragmentary fractures may feature osteochondral fragments that can only be fixed using totally buried, headless screws, in combination with plate fixation.

Indications

  • Partial articular fractures with multifragmentary features

Contraindications

  • Unacceptable surgical risks
  • Poor bone quality
  • Overwhelming comminution
  • Noncompliant patient

Advantages

  • Reduction and fixation of osteochondral fragments
  • Articular congruity
  • Early functional aftertreatment
  • Reduced risk of degenerate joint disease

Disadvantages

  • Need for extensive approach
  • Need for high level of surgical skill
  • Frequent need for lateral wire removal from olecranon
  • Risk of infection
  • Risk of fixation failure
  • Requirement for anesthesia
  • Cost
  • If a transolecranon approach is chosen, 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