Trauma 2008; 10: 125132

Fractures of the distal humerus

B Youssefa, S Youssefb, S Ansarac and K Porterd

Fractures of the distal humerus are challenging injuries to treat. They are rare injuries and frequently involve the joint. The advent of modern operative fixation techniques has led to an increasing trend towards open anatomical reduction and internal fixation of these fractures. This review examines the basic anatomy of the distal humerus and the applied anatomy with regards to fracture classification and surgical approach. This is followed by a discussion of the methods and results of treatment. Key words: distal humeral fracture; treatment; surgical approach

Introduction
Many of the problems that face orthopaedic surgeons when dealing with distal humeral fractures are due to the complex anatomy of the elbow joint. The highly constrained nature of the elbow means that large amounts of energy are absorbed during trauma. The distal humerus has a narrow supracondylar isthmus with a sparsity of adequate subchondral metaphyseal supporting bone, especially within the olecranon fossa. These are rare injuries, the majority involve the joint, and they are often open when associated with high energy trauma. As a result they are difficult to reconstruct. There is little in the way of historical information regarding the management of these injuries. Prior to the development of radiography, it is likely that these injuries would have been treated with immobilisation (Robinson et al., 2003; Robinson, 2006) resulting in a stiff, poorly functioning elbow.

a Registrar, Trauma and Orthopaedic Surgery, University Hospital Birmingham NHS Trust, Birmingham, UK. b Foundation Year 1 Doctor, Emergency Medicine, Kings College Hospital NHS Trust, London, UK. c Associate Specialist, Trauma and Orthopaedic Surgery, Sandwell and West Birmingham Hospital NHS Trust, Birmingham, UK. d Professor, Traumatology, University Hospital Birmingham NHS Trust, Birmingham, UK.

Address for correspondence: B Youssef, 7 Kesteven Close, Edgbaston, Birmingham, B15 2UT, UK. E-mail: bishoy_youssef@hotmail.com

The advent of modern warfare and the industrial revolution saw a massive increase in the number of open fractures of the elbow. These were often treated by immediate amputation to save life before limb, or delayed amputation to treat infection or painful bony ankylosis. The other commonly undertaken procedure was excision of the elbow joint, performed either as a primary or secondary procedure. Descriptions of these procedures notably date back to the Crimean War, the American Civil War and the First and Second World Wars. Data from the American Civil War associated resection of the elbow joint with a mortality rate of 25% (Nicholson, 1946). In 1937, Eastwood described the bag of bones technique. This involved compressive manipulation of the distal fragments and collar and cuff support with the elbow in flexion, as well as early mobilisation. Reasonable results have been achieved using this technique; a functional range of movement of 116 degrees of flexion after 2.5 years of follow up has been reported (Brown and Morgan, 1971). However, this technique has its problems, which include weakness and instability of the joint (Evans, 1953). Despite the advent of anti-sepsis and anaesthesia, the majority of these fractures continued to be managed non-operatively with the bag of bones approach, closed manipulation or overhead skeletal traction. The Arbeitsgemeinschaft fur Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) techniques of internal fixation have resulted in a change towards operative management of these injuries, which involves anatomical reduction of the
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distal articular surface in an inverted Y configuration. The medial column diverges from the central humeral axis at an angle of 45 and the lateral column at an angle of 20 . Each column is triangular in cross section, its apices pointing towards the central fossa. The articular surface of the capitellum represents the anterior surface of the inferior portion of the lateral column. The medial column is entirely extra-articular (McKee et al., 1998). The most inferior part of the distal humerus is the condyle. The condyle is made up of the trochlea, capitellum and the olecranon, coronoid and radial fossae. The two articular surfaces of the condyle are the lateral capitellum (Latin for little head), which articulates with the radial head, and the medial trochlea (Latin for pulley), which articulates with the trochlear notch of the ulna. The stability of the elbow relies on the articulation of the central trochlear sulcus with a corresponding ridge of bone in the trochlear groove of the ulna. Proximal to the trochlea is the anteriorly located coronoid fossa, which receives the coronoid process of the ulna during full flexion of the elbow. Posteriorly is the olecranon fossa, which accommodates the tip of the olecranon when the elbow is fully extended (Moore and Dalley, 1999) (Figure 1). The ulnar nerve is directly inferior to the medial column in the cubital tunnel. The centrally located trochlea links the two columns and articulates with the olecranon. The articular surface of the trochlea subtends an arc of 270 , allowing a large range of movement at the ulno-humeral joint. The capitellum subtends an arc of 180 . The distal articular surface lies in 4 8 of valgus and is externally rotated 3 4 , relative to the central axis of the humerus. The capitellum and trochlea are translated anteriorly relative to the humeral diaphysis, creating an angle at the distal articular segment of 30 40 . The medial collateral ligament attaches proximally from the antero-inferior aspect of the medial epicondyle and has its distal attachment on the medial aspect of the ulna, immediately distal to the coronoid process. It consists of three structures; the anterior band a strong round cord which is taut in extension, the posterior band a weak fan-like structure that is taut in flexion, and oblique fibres which deepen the socket for the trochlea of the humerus. The lateral collateral ligament has its proximal attachment at a point along the axis of the humerus that marks the centre of rotation for the ulno-humeral

fracture, rigid internal fixation, and early mobilisation, aiming to restore function and alleviate pain.

Epidemiology
Distal humeral fractures are rare injuries, comprising of 2% of all fractures (Jupiter and Morrey 1993) and a third of all humeral fractures (Rose et al., 1982). A 10-year prospective cohort study of patients over the age of 12 who had sustained fractures of the distal humerus suggested that the incidence was 5.7 per 100 000 population per year. This data comes from Edinburgh, a city with a stable urban population and with one trauma unit covering the entire population, therefore the quoted incidence is likely to be representative of a European city. There is good evidence that the incidence of distal humeral fractures is increasing world wide (Palvanen et al., 1998, 2003) due to the rising incidence of osteoporotic fractures in elderly patients. They described a rise of 12 per 100 000 to 28 per 100 000 from 1970 to 1995 in Finnish women over the age of 60. There is a bimodal distribution of distal humeral fractures with respect to age and gender, with peaks of incidence in males aged 1219 and females aged over 80. The incidence declines in males until the age of 70, when it begins to increase again (Rose et al., 1982). In females, the incidence falls slightly between the second and third decades and then increases with age. The actual number of fractures occurring in each age group is the same, despite the differences in distribution. The mean age for males is 36.8 years and for females 59.7 years (Rose et al., 1982). The majority are intra-articular involving both the medial and lateral columns (Jupiter and Mehne, 1992). A total of 34% involve a single column with the lateral column being more commonly involved than the medial column.

Anatomy
The trochlea and medial and lateral columns represent a mechanical triangle at the distal end of the humerus. As the humerus widens distally, it diverges to form sharp medial and lateral supracondylar ridges and then ends forming prominent medial and lateral extensions, the epicondyles. The divergent medial and lateral columns of bone support the
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A1 A2 A3 A4

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Radial fossa

Coronoid fossa

B1
Lateral epicondyle Capitulum Trochlea A. Anterior view Medial epicondyle

B2

B3

C1

C2

C3

Olecranon fossa

Figure 2 AO/OTA classification of distal humeral fractures. Reproduced from Muller et al. 1990 with kind permission of Springer Science Business Media.

Medial epicondyle Trochlea B. Posterior view

Lateral epicondyle

to each long bone and fractures are identified as being A, B or C.  Type A: Extra-articular fractures.  Type B: Partial articular fractures.  Type C: Entirely articular fractures. There are further sub-categories allowing for more detailed accounts of specific fractures (Figure 2). This classification is particularly useful in researching different fracture patterns but it is somewhat cumbersome and complicated to use in everyday clinical practice (Muller et al., 1990).

Figure 1 humerus

Anterior and posterior views of the distal

joint, and is a fan-shaped structure that attaches distally to the annular ligament of the radius and the lateral border of the ulna (Moore et al., 1999).

Classification
There are several classification systems used to describe fractures of the distal humerus. The AO/ OTA, Milch, Mehne and Matta and the Riseborough and Radin classification systems will be discussed in this article.

Milch system
Single column fractures are defined using the Milch classification into patterns involving the medial or lateral condyle, and as type I (low) or type II (high) depending on how proximal the fracture started before travelling obliquely across the trochlea. These fractures usually occur as a result of an abduction or adduction force. Capitellar and trochlear fractures occur in the coronal plane and can be classified as follows: Type I: Isolated capitellar fractures.
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AO/OTA
This classification system is a complex alphanumerical radiographic system that assigns numbers

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anatomically reconstruct, or a free-floating articular fragment. High T and Y fractures begin in the centre of the trochlea, the force from impaction of the trochlea into the olecranon-trochlear ridge causes the fracture to propagate vertically and across each column. If a fracture involves both columns at a distal level, it may enter the olecranon and coronoid fossa and produce comminuted articular fragments that are too small to reconstruct. It also accounts for oblique fracture patterns, medial and lateral lambda fractures, in which one column is fractured above the olecranon fossa and the other below it.

Type II: Fractures involving the articular surface. Type III: Comminuted osteochondral fractures. Type IV: Fracture involving the capitellum and the trochlea.

Mehne and Matta system

The classification system devised by Mehne and Matta (1986) developed from the authors improved understanding of these injuries as a result of the increasing trend towards internal fixation of such fractures. The classification is based on their intraoperative appearance. They describe the bi-column fractures of the distal humerus and take into account the height of the fracture. They are divided into intraarticular, intra-capsular or extra-capsular fractures. This system is used to guide surgical management. Fracture configurations are divided into high or low and T, H, Y, medial lambda and lateral lambda (Figure 3). Distal fractures involving single or both columns, such as low H-type fractures, involve the olecranon or coronoid fossa, producing small articular fragments that can be difficult to
A. High T B. LowT

Risenborough and Radin system

The Risenborough and Radin classification (Risenborough and Radin, 1969) differentiates fractures on the basis of displacement and rotation. It is a simple system, but limited because it fails to account for a large variety of fracture patterns. Type I: Minimally displaced articular fragments. Type II: Displaced articular fragments but not rotated. Type III: Displaced and rotated fragments. Type IV: Comminuted fracture fragments.

Conservative management
Non-surgical treatment is appropriate for patients with stable un-displaced fractures. It also has a role to play in low demand patients with unstable or displaced fracture patterns. As previously mentioned, the bag of bones approach, which encompasses compressive manipulation, temporary immobilisation and early supervised active range of movement, can achieve reasonable functional results. The key to managing these patients is a comprehensive evaluation of their expectations and pre-morbid condition. This treatment may result in instability of the elbow joint, fracture displacement and non-union.

C. Y

D. H

E. Medial lambda

F. Lateral lambda

Figure 3 Mehne and Matta classification of distal humeral fractures. Fracture configurations are divided into high or low and T, H, Y, medial lambda and lateral lambda. Reproduced from Muller et al. 1990 with kind permission of Springer Science Business Media.

Pre-operative assessment
Pre-operative assessment includes documentation of the neurovascular status, in particular, attention should be paid to the assessment of the ulnar nerve.

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The joint above and below should be assessed clinically and radiographically. Pre-operative planning should take into consideration bone grafting requirements and patients should be prepared and consented accordingly. Standard plain film radiography of the distal humerus is often not sufficient and specialised views with traction taken in two planes may be more informative. Computed tomography with 3D reconstruction has superseded plain film radiography and can provide detailed images for pre-operative planning.

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dissection proximally. This technique has been employed for the treatment of open fractures of the humerus (McKee et al., 2000). They proposed that the posterior wound and traumatic injury to the triceps that often accompanies open fractures of the humerus can be incorporated into the incision and approach. They found no difference between the triceps splitting approach and those incorporating an olecranon osteotomy. Regardless of the approach, patients rarely regained more than 75% of the flexion, extension and strength of the unaffected limb.
BryanMorrey Approach This extensive posterior approach that spares the triceps was described in 1982 by Bryan and Morrey (1982). A straight or curvilinear incision ulnarly directed exposes the proximal ulna, medial epicondyle, ulnar nerve and triceps. The ulnar nerve is released and transposed anteriorly. The triceps insertion is elevated subperiosteally lateral to medial off the olecranon. Anconeus is then released subperiosteally, exposing the radial head. The most proximal tip of the olecranon is then removed providing a full exposure of the humerus. Additional exposure can be achieved by partially releasing the medial and lateral collateral ligaments. The triceps aponeurosis is repaired to the proximal ulna through transosseous tunnels and non-absorbable sutures.

Surgical approaches
The patient is placed in the lateral decubitus position with the affected limb draped over a bolster or supine with the arm placed across the body. Most fractures of the distal humerus are approached through a posterior incision. This area has a rich blood supply and an incision here minimises the risk of painful neuroma developing. The first step is to identify and protect the ulnar nerve, some routinely release the nerve and transpose it anteriorly at the end of the procedure.
Triceps sparing approach (Alonso-Llames) This is a useful approach for the treatment of simple extra-articular fractures of the distal humerus. A posterior skin incision is made, full thickness fascio-cutaneous flaps are developed exposing the underlying triceps. Windows are made along the medial and lateral borders of the triceps, and the entire muscle belly of the triceps is elevated subperiosteally off the posterior aspect of the distal humerus. Its insertion into the olecranon remains uninterrupted. The majority of the triceps is unaffected. The disadvantages are poor access to the articular surface and the fact that it is not possible to extend the exposure proximally more than 12 cm from its most distal margin without potentially compromising the radial nerve.

Triceps-reflecting aconeus pedicle (TRAP) approach An incision is placed laterally between extensor carpi ulnaris and anconeus. The plane between these two muscles is developed. The anconeus is elevated subperiosteally off the ulna and its lateral epicondylar origin whilst maintaining its fascial continuity with the triceps. Dissection continues along flexor carpi radialis and the triceps insertion into the olecranon, elevating the triceps-anconeus flap as one. Exposure of the elbow joint is achieved and the function of anconeus is preserved when it is re-attached using non-absorbable sutures and trans-osseous tunnels.

Triceps splitting approach (Campbell) A posterior midline incision is made, the triceps is split longitudinally through the middle of the triceps down to bone and down to the olecranon. The medial and lateral columns are exposed by subperiosteal dissection. The radial nerve limits surgical

Olecranon osteotomy This is the traditional work-horse exposure to gain access to the elbow joint. It offers excellent exposure for the fixation of distal humeral fractures. Trauma 2008; 10: 125132

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Type B fractures involving part of the articular surface, often a single column fracture, can be treated using lag screws alone if the bone quality is good. Alternatively, a buttress or antiglide plate can be used. Isolated capitellar fractures can fixed with lag screws from posterior to anterior, through a lateral or posterior approach. Type C, complete articular fractures require more aggressive exposure of the elbow joint using the Bryan and Morrey approach, extensile lateral approach or the trans-olecranon approach. The priority is anatomical reduction of the articular surface to limit the occurrence of post-traumatic osteoarthritis. Next is the restoration of the shaft alignment and then rigid stabilisation of the shaft to the articular surface to permit early mobilisation. K-wires can assist the surgeon by stabilising the articular fragments. Transverse lag screws are used to secure these fragments. Small osteochondral fragments should be salvaged and they can be secured with countersunk minifragment screws, Herbert screws or K-wires. Care needs to be taken to make sure they are buried beneath the articular surface. The loss of the trochlea may require placement of a structural graft to avoid narrowing the base of the triangle. Two orthogonal plates are used to reconstruct the columns. The plates are placed to end at different positions to prevent the formation stress riser. A 3.5 mm small fragment dynamic compression plate is then used to reconstruct the lateral column and is applied postero-laterally. The medial column frequently requires a 3.5 mm pelvic reconstruction plate, contoured to incorporate the slope of the medial epicondyle. There are alternatives to the above, including parallel plating, locking compression plates and specifically designed contoured elbow plates. Diaphyseal comminution can be treated by shortening the humerus or with a bridging humeral plate. The excellent blood supply will usually ensure bony healing. Good to excellent results have been achieved in 5090% of patients reported with open reduction and internal fixation of intra-articular fractures of the distal humerus (Brown and Morgan, 1971; Gabel et al., 1987; Holdsworth and Mossad, 1990; Kundel et al., 1996; Letsch et al., 1989; Pajarinen and Bjorkenhelm, 2002; Tyllianakis et al., 2004; Soon et al., 2004; Aslam and Willet, 2004).

Previous studies have demonstrated that the osteotomy offers greater exposure than the triceps sparing or splitting approaches (Wilkinson and Stanley, 2001). The osteotomy site is identified by elevating part of the anconeus off the lateral olecranon or by incising the medial capsule, after identification and preservation of the ulnar nerve. The ulna is predrilled and a chevron osteotomy, with its apex distally, is made into the olecranon, (the cut should be approximately 3 cm from the tip to enter the joint at the bottom of the curve). An oscillating saw is used to cut through most of the bone and the final cut is made with an osteotome. The olecranon is then reflected proximally by dividing the joint capsule and the triceps is mobilised medially and laterally taking care to protect the ulnar nerve medially and the radial nerve laterally. The posterior elbow capsule is then incised along the medial and lateral borders of the triceps and is lifted off the posterior surface of the bone with the olecranon. After fixation of the distal humeral fracture, the pre-drilled osteotomy can be replaced and fixed with a screw. Alternatively, it can be re-attached using the tension band principle, using two K-wires and a figure of eight cerclage wire.

Extended lateral approach This is a useful approach for internally fixing shear type fractures limited to the articular surface. The lateral epicondyle can be osteotomised and reflected distally with the lateral collateral ligament and the common extensor origin. Otherwise, the common extensor origin and the lateral collateral ligament can be detached and repaired later. The triceps is then elevated off the distal humerus and the elbow joint hinged open on the medial capsule and collateral ligament. Exposure can be improved by partially elevating the anconeus and the triceps.

Internal fixation
Type A, non-articular fractures are usually approached through a triceps sparing approach. They can be treated by restoring alignment and double plating to fix both columns, which can occasionally be accomplished with lag screws alone.
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Total elbow arthroplasty (TEA)

In the elderly and poorly mobile patient TEA offers restoration of some function and pain relief following a distal humeral fracture. The results of this treatment have produced good results. One study looked at seven elbows treated with TEA after complex fractures of the distal humerus. Three patients had joint destruction as a result of rheumatoid arthritis the others had complex C2 or C3 fracture configurations. The mean age was 81.7 years and an excellent result was achieved in five of the seven elbows, with a mean Mayo elbow score of 92 points (Ray et al., 2000). A retrospective comparative study looked at the TEA and internal fixation in women aged 65 years or older. At a minimum of 24 months follow up 100% (n 12) of patients treated with TEA had good or excellent results compared with 67% (n 12) of those treated with internal fixation (Frankle et al., 2003). TEA is not without its problems including limitation of movement and the potentially disastrous complication of infection.

References
Aslam N, Willett K. 2004. Functional outcome following internal fixation of intraarticular fractures of the distal humerus (AO type C). Acta Orthop Belg 70: 11822. Brown RF, Morgan RG. 1971. Intercondylar T-shaped fractures of the distal humerus: results in ten cases treated by early mobilisation. J Bone Joint Surg 53B: 42528. Bryan RS, Morrey BF. 1982. Extensive posterior exposure of the elbow: A triceps-sparing approach. Clin Orthop 166: 18892. Evans EM. 1953. Supracondylar-Y fractures of the humerus. J Bone Joint Surg 35B: 37175. Gabel GT, Hanson G, Bennett JB, Noble PC, Tullos HS. 1987. Intraarticular fractures of the distal humerus in the adult. Clin Orthop 216: 99108. Helfet DL, Kloen P, Anand N, Rosen HS. 2003. Open reduction and internal fixation of delayed unions and non-unions of fractures of the distal part of the humerus. J Bone Joint Surg 17A: 47380. Holdsworth BJ, Mossad MM. 1990. Fractures of the adult distal humerus: elbow function after internal fixation. J Bone Joint Surg 72B: 36265. Jupiter JB, Morrey BF. 1993. Fractures of the distal humerus in the adult. In: Morrey BF ed. The elbow and its disorders, 2nd edn. WB Saunders: Philadelphia, 32866. Jupiter JB, Mehne DK. 1992. Fractures of the distal humerus. Orthopaedics 15: 82533. Frankle MA, Herscovici Jr D, DiPasquale TG, Vasey MB, Sanders RW. 2003. 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 7: 47380. Kundel K, Braun W, Wieberneit J, Rutter A. 1996. Intrarticular distal humerus fractures:factors affecting functional outcome. Clin Orthop 332: 20008. Letsch R, Schmit-Neurerburg KP, Sturmer KM, Walz M. 1989. Intraarticular fractures of the distal humerus: surgical treatment and results. Clin Orthop 241: 23844. McKee MD, Mehne DK, Jupiter JB. 1998. Fractures of the distal humerus. In: Browner BD, Levine AM, Jupiter JB, Traffon PG eds. Skeletal Trauma, 1st edn. WB Saunders: Philadephlia, PA, 4831522. McKee MD, Wilson TL, Winston L, Schemitsch EH, Richards RR. 2000. Functional outcome following surgical treatment of intrarticular distal humeral fractures through a posterior approach. J Bone Joint Surg 82A: 170107. Mehne DK, Matta J. (1986). Bicolumn fractures of the adult humerus. Presented at the 53rd Annual Meeting of the American Academy of Orthopaedic Surgeons, New Orleans, Louisiana.

Complications
Poor outcomes are seen, usually in those who have sustained open fractures and in patients with poor bone quality (Kundel et al., 1996). Internal fixation does have complications. Non-union occurs in approximately 210% (Helfet et al., 2003). Painful metalwork often requires removal. Transient ulnar nerve palsy does occur following this procedure despite release and anterior transposition of the nerve. Post-traumatic elbow stiffness is also common and is prevented by early mobilisation in the postoperative phase. Heterotopic bone ossification is most frequently seen after surgery on the elbow.

Conclusion
Injuries to the elbow joint can have devastating consequences for patients quality of life. The joint is extremely important to the function of the upper limb and hand. A detailed understanding of the anatomy and treatment options is essential to secure adequate exposure of the fracture, provide stable fixation and allow early functional recovery.

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