TREATMENT OF COMPLEX FRACTURES 0030–5898/02 $15.00 + .

00

MANAGEMENT OF THE SMASHED

DISTAL HUMERUS
Shawn W. O’Driscoll, PhD, MD, Joaquin Sanchez-Sotelo, MD, PhD,
and Michael E. Torchia, MD

Among the most dreaded of injuries that the geometry of the distal humerus, and stable fix-
orthopedic surgeon on call for trauma must ation of the fractured fragments to allow early
treat is what can be referred to simply as the and full rehabilitation.2, 4, 6, 8–10, 12 Although
smashed distal humerus. Resulting from high- these goals are now widely accepted by the or-
energy injuries, such as motor vehicle acci- thopedic community, they may be technically
dents and falls from a great height, these frac- difficult to achieve, especially in the presence
tures present special challenges to even the of bone loss, substantial comminution, or os-
most experienced elbow or trauma surgeon. teoporosis.12
Not only can there be extensive comminution When treatment of severe distal humerus
of both the joint surface and the supracondy- fractures fails, it does so either because of
lar metaphyseal region but also significant nonunion at the supracondylar level or stiff-
bone loss may have occurred. To make mat- ness resulting from prolonged immobilization
ters much worse, these elbows usually present that has been used in an attempt to avoid fail-
with open wounds and sometimes soft tissue ure of inadequate fixation.12 Either way, the
loss (Fig. 1). limiting factor is fixation of the distal frag-
When faced with such a daunting task of ments to the shaft. Achieving the goals stated
treating this type of elbow, it is helpful to earlier and, therefore, successful treatment of
pause and consider the ultimate goals of treat- the smashed elbow require a departure from
ment, which include: traditional teaching, such as the misconcep-
1. Soft tissue healing without infection tion that plates must be applied in two per-
2. Restoration of diaphyseal bone stock pendicular planes, 90◦ to each other, as is
3. Union between the distal fragments and recommended by the Arbeitgemeinshaft für
the shaft Osteosynthesefragn/Association for the Study
4. A stable and mobile articulation for Internal Fixation (AO/ASIF) group and
currently used by most surgeons.5, 9, 12, 14 Us-
When sufficient bone loss precludes a sta- ing existing techniques, different investigators
ble anatomic reduction, a nonanatomic recon- have reported unsatisfactory results in 20% to
struction that is stable and that achieves all 25% of the patients.2, 4, 6, 8–10
four of these goals is the preferable plan. In an effort to increase the yield of excel-
Restoration of painless and satisfactory lent and satisfactory results obtained after
elbow function after a fracture of the distal fixation of distal humerus fractures and to
humerus requires anatomic reconstruction of reproducibly obtain stable fixation in the
the articular surface, restitution of the overall presence of osteoporosis or comminution, the

From the Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota (SWO, MET); and the Shoulder and
Elbow Service, Hospital La Paz, University of Autonoma de Madrid, Spain ( JSS)

ORTHOPEDIC CLINICS OF NORTH AMERICA

VOLUME 33 • NUMBER 1 • JANUARY 2002 19

20 O’DRISCOLL et al

A B

Figure 1. A and B, A smashed distal humerus. These high-energy injuries usually occur from motor
vehicle accidents or falls from a great height. They are characterized by extensive intra-articular and
supracondylar comminution, and often bone loss. In this case, a 4-cm length of the lateral column is
missing. The lateral half of the trochlea is missing, while the medial half is in multiple pieces. Com-
minution sometimes extends well up into the diaphysis.

authors have developed and used for the 1. Soft tissue healing without infection
past 11 years an alternative philosophy and Principles
technique based on principles that maxi- Extensive débridement to minimize
mize fixation in the distal fragments and risk for infection with open fractures.
compression at the supracondylar level. The Shorten the limb to relax soft tissues.
stability achieved has allowed the authors Technical objectives
to routinely commence an intensive rehabil- Leave clean surfaces on all soft tissues
itation program 36 hours postoperatively, and bones.
including full active motion with no external Cover essential structures (nerves, ten-
protection. dons, hardware).
This discussion expands on the general Obtain early closure (3–5 days).
principles of the authors’ current approach to Osteotomy of distal end of shaft to
these fractures, the specific technical details, permit 0.5 to 2.0 cm of supracondy-
the postoperative program, and the potential lar shortening, with maximal con-
complications. tact and interfragmentary compres-
sion between the distal fragments
and the shaft
PRINCIPLES AND 2. Restoration of diaphyseal bone stock
TECHNICAL OBJECTIVES Principles
Obtain an anatomic reduction and sta-
Before discussing the details of surgical ble fixation.
techniques, it is imperative that the treating Bone graft as necessary
surgeon understand the principles and tech- Technical objectives
nical objectives that, if followed and achieved Diaphyseal bone segments should be
respectively, will maximize the likelihood of reduced and fixed with interfrag-
a successful outcome from treatment of these mentary compression.
severe fractures. At least one dynamic compression or
The principles by which the earlier-men- equivalent strength plate should ex-
tioned goals are achieved, and the technical tend an adequate length and num-
objectives at the time of surgery for achieving ber of screws (usually eight cortices)
them, are: proximal to the fracture.
 MANAGEMENT OF THE SMASHED DISTAL HUMERUS 21

Dual plating is not required for the dia- pared and draped in the usual fashion. The
physeal region. lateral position with the arm on a support
3. Union between the distal fragments and can be used, but hyperflexion (which is neces-
the shaft sary with the triceps reflecting anconeus pedi-
Principles cle [TRAP] approach) is easier in the supine
Maximize fixation in the distal frag- position. A sterile tourniquet can be used for
ment. the initial ulnar nerve dissection, but the au-
All fixation in distal fragments should thors prefer to avoid the use of the tourni-
contribute to stability between the quet. The ulnar nerve is routinely identified,
distal fragments and the shaft. isolated, and transposed subcutaneously. Ole-
Technical Objectives cranon osteotomy is the most commonly used
Concerning screws in the major distal and recommended approach, but the TRAP
fragments (articular segment): approach11 allows for wide exposure with-
• Each screw should pass through a out the need for an olecranon osteotomy. This
plate. is especially important in older patients, in
• Each screw should engage a frag- whom elbow replacement may be necessary.
ment on the opposite side that is The details of the TRAP exposure have been
also fixed to a plate. described elsewhere.11 With this approach, the
• As many screws as possible should intact proximal ulna and radial head can be
be placed in the distal fragments used as a template against which the distal
• Each screw should be as long as humerus can be reconstructed. In addition, the
possible. potential complications associated with ole-
• Each screw should engage as many cranon osteotomies are avoided,4, 15 and the in-
articular fragments as possible. nervation of the anconeus is preserved.11
Concerning the plates used for fixation: The first priority (goal 1) in managing open
• Plates should be applied such injuries is to obtain soft tissue healing without
that compression is achieved at deep infection. With open wounds, the em-
the supracondylar level for both phasis is on extensive sharp débridement of all
columns. devitalized and potentially contaminated tis-
• Plates used must be strong enough sues. Prevention of infection is of paramount
and stiff enough to resist break- importance even if the internal fixation fails
ing or bending before union oc- because later reconstructive options may be
curs at the supracondylar level. limited if infection occurs. Lavage, regard-
4. A stable and mobile articulation less of the number of liters of saline used, is
Principles not nearly as effective as débridement with
Restore or recreate a stable hinge artic- a scalpel. With extensive soft tissue injuries
ulation for flexion–extension. and occasionally soft tissue loss, it is not al-
Technical objectives ways possible to cover the essential structures.
Preserve all ligaments and tendons at- The senior author (SOD) reasoned that, as
tached to the distal fragments. in limb replant surgery, shortening the limb
Obtain a stable congruous reduction would facilitate stable bony reduction (see
of either the trochlea, or the me- subsequent discussion) and relax the soft tis-
dial trochlea and capitellum; these sues, making coverage of the essential struc-
are the minimum requirements for a tures more achievable. Shortening of up to
functioning hinge articulation. 1 cm is of negligible consequence, and up to
Ensure that fixation is adequate to per- 2 cm of shortening is well tolerated if needed.
mit immediate rehabilitation of the More extensive soft tissue defects that cannot
joint and limb starting within a few be covered by such shortening should be con-
days of surgery. sidered for free or pedicle flap coverage.
In the authors’ experience, it is preferable
to stabilize or fix the fractures acutely, even in
the face of significant soft tissue damage, loss,
SURGICAL TECHNIQUE or contamination. The wound is cleaner than
it will be a few days later after very thor-
Exposure ough surgical débridement. Soft tissue edema
will only increase in the days following injury,
The patient is placed in the supine posi- making both surgery and closure more diffi-
tion and the affected upper extremity is pre- cult. Finally, the stability provided by fracture
22 O’DRISCOLL et al

fixation permits optimized position of the limb level, whereas the intra-articular fractures
for nursing, wound care, and edema control. typically unite. Based on current practice and
recommendations, this should not be surpris-
ing. Many of the fractures are dependent on
Bony Reconstruction
only two or three screws for stability at the
supracondylar level. The fixation strategy
Diaphyseal Region
should concentrate on maximizing stability
For any fracture fixation or delayed recon- between the distal fragments and the shaft of
struction, restoration of diaphyseal bone stock the humerus at the metaphyseal level. These
is required (goal 2). Diaphyseal bone segments “principles” are achieved by the successful
should be reduced and fixed with interfrag- execution of the seven technical objectives
mentary compression. At least one dynamic listed earlier, each of which contributes to
compression or equivalent strength plate maximizing stability between the articular
should extend an adequate length and number segment and the shaft (see goal 3).
of screws (usually eight cortices) proximal to The practical application of these princi-
the fracture. Dual plating is not required for ples involves parallel plates that permit a to-
the diaphyseal region. tal of four to six long (45–70 mm) screws to
be placed in the distal fragments, from one
Articular Surface side across the other (the plates are placed
with a slight offset, posteromedially and pos-
The articular surface of the distal humerus
terolaterally). The screws are placed at the
should be reconstructed anatomically unless
epiphyseal level interdigitate, which greatly
bone is missing. If bone is missing, two im-
increases the stability of the construct. The
portant principles should be taken into con-
plates must be contoured or precontoured to
sideration. First, the anterior aspect of the dis-
the normal geometry of the distal humerus
tal humerus is the critical part that needs to
to allow for screw placement at the appropri-
be fixed to have a functional joint; reconstruc-
ate places and also not to be too prominent
tion of the posterior half is important but not
under the skin. One can contour a 3.5-mm
as crucial. Second, stability of the articulation
dynamic compression plate (DCP) or a pelvic
(goal 4) requires the medial trochlea and either
reconstruction plate (Synthes USA, Paoli,
the lateral half of the trochlea or the capitel-
PA) on the medial side and a DuPont plate
lum. Thus, the medial trochlea is essential to
(Howmedica, Rutherford, NJ) on the lateral
obtain a stable and well-aligned joint. Struc-
side. Currently, the authors use the Mayo
tural bone grafts, such as tricortical or bicorti-
Congruent Elbow Plates (Acumed, Portland,
cal grafts from the iliac crest, can be used to fill
OR), which are custom designed for the distal
defects in the joint surface.
humerus (see Figs. 4–7 and 10). They are pre-
The articular surface is fixed provision-
contoured to the geometry of the distal humer-
ally with small smooth Kirschner wires. In
us and designed to permit placement of mul-
addition, or alternatively, very small (0.035,
tiple long screws (2.7 or 3.5 mm) in the distal
0.045) threaded Kirschner wires can be placed
fragments by clustering the distal screw holes.
in the subchondral bone and left in place
They have a dynamic compression profile in
for definitive fixation after cutting them off.
the diaphyseal and metaphyseal regions, with
No screws are placed in the distal fragments
a continuously tapering articular region that
before applying the plates. Although this goes
is low profile. The undersurface of the dia-
against what has traditionally been taught by
physeal and metaphyseal regions is tubular in
the AO/ASIF group, the reason for this ap-
cross-section to greatly enhance sagittal plane
proach relates to the technical objective “Every
stability and to permit provisional fixation
screw in the distal fragments should pass
with a singe screw in the slotted hole.
through a plate.” Doing so enhances fixation
Interfragmentary compression is obtained
of the distal fragments, but, more important,
both between articular fragments and at the
it contributes to stability between the distal
metaphyseal level with large bone clamps that
fragments and the shaft (goal 3).
provide compression during the insertion of
the screws. This is done instead of using lag
Fixation of the Articular screws to provide maximum thread purchase
Segment to the Shaft for each screw. Additional compression at the
metaphyseal level results from slight under-
By far, most fixation failures after a distal contouring of the plates and the use of dy-
humerus fracture occur at the supracondylar namic compression holes in the plates.
 MANAGEMENT OF THE SMASHED DISTAL HUMERUS 23

Provisional Assembly of the plates into the distal fragments. No screws are
Articular Surface placed in the distal fragments until the plates
are applied.
Once the fracture is exposed, the first step
is the anatomic reconstruction of the articular Supracondylar Shortening
surface. The intact ulna and radial head can
be used as a template for the reconstruction In cases of supracondylar bone loss or
of the distal humerus. The articular fragments severe comminution that are interpreted to
are assembled paying attention to their rota- preclude anatomic reduction and stable fixa-
tional alignment and are held in place provi- tion, supracondylar shortening osteotomy is a
sionally with smooth Kirschner wires (Fig. 2). viable option (Fig. 3). This is especially true
Fine-threaded wires (0.030 or 0.045) are used if structural bone grafting is contraindicated,
in cases with extensive comminution, cut off, particularly when associated with severe soft
and left in as definitive adjunct fixation. The tissue injuries. The principles and details of
articular fragments are fixed in the following the technique are described later.
order:
Plate Placement and
1. Anterior trochlea and capitellum Provisional Reduction
2. Medial trochlea
3. Posterior fragments The next step is to contour plates to fit the
distal humerus medially and laterally or to
As stated earlier, in cases with severe intra- chose medial and lateral precontoured plates
articular comminution, all efforts should be from the Mayo Congruent Elbow Plate Sys-
directed to reconstruct the anterior half of tem (Acumed, Portland, OR). This set also
the distal humerus articular surface and the provides for triple plating with both lateral
condyle and medial trochlea. It is necessary and posterolateral plates; however, in the au-
that all wires are placed at the subchondral thors’ experience with “parallel plating,” de-
level so as not to interfere with plate appli- scribed later, triple plating has never been nec-
cation nor with passage of screws from the essary thus far. At the medial side, a 3.5-mm

Figure 2. Provisional assembly of the articular surface. The articular frag-

ments, which tend to be rotated toward each other in the axial plane, are
reduced anatomically and provisionally held with 0.035 or 0.045 smooth
Kirchner wires. It is essential that they be placed close to the subchondral
level to avoid interference with later screw placement, and away from where
the plates will be placed on the lateral and medial columns. One or two large
(2-mm) pins are placed through the epicondyles where a hole in the plate will
be (see Fig. 4) and are later replaced by screws. One or two strategically
placed pins can be used to provisionally hold the distal fragments aligned
with the shaft.
24 O’DRISCOLL et al

length of the plates is selected so that at least

three screws are placed on each side proximal
to the metaphyseal component of the fracture.
Ideally, the plates should end at different lev-
els to avoid the creation of a stress riser. The
Mayo Congruent Plates are designed to al-
ways stop at different levels regardless of how
they are combined. The plates are then pro-
visionally applied according to the following
steps (Fig. 4):
1. Two 2.0-mm smooth Steinmann pins
are introduced at the medial and lateral
epicondyles through holes in the plates
while they are held accurately against
the bone; the most commonly used holes
are the second laterally and the third
medially.
2. The appropriate reduction of the dis-
tal fragments to the humeral shaft at
Figure 3. Supracondylar shortening osteotomy. In cases
of supracondylar bone loss, and in some cases of severe the supracondylar level is confirmed. If
comminution, anatomic placement of the distal humerus supracondylar shortening is chosen over
with respect to the shaft would leave a large structural anatomic reduction at the metaphyseal
defect in one or other column, and only point contact level (see later section on metaphyseal
in the other. In such cases, a supracondylar shortening
osteotomy is a viable option when an anatomic recon-
region), the appropriate alignment is set
struction is thought not to be possible or structural bone and held.
grafting is undesirable, particularly when associated with 3. One cortical screw is inserted into the
severe soft tissue injuries. This involves reshaping the dis- slotted hole in each plate, but not fully
tal end of the shaft (solid lines, never the articular seg- tightened, to provide for provisional re-
ments) to enhance contact between the distal articular
segment and the shaft. Usually, only a small amount of duction of the distal fragments with re-
bone is resected off one side distally, and sometimes off spect to the shaft. The use of slotted holes
one side (for side-to-side apposition and compression). for these screws facilitates later adjust-
The limb is shortened through the fracture site to per- ments in plate positioning. The tubular
mit interfragmentary compression between the trochlea
and the distal shaft, between the capitellum and the distal
contour under the Mayo Clinic Congru-
shaft, and side to side on one or both sides. Once these ent Elbow Plates ensures alignment of the
surfaces have been compressed and fixed with the plates, plate on the bone and greatly simplifies
stability is strong enough to permit immediate motion and provisional reduction and fixation.
rehabilitation. It is acceptable to translate the distal seg-
ment medially or laterally, and also slightly anteriorly, pro-
vided that rotational and valgus alignment are maintained. Articular and Distal Fixation
Once the plates are provisionally applied,
distal medial and lateral screws are introduced
pelvic reconstruction plate is used unless the to provide stable fixation of the intra-articular
patient size or fracture comminution require fragments and rigid anchorage of the plates
the use of a stronger DCP. One-third tubular distally (Fig. 5).
plates are not strong enough. The medial plate
can be extended to the articular margin in 1. Two distal screws, one medial and one
very low or comminuted fractures and is con- lateral, are inserted. As stated earlier, the
toured to the shape of the medial epicondyle. screws should be as long as possible, pass
If a precontoured DuPont plate (Howmedica, through as many fragments as possible,
Rutherford, NJ) is used at the lateral side, and engage in the opposite column. Be-
it must be slightly uncontoured at the distal fore their application, a large bone clamp
end or placed more posteriorly to prevent im- is used to compress the intra-articular
pinging on, or cutting into, the common ex- fracture lines unless a gap is present
tensor tendon and lateral collateral ligament in the articular surface. This ensures in-
complex. Both plates should be slightly under- terfragmentary compression without the
contoured to provide additional compression need for lag screws. If a segmental de-
at the metaphyseal region when applied. The fect is present, iliac crest bone graft can
 MANAGEMENT OF THE SMASHED DISTAL HUMERUS 25

Figure 4. Plate placement and provisional reduction. A, Medial and lateral precontoured plates are
placed and held apposed to the distal humerus, while one smooth 2.0-mm Steinmann pin is in-
serted through hole No. 2 (numbered from distal to proximal) of each plate through the epicondyles
and across the distal fragments, to maintain provisional fixation of the plates to the distal fragments.
B, A screw is placed in the slotted hole ( No. 5) of each plate, but not fully tightened, leaving some free-
dom for the plate to move proximally during compression later. Because the undersurface of each plate
is tubular in the metaphyseal and diaphyseal regions, the screw in the slotted hole only needs to be
tightened slightly to provide excellent provisional fixation of the entire distal humerus.
26 O’DRISCOLL et al

Figure 5. Articular and distal fixation. Screws are inserted through hole No. 1 of the lat-
eral plate and across the distal articular fragments from lateral to medial and tightened. This
step is repeated on the medial side, using hole No. 3. In young patients, 3.5 cortical screws
are used (to prevent breakage) while long 2.7 screws are used in patients with osteoporotic
bone. The distal screws should be as long as possible, passing through as many fragments
as possible, and engaging the condyle or epicondyle of the opposite column.

be inserted but should be contoured to re- ternative reconstructive technique supracondy-

main below the level of the preexisting lar shortening. This technique is specially use-
articular cartilage so that it does not ar- ful in cases of combined soft-tissue and bone
ticulate with the ulnar cartilage or radial loss. Shortening by 1 cm or less creates no
head. apparent loss of function, and up to 2 cm
2. The 2.0-mm Steinmann pins can be re- of shortening can be tolerated without severe
placed with screws at this point, but the disturbance of elbow biomechanics.7 Maxi-
authors usually wait until the plates have mum stability and, therefore, minimum likeli-
been rigidly fixed to the shaft to do so hood of nonunion at the supracondylar level
because it leaves more flexibility in mak- are achieved by maximizing interfragmentary
ing fine adjustments to the supracondylar compression between the distal fragments and
reduction. the shaft (Fig. 6). The technical details for per-
forming the supracondylar shortening are de-
scribed below.
Metaphyseal Region: Supracondylar
1. A large tenaculum is used to apply
Compression and Proximal Plate Fixation
compression across the fracture at the
The metaphyseal region of the distal hu- supracondylar level of the lateral col-
merus can be fixed in two ways. An anatomic umn (Fig. 6A). A screw then is inserted
reconstruction is desirable whenever possi- through the lateral plate proximally in
ble; however, adequate bony contact with in- compression mode to maintain the inter-
terfragmentary compression is necessary to fragmentary compression. Care should
ensure the stability of the construct and even- be taken not to change the varus–valgus
tually fracture union at this level. If meta- or rotational alignment of the articu-
physeal comminution or bone loss preclude lar surface when the bone clamps are
an anatomic reconstruction with satisfactory applied.
bony contact, the humerus can be shortened at 2. The same steps are followed on the oppo-
the metaphyseal fracture site provided that the site side (Fig. 6B). The amount of stability
overall alignment and geometry of the distal achieved after this step is finished is typi-
humerus are restored. The authors call this al- cally very gratifying already.
 MANAGEMENT OF THE SMASHED DISTAL HUMERUS 27

Figure 6. Supracondylar compression and proximal plate fixation. A, Using a large tenaculum to pro-
vide interfragmentary compression across the fracture at the supracondylar level, the lateral column
is first fixed. A screw is placed in dynamic compression mode (inset ) in hole No. 4 of the lateral
plate. Tightening this further enhances interfragmentary compression at the supracondylar level (open
arrows) to the point of causing some distraction at the medial supracondylar ridge (solid arrows).
B, The medial column is then compressed in a similar manner using the large tenaculum and a screw
inserted in the medial plate in dynamic compression mode.
28 O’DRISCOLL et al

3. The remaining diaphyseal screws are olecranon can be partially removed if it

then introduced providing additional impinges in extension-limiting motion.
compression as a result of the under- Recreating the olecranon fossa with a
contoured plates being pushed to gain burr can be performed if the fossa has
intimate contact with the underlying been obliterated because of supracondy-
bone. The two Steinmann pins then are lar shortening (Fig. 8).
replaced with distal screws that again 4. The final intraoperative motion achieved
follow the principles mentioned earlier should be recorded as a baseline to moni-
regarding length and positioning. (Fig. 7) tor postoperative progress. One deep and
one subcutaneous drain are placed and
the type of approach used dictates the
Fixation of Remaining Intra-Articular closure. The skin should be closed with
Fragments and Motion Verification staples or interrupted sutures.
Once the overall architecture of the distal
humerus has been rigidly restored, any poste-
rior articular fragments remaining to be fixed Supracondylar Shortening
are addressed, and intraoperative range of
motion is verified. Principles
1. Posterior articular fragments often re- In cases with supracondylar bone loss or ex-
quire definitive fixation with either tensive comminution, it is not possible to per-
threaded metallic Kirschner wires or form an anatomic reconstruction and main-
ideally bioabsorbable pins. tain enough bone contact at the supracondylar
2. Any remaining provisional wires are level. A supracondylar shortening allows for
removed. restoration of bony contact and functional el-
3. The final step before closure is to as- bow reconstruction provided that the follow-
sess the range of motion. The arc of mo- ing guidelines are followed.
tion should be smooth and free of im- 1. Shortening should be limited to no more
pingement of the coronoid or olecranon than 2 cm.
at their respective fossae, which would 2. The distal fragments can be translated
limit flexion or extension. The tip of the laterally or medially with respect to the
center of the humeral canal to improve
bone contact at the metaphyseal level, but
the rotational and varus–valgus align-
ment of the distal articular surface should
be restored carefully.
3. The coronoid and olecranon fossae
should be recreated. A convenient meth-
od to provide room for the coronoid
and olecranon is to translate the epiphy-
seal segment anteriorly (taking care not
to flex it) and to sculpt the olecranon
fossa with a burr once the fixation is
complete. The tip of the olecranon can
also be resected to allow extension to at
least 10◦ to 20◦ .

Technique
The first step is to provisionally reduce the
articulation. At that point, one attempts to de-
termine how the existing contour of the dis-
Figure 7. The remainder of the screws are inserted, in- tal segment would best fit against the shaft for
cluding the distal screws, which interdigitate for maximum maximum bone contact (see Fig. 3). The end of
fixation in the distal articular fragments. If the plates are
slightly undercontoured, they can be compressed against
the shaft then is trimmed to match that con-
the metaphysis with a large bone clamp, giving further tour until maximum bony contact exists, while
supracondylar compression. the distal segment is positioned in proper
 MANAGEMENT OF THE SMASHED DISTAL HUMERUS 29

Figure 8. After shortening the distal humerus, the olecranon

fossa will be compromised. To preserve terminal extension,
the olecranon fossa can be recreated by burring out the same
shape from the distal end of the shaft. The tip of the olecranon
can be removed. The coronoid fossa and radial fossa are best
preserved by offsetting the distal segment anteriorly. It is tech-
nically easier to recreate a fossa posteriorly than anteriorly.

varus–valgus and rotational alignment. After keep the elbow in extension, and the upper
applying the first two principles just men- extremity is kept elevated for 36 hours. After
tioned, the plates are applied medially and lat- that, the Robert-Jones dressing is removed; an
erally and the fractures fixed. Bone graft can elastic, nonconstrictive sleeve is applied over
be placed under the plates in the triangular de- an absorbent dressing placed on the wound;
fects between the plate and bone, adjacent to and a program of continuous passive motion
where the shortening was performed. (CPM) is started with the goal being to flex
When a supracondylar shortening has been and extend the elbow as much as tolerated to
performed, the loss of the coronoid and radial avoid fluid accumulation at the elbow region.
fossae need to be compensated for by ante- If the fracture unites with the normal
rior translation of the distal fragment, with- anatomic relationships restored and hetero-
out changing its position in other planes. In topic bone formation does not occur, the
addition, the olecranon fossa may need to ultimate range of motion will depend on
be sculpted with a burr removing bone only the avoidance of intra-articular adhesions
from the shaft, not from the distal fragments. and the characteristics the connective tissue
Whenever the burr is used, the field should deposited in response to the traumatic and
be covered with sponges except for the region surgical insult. An intensive program of CPM
where bone needs to be removed, and irriga- is a reliable method to achieve a satisfactory
tion should be used thoroughly to avoid leav- range of motion. The CPM is used to avoid
ing bone dust in the wound that might facili- fluid accumulation at the elbow. Experimental
tate heterotopic bone formation. and clinical data support the use of CPM for
this purpose.3 The fluid that would tend to
Postoperative Treatment accumulate at the surgical site as part of the
inflammatory response is literally squeezed
Immediately after closure the elbow is out of the elbow region by the high hydrostatic
placed in a bulky, noncompressive Robert- pressures generated when maximally flexing
Jones dressing with an anterior plaster slab to and extending the elbow. The stability of the
30 O’DRISCOLL et al

bony reconstruction allows such motion with- The CPM program is continued at home
out fear of failure of fixation. The only factors for 3 to 4 weeks. The patient determines how
limiting full range of motion immediately much time he can spend out of the machine
after the operation are the amount of swelling, each day: if, by the time he or she goes back
the response of the overlying skin, and any to the CPM machine, the elbow is more diffi-
problems with pain control. cult to move through its whole range, the time
The CPM program is labor intensive. The out of the CPM was too long. Most commonly,
CPM machine is adjusted so that the elbow is the CPM machine will be used for approxi-
higher than the shoulder. For the first days, the mately 20 hours a day for the first week, and
CPM is continued virtually 23.5 to 24.0 hours the number of hours spent in the CPM ma-
and the patient is allowed out of bed only chine is decreased progressively in the follow-
for bathroom privileges. During this time, the ing weeks. If, by the fourth week, motion is
patient works on progressively stretching the still substantially less than what was achieved
end ranges of flexion and extension. Full ex- intraoperatively, formation of heterotopic os-
tension is normally easier to achieve because sification should be investigated and a pro-
the elbow was initially splinted in extension. gram of patient-adjusted static flexion and
The patient lets the machine extend his or her extension splints used up to 3 to 4 months af-
elbow to the point at which the patient feels ter surgery.
tightness. The patient then backs the elbow
into flexion a few degrees and keeps the el-
bow in that position for approximately 1 or RESULTS TO BE EXPECTED
2 minutes while the fluid is being squeezed
from the tissues. After that couple of min- In the authors’ experience, the stability of
utes, the patient will tolerate further exten- the fixation has been adequate to permit an
sion and continues working with several stops immediate intensive rehabilitation program
and starts until full extension is achieved. The consisting of active and passive motion, re-
same sequence is then repeated for flexion. gardless of the severity of the fracture. A few
Once a full range of motion is achieved, the cases have had severe soft tissue injuries that
patient does not need to actively control the delayed the rehabilitation. By combining these
machine and can let the elbow be moved principles to obtain truly rigid fixation and
through the whole range. On the second or commencing early aggressive rehabilitation,
third day, the patient can try to gain more excellent clinical results are possible (Fig. 9).
motion than the CPM machine will provide The main challenges relate to fixation of the
by placing a folded towel alternatively under distal fragments to the shaft and being able to
the wrist to increase flexion and under the contour strong plates to the complex anatomy
elbow to increase extension. As part of the of the distal humerus (especially considering
postoperative management, the patient is also that it has been fractured and cannot be used
encouraged to work on passive and active- easily as a templating surface). These tasks are
assisted pronation and supination exercises. made easier by the use of precontoured plates
Finally, thorough massage of the elbow by the that are specially designed for these fractures
patient or a relative will help with squeez- (Fig. 10).
ing the fluid out of the elbow region and also
partially desensitize it to pain. Close atten-
tion should be paid to the neurovascular sta- POTENTIAL COMPLICATIONS
tus and the condition of the skin while the
patient is in the CPM machine. The patient The main complications that have been re-
should be encouraged to continuously read- ported after internal fixation of distal humerus
just his or her position in the machine to avoid fractures are residual decreased range of mo-
radial nerve dysfunction secondary to contin- tion, fixation failure with nonunion or malu-
uous pressure on the posterior aspect of the nion, nerve dysfunction, extensor mecha-
arm if it is held in a fixed position for long pe- nism dysfunction, posttraumatic degenerative
riods of time. Some discoloration of the poste- changes, wound and skin problems, and avas-
rior skin is to be expected with elbow motion, cular necrosis.1–2, 4, 6, 8–10, 15
but if the integrity of the skin is in doubt, the As stated earlier, the neurovascular status
CPM should be stopped and the arm elevated and the condition of the skin should be fol-
in a Robert-Jones dressing until the status of lowed carefully during the postoperative pe-
the skin improves. riod. Anterior subcutaneous transposition of
 MANAGEMENT OF THE SMASHED DISTAL HUMERUS 31

A B

C D

Figure 9. Radiographic (A and B ) and clinical (C and D ) outcome 9 months after fixing the smashed
distal humerus fracture shown in Figure 1 by applying the principles laid out in this article.

the ulnar nerve prevents many of the ulnar the misconception that plates must be applied
nerve complications.16 A radial neurapraxia in two perpendicular planes. Although that
may develop secondary to sustained pressure used to be true when very weak, 3.5, one-
on the dorsal aspect of the arm if the pa- third tubular plates were used, it most cer-
tient does not readjust his position while using tainly is not true when strong plates are used.
the CPM machine. Most skin problems can be The parallel, double-plate construct has been
avoided if motion is held and the elbow ele- shown to provide excellent stability even in
vated in extension as soon as the aspect of the the presence of supracondylar gaps.13 In fact,
skin is worrisome. Schemitsch et al13 showed that the combina-
The biggest impediment to successful ap- tion of a medial reconstruction and lateral
plication of this principle-based technique is DuPont plate in parallel planes was stronger
32 O’DRISCOLL et al

A B

Figure 10. A, A smashed elbow with extensive bone loss and comminution that was referred by a col-
league as unfixable. In this case, as is frequently so, the olecranon and proximal ulna are also severely
fractured. B, The fractures are most conveniently and effectively fixed using the Mayo Clinic Congruent
plates (Acumed, Portland, Oregon) that are specially designed for these fractures. They are precon-
toured to fit each bone and fracture pattern. Unique design features permit provisional fixation, greatly
enhanced fixation in the articular fragments, increased sagittal plane stability, and ease of application.

than were two reconstruction plates placed release that can be performed 6 months to
in two planes 90◦ to each other, as is recom- 1 year after the initial surgery; at the time
mended by the AO/ASIF group and currently of capsular release, the hardware should be
used by most surgeons.5, 9, 12, 14 removed if the fracture is strongly healed.
With the internal fixation technique de- Dysfunction of the extensor mechanism
scribed earlier, the authors have experienced may occur if the triceps tendon fails to heal to
only one case of fixation failure. A 3.5 recon- the olecranon. Careful attention to reattach-
struction plate experienced fatigue fracture ment of the extensor mechanism at surgery
6 months after surgery in a patient with a should help prevent this complication. The
severe open injury treated by supracondylar reconstruction should be solid enough to
shortening and coverage with a local flap and allow passive elbow flexion. Weakness does
skin graft. The lateral column had healed, ne- not seem to be a major problem with use of the
cessitating only refixation and bone grafting of TRAP approach for distal humerus fractures.
the medial column, which did result in union. Should discontinuity or subluxation of the
His final range of motion was 20◦ to 120◦ . extensor mechanism occur, it can be surgically
Decreased range of motion may occur se- treated by primary repair or augmentation
condary to heterotopic ossification, intra- with an Achilles tendon allograft. Patients
articular adhesions, or capsular contracture. might experience a degree of triceps weak-
If motion does not respond to a program of ness following supracondylar shortening,
splinting, the patient may require a capsular but weakness is not uncommon following
 MANAGEMENT OF THE SMASHED DISTAL HUMERUS 33

these severe injuries. Thus, the authors have (CPM): Theory and principles of clinical application.
not been able to discern clinically any conse- J Rehabil Res Dev 37:179–188, 2000
quences of the approach or treatment, separate 4. Henley MB, Bone LB, Parker B: Operative man-
agement of intra-articular fractures of the distal
from those of the injuries themselves. humerus. J Orthop Trauma 1:24–35, 1987
Joint deterioration may be secondary to the 5. Helfet D, Hotchkiss R: Internal fixation of the distal
cartilage damage sustained at the initial in- humerus: A biomechanical comparison of methods.
jury or the avascular necrosis secondary to J Orthop Trauma 4:260–264, 1990
6. Holdsworth BJ, Mossad MM: Fractures of the adult
the devascularization of some articular frag- distal humerus: Elbow function after internal fixation.
ments in severely comminuted injuries. The J Bone Joint Surg Br 72:362–365, 1990
authors have had one case of osteonecrosis in a 7. Hughes RE, Schneeberger AG, An KH, et al: Reduc-
severely multifragmentary fracture. If the like- tion of triceps muscle force after shortening of the
lihood of this complication is to be minimized, distal humerus: A computational model. J Shoulder
Elbow Surg 6:444–448, 1997
it is necessary to leave all soft tissues attached 8. John H, Rosso R, Neff U, et al: Operative treatment
to the distal fragments during surgery. of distal humeral fractures in the elderly. J Bone Joint
Finally, a question that is often asked re- Surg Br 76:793–796, 1994
lates to blocking of motion caused by loss of 9. Jupiter JB, Neff U, Holzach P, et al: Intercondylar frac-
tures of the humerus. J Bone Joint Surg Am 67:226–
the olecranon fossa. These injuries for which 239, 1985
supracondylar shortening is indicated are so 10. Letsch R, Schmit-Neuerburg KP, Sturmer KM, et al:
severe that even experienced surgeons would Intraarticular fractures of the distal humerus. Surgical
be pleased to reliably obtain healing of the treatment and results. Clin Orthop 241:238–244, 1989
soft tissues and bones with a functional arc 11. O’Driscoll SW: The triceps-reflecting anconeus pedi-
cle (TRAP) approach for distal humeral fractures and
of motion (≈30◦ –130◦ ). If motion is sufficient nonunions. Orthop Clin North Am 31:91–101, 2000
to permit impingement, the hardware can be 12. Ring D, Jupiter JB: Fractures of the distal humerus.
removed and the bone recontoured at a later Orthop Clin North Am 31:103–113, 2000
date. 13. Schemitsch EH, Tencer AF, Henley MB: Biomechani-
cal evaluation of methods of internal fixation of the
distal humerus. J Orthop Trauma 8:468–475, 1994
14. Self J, Viegas SF, Buford WL, et al: A comparison
of double-plate fixation methods for complex distal
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Shawn W. O’Driscoll, MD, PhD
Medical Sciences Building, 3–69
Mayo Clinic
200 First Street SW
Rochester, MN 55905

e-mail: [email protected]