Controversies in the Management of Bicolumnar Fractures of the Distal Humerus

Published:November 12, 2022DOI:
      Bicolumnar fractures of the distal humerus pose numerous treatment challenges for upper-extremity surgeons. Although open reduction and internal fixation demonstrates advantages compared with nonsurgical treatment, restoration of osseous anatomy can be difficult, particularly for comminuted, intra-articular fractures. Despite well-recognized complications, total elbow arthroplasty remains an option for elderly patients with fractures not amenable to fixation. Although indications remain controversial, distal humerus hemiarthroplasty has emerged as a potential alternative to total elbow arthroplasty in carefully selected patients with nonreconstructable fractures. Numerous controversies remain with respect to the management decisions for these complex injuries, including the optimal surgical approach, management of the ulnar nerve, and ideal fixation constructs for open reduction internal fixation. Our purpose is to review the management of bicolumnar distal humerus fractures in adult patients and discuss current controversies related to treatment.

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        • Bergdahl C.
        • Ekholm C.
        • Wennergren D.
        • Nilsson F.
        • Möller M.
        Epidemiology and patho-anatomical pattern of 2,011 humeral fractures: data from the Swedish Fracture Register.
        BMC Musculoskelet Disord. 2016; 17: 159
        • Robinson C.M.
        • Hill R.M.
        • Jacobs N.
        • Dall G.
        • Court-Brown C.M.
        Adult distal humeral metaphyseal fractures: epidemiology and results of treatment.
        J Orthop Trauma. 2003; 17: 38-47
        • Kozánek M.
        • Bartoníček J.
        • Chase S.M.
        • Jupiter J.B.
        Treatment of distal humerus fractures in adults: a historical perspective.
        J Hand Surg Am. 2014; 39: 2481-2485
        • Kinaci A.
        • Buijze G.A.
        • van Leeuwen D.H.
        • Jupiter J.B.
        • Marti R.K.
        • Kloen P.
        Corrective osteotomy for intra-articular distal humerus malunion.
        Arch Bone Jt Surg. 2016; 4: 161-165
        • Helfet D.L.
        • Kloen P.
        • Anand N.
        • Rosen H.S.
        Open reduction and internal fixation of delayed unions and nonunions of fractures of the distal part of the humerus.
        J Bone Joint Surg Am. 2003; 85: 33-40
        • Strelzow J.A.
        • Frank T.
        • Athwal G.S.
        • Faber K.J.
        • King G.J.W.
        Results of linked convertible total elbow arthroplasty for the management of distal humeral fractures in the elderly.
        J Hand Surg Am. 2021; 46: 396-402
        • O'Driscoll S.W.
        Optimizing stability in distal humeral fracture fixation.
        J Shoulder Elbow Surg. 2005; 14: 186S-194S
        • Bazzocchi A.
        • Gomes M.P.A.
        • Bartoloni A.
        • Guglielmi G.
        Emergency and trauma of the elbow.
        Semin Muscoloskelet Radiol. 2017; 21: 257-281
        • Sabo M.T.
        • Athwal G.S.
        • King G.J.W.
        Landmarks for rotational alignment of the humeral component during elbow arthroplasty.
        J Bone Joint Surg Am. 2012; 94: 1794-1800
        • Gofton W.T.
        • MacDermid J.C.
        • Patterson S.D.
        • Faber K.J.
        • King G.J.W.
        Functional outcome of AO type C distal humeral fractures.
        J Hand Surg Am. 2003; 28: 294-308
        • Galloway J.D.
        • Shymon S.J.
        • Adams M.R.
        • et al.
        Distal humerus traction radiographs: is the interobserver and intraobserver reliability comparable with computed tomography?.
        J Orthop Trauma. 2022; 36: e265-e270
        • Luxenhofer M.
        • Beisemann N.
        • Schnetzke M.
        • et al.
        Diagnostic accuracy of intraoperative CT-imaging in complex articular fractures - a cadaveric study.
        Sci Rep. 2020; 10: 4530
        • Brouwer K.M.
        • Lindenhovius A.L.
        • Dyer G.S.
        • Zurakowski D.
        • Mudgal C.S.
        • Ring D.
        Diagnostic accuracy of 2- and 3-dimensional imaging and modeling of distal humerus fractures.
        J Shoulder Elbow Surg. 2012; 21: 772-776
        • Eastwood W.J.
        The T-shaped fracture of the lower end of the humerus.
        J Bone Joint Surg Am. 1937; 19: 364-369
        • Desloges W.
        • Kaber K.J.
        • King G.J.W.
        • Athwal G.S.
        Functional outcomes of distal humerus fractures managed nonoperatively in medically unwell and low demand patients.
        J Shoulder Elbow Surg. 2015; 24: 1187-1196
        • Rangan A.
        • Handoll H.
        • Brealey S.
        • et al.
        Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus. The PROFHER randomized clinical trial.
        JAMA. 2015; 313: 1037-1047
        • Duckworth A.D.
        • Clement N.D.
        • McEachan J.E.
        • White T.O.
        • Court-Brown C.M.
        • McQueen M.M.
        Prospective randomized trial of non-operative versus operative management of olecranon fractures in the elderly.
        Bone Joint J. 2017; 99-B: 964-972
        • Marot V.
        • Bayle-Iniguez X.
        • Cavaignac E.
        • Bonnevialle N.
        • Mansat P.
        • Murgier J.
        Results of non-operative treatment of olecranon fracture in over 75-year-olds.
        Orthop Traumatol Surg Rest. 2018; 104: 79-82
        • Chung K.C.
        • Kim H.M.
        • Malay S.
        • et al.
        Comparison of 24-month outcomes after treatment for distal radius fracture: the WRIST randomized clinical trial.
        JAMA Netw Open. 2021; 4e2112710
        • DeGeorge B.R.
        • Van Houten H.K.
        • Mwangi R.
        • Sangaralingham L.R.
        • Larson A.R.
        • Kakar S.
        Outcomes and complications in the management of distal radial fractures in the elderly.
        J Bone Joint Surg Am. 2020; 102: 37-44
        • MacAusland W.R.
        Ankylosis of the elbow with report of four cases treated by arthroplasty.
        JAMA. 1915; 64: 312-318
        • Cassebaum W.H.
        Operative treatment of T- and Y- fractures of the lower end of the humerus.
        Am J Surg. 1952; 83: 265-270
        • Wilkinson J.M.
        • Stanley D.
        Posterior surgical approaches to the elbow: a comparative anatomic study.
        J Shoulder Elbow Surg. 2001; 10: 380-382
        • Amemiya T.
        • Iwamoto T.
        • Suzuki T.
        • Oki S.
        • Matsumura N.
        • Sato K.
        Comparison of the visible articular surface between the lateral para-olecranon approach and two other common posterior approaches for distal humeral fracture: an anatomical study.
        Journal of Hand Surgery Global Online. 2019; 1: 85-90
        • Daneshvar P.
        • Gee A.
        • Schemitsch E.H.
        • et al.
        Proximal ulna osteotomy for complex fractures of the distal humerus: a 3-dimensional laser analysis and comparison with olecranon osteotomy.
        J Hand Surg Am. 2022; 47: 320-328
        • Fei T.T.
        • Evans P.J.
        • Bafus B.T.
        Triceps fascial tongue exposure for intra-articular distal humerus fractures: revisiting the Van Gordner approach.
        J Shoulder Elbow Surg Int. 2020; 4: 39-43
        • Marinello P.G.
        • Peers S.
        • Styron J.
        • Pervaiz K.
        • Evans P.J.
        Triceps fascial tongue exposure for total elbow arthroplasty: surgical technique and case series.
        Tech Hand & Upper Extr Surg. 2015; 19: 60-63
        • Weber M.B.
        • Cho E.
        • Evans P.J.
        • Styron J.
        • Bafus B.T.
        Triceps tongue versus olecranon osteotomy for intra-articular distal humeral fractures: a matched-cohort study.
        J Shoulder Elbow Surg. 2022; 31: 1215-1223
        • Kudo T.
        • Hara A.
        • Iwase H.
        • et al.
        Biomechanical properties of orthogonal plate configuration versus parallel plate configuration using the same locking plate system for intra-articular distal humeral fractures under radial or ulnar column axial load.
        Injury. 2016; 47: 2071-2076
        • Taylor P.A.
        • Owen J.R.
        • Benfield C.P.
        • Wayne J.S.
        • Boardman D.N.
        Parallel plating of simulated distal humerus fractures demonstrates increased stiffness relative to orthogonal plating with a distal humerus locking plate system.
        J Orthop Trauma. 2016; 30: e118-122
        • Zalavras C.G.
        • Vercillo M.T.
        • Jun B.J.
        • Otarodifard K.
        • Itamura J.M.
        • Lee T.Q.
        Biomechanical evaluation of parallel versus orthogonal plate fixation of intra-articular distal humerus fractures.
        J Shoulder Elbow Surg. 2011; 20: 12-20
        • Yetter T.R.
        • Weatherby P.J.
        • Somerson J.S.
        Complications of articular distal humerus fracture fixation: a systematic review and meta-analysis.
        J Shoulder Elbow Surg. 2021; 30: 1957-1967
        • Wang X.
        • Liu G.
        A comparison between perpendicular and parallel plating methods for distal humerus fractures: a meta-analysis of randomized controlled trials.
        Medicine (Baltimore). 2020; 99e19602
        • Sanchez-Sotelo J.
        • Torchia M.E.
        • O'Driscoll S.W.
        Complex distal humeral fractures: internal fixation with a principle-based parallel-plate technique.
        J Bone Joint Surg Am. 2007; 89: 961-969
        • Rajaee S.S.
        • Lin C.A.
        • Moon C.N.
        Primary total elbow arthroplasty for distal humeral fractures in elderly patients: a nationwide analysis.
        J Shoulder Elbow Surg. 2016; 25: 1854-1860
        • McKee M.D.
        • Veillette C.J.H.
        • Hall J.A.
        • et al.
        A multicenter, prospective, randomized, controlled trial of open reduction: internal fixation versus total elbow arthroplasty for displaced intra-articular distal humeral fractures in elderly patients.
        J Shoulder Elbow Surg. 2009; 18: 3-12
        • Perretta D.
        • van Leeuwen W.F.
        • Dyer G.
        • Ring D.
        • Chen N.
        Risk factors for reoperation after total elbow arthroplasty.
        J Shoulder Elbow Surg. 2017; 26: 824-829
        • Barco R.
        • Streubel P.N.
        • Morrey B.F.
        • Sanchez-Sotelo J.
        Total elbow arthroplasty for distal humeral fractures: a ten-year-minimum follow-up study.
        J Bone Joint Surg Am. 2017; 99: 1524-1531
        • Logli A.L.
        • Shannon S.F.
        • Boe C.C.
        • Morrey M.E.
        • O’Driscoll S.W.
        • Sanchez-Sotolo J.
        Total elbow arthroplasty for distal humerus fractures provided similar outcomes when performed as a primary procedure or after failed internal fixation.
        J Orthop Trauma. 2020; 34: 95-101
        • Bartels S.
        • Kristensen T.B.
        • Gjertsen J.E.
        • et al.
        Total hip arthroplasty leads to better results after low-energy displaced femoral neck fracture in patients aged 55 to 70 years: a randomized controlled multicenter trial comparing internal fixation and total hip arthroplasty.
        J Bone Joint Surg Am. 2022; 104: 1341-1351
        • Seitz W.H.
        • Bismar H.
        • Evans P.J.
        Failure of the hinge mechanism in total elbow arthroplasty.
        J Shoulder Elbow Surg. 2010; 19: 368-375
        • Jukes C.P.
        • Dirckx M.
        • Phadnis J.
        Current concepts in distal humeral hemiarthroplasty.
        J Clin Orthop Trauma. 2021; 19: 224-230
        • Kaufmann R.A.
        • D'Auria J.L.
        • Schneppendahl J.
        Total elbow arthroplasty: elbow biomechanics and failure.
        J Hand Surg Am. 2019; 44: 687-692
        • Schultzel M.
        • Rangarajan R.
        • Blout C.
        • Manuputy I.
        • Lee B.K.
        • Itamura J.M.
        Hemiarthroplasty for the treatment of distal humerus fractures: long-term clinical results.
        J Shoulder Elbow Surg. 2022; 31: 1510-1514
        • Al-Hamdani A.
        • Rasmussen J.V.
        • Sorenson A.K.B.
        • et al.
        Good outcome after elbow hemiarthroplasty in active patients with an acute intraarticular distal humeral fracture.
        J Shoulder Elbow Surg. 2019; 28: 925-930
        • Nestorson J.
        • Ekholm C.
        • Etzner M.
        • Adolfsson L.
        Hemiarthroplasty for irreparable distal humeral fractures: medium-term follow-up of 42 patients.
        Bone Joint J. 2015; 97B: 1377-1384
        • Smith G.C.S.
        • Bayne G.
        • Page R.
        • Hughes J.S.
        The clinical outcome and activity levels of patients under 55 years treated with distal humeral hemiarthroplasty for distal humeral fractures.
        Shoulder Elbow. 2016; 8: 264-270
        • Phadnis J.
        • Banerjee S.
        • Watts A.C.
        • Little N.
        • Hearnden A.
        • Patel V.R.
        Elbow hemiarthroplasty using a “triceps-on” approach for the management of acute distal humeral fractures.
        J Shoulder Elbow Surg. 2015; 24: 1178-1186
        • Jonsson E.O.
        • Nesterson J.
        • Ekholm C.
        • Etzner M.
        • Hallgren H.
        • Adolfsson L.
        Elbow hemiarthroplasty versus total elbow arthroplasty for irreparable distal humeral fractures. Preliminary results of a randomized controlled trial.
        J Shoulder Elbow Surg. 2022; 31: e137
        • Vazquez O.
        • Rutgers M.
        • Ring D.C.
        • Walsh M.
        • Egol K.A.
        Fate of the ulnar nerve after operative fixation of distal humerus fractures.
        J Orthop Trauma. 2010; 24: 395-399
        • Dehghan N.
        • Nauth A.
        • Hall J.
        • et al.
        In site placement vs. Anterior transposition of the ulnar nerve for distal humerus fractures treated with plate fixation: a multi centre randomized controlled trial.
        J Orthop Trauma. 2021; 35: 465-471
        • Ruan H.J.
        • Liu J.J.
        • Fan C.Y.
        • Jiang J.
        • Zeng B.F.
        Incidence, management, and prognosis of early ulnar nerve dysfunction in type C fractures of distal humerus.
        J Trauma. 2009; 67: 1397-1401
        • Chen R.C.
        • Harris D.J.
        • Leduc S.
        • Borrelli Jr., J.J.
        • Tornetta III, P.
        • Ricci W.M.
        Is ulnar nerve transposition beneficial during open reduction internal fixation of distal humerus fractures?.
        J Orthop Trauma. 2010; 24: 391-394