Intercondylar humerus
the management of this relatively uncommon injury, its associated
fractures: current concepts
and controversies
Vivek Trikha, MS (Ortho)*
Tarun Goyal, MS (Ortho)**
Abstract
Intrercondylar distal humerus fractures are uncommon injuries with less
than satisfactory result in a large number of cases despite numerous
advancements in surgical techniques. Anatomical and stable internal fixa-
tion with early postoperative mobilization is expected to improve the func-
tional outcomes. The present discussion is an attempt to understand the
current standards of care in surgical management of this complex injury.
Keywords Intercondylar humerus, techniques, olecranon osteotomy, TRAP
INTRODUCTION
The distal humerus fractures are relatively uncommon com-
prising about 2% of all adult fractures and about one third of
humerus fractures.1–5 Majority of the distal humerus fractures
(96%) have a complex pattern involving both the columns and
the articular surface (AO type C injuries).6 The incidence of
this fracture pattern has been increasing in older age group,
which is attributed to osteoporosis.7–10 The contemporary treat-
ment of displaced intercondylar fractures of distal humerus is
based on observations that open reduction and internal fixation
of these fractures yield superior outcomes vis-à-vis closed ma-
nipulation and immobilization.11–14 This has been associated with
lower risk of mal-union, non-union, joint stiffness, secondary os-
teoarthritis and better return to near normal range of motion.15–17
There are marginally raised instances of wound infection and
neurovascular injury. Perfect congruity of the articular surfaces
and early postoperative mobilization should be the aim to restore
range of motion as close to normal as possible.
Thus, it is well recognized that open reduction and stable
internal fixation is the optimal treatment for distal humerus
intra-articular fractures. But several areas in the management
of these injuries are not clear. There are controversies regarding
the ideal surgical approach, placement of the plates, role of
locking and pre-contoured plates, role of ulnar nerve transposi-
tion and prophylaxis for heterotopic ossification.
*Assistant Professor, JPN Apex Trauma Center, **Senior Resident, AIIMS,
New Delhi.
Correspondence: Dr. Vivek Trikha, L-381, Sarita Vihar, New Delhi – 110076.
E-mail: vivektrikha@gmail.com
JCOT Vol 1 No 2
The purpose of this paper is to highlight the controversies in
complications and final outcome.
SPECIFIC ANATOMY
The ulnotrochlear joint serves as a semi-constraint hinge joint
with motion in flexion and extension. In addition, there are five
degrees of varus or valgus laxity in response to applied force.18,19
The forearm rotation takes place at radiocapitellar joint. The
articular surface of distal humerus is inclined at about carrying
angle of 11–17° of valgus angulations (Figure 1). Trochleo-
capitellum forms a tie arch, supported by the inverted Y-shaped
medial and lateral columns. Most distal humerus intra-articular
fractures split through the trochlear waist, causing comminu-
tion and often leading to narrowing of the trochlea after inter-
nal fixation.18 Restoration of the width of the distal articular
surface is essential to regain full range of motion.
Distal humerus may be visualized to be composed of two
columns: medial column extending from the medial supracondy-
lar ridge and ending at medial epicondyle, about 1 cm proximal
to the trochlea, lying in the long axis of the humerus. The lat-
eral column ends at the capitellum, which projects about 30–40
degrees anteriorly from the long axis of humerus (Figure 2). The
posterior aspect of the lateral column distally is extra-articular,
thus, allowing distal placement of the plate. The lateral condyle
lies at approximately 20° of valgus relative to the humeral shaft
and the medial condyle lies at 40° of varus. If a line is drawn
along the anterior surface of the shaft of humerus on a lateral pro-
jection of the elbow and extended distally it cuts lateral condyle
into two parts, anterior one-third, and posterior two-thirds.
CLASSIFICATIONS
A number of classification systems have been developed for
distal humerus fractures (Figures 3 and 4). These systems sub-
categorize fractures according to the articular surface involve-
ment and the presence and extent of comminution. The most
commonly followed is the Orthopedic Trauma Association/AO
classification (Table 1). An important shortcoming of these
classification systems used for the distal humerus fractures is
that they do not address the closeness of the fracture line from
the joint surface and the fractures with a coronal split. Both
these features have an important prognostic implication.
TREATMENT
Earlier, the results of the operative treatment were poor because
of the inability to achieve stable internal fixation, which pro-
longed the time required in cast immobilization and thus, resulted
in a stiff elbow. With better understanding of the distal humerus
anatomy it is now possible to achieve stable internal fixation
with early postoperative mobilization, yielding satisfactory range
57
 Trikha and Goyal

Figure 1 Anatomy of the distal part of the humerus.

*Note that the capitellum is projected 30–40° anteriorly from the long axis of the humerus. Line drawn from anterior shaft cuts the lateral condyle into
one-third and two-thirds.
Medi
column

al co
ral

lu m
Late

A A1 A2 A3
“Tie arch
”

Figure 2 The two columns of distal humerus. The trochlea and the capitel-
lum form the horizontal “tie arch” in between the two columns.

B B1 B2 B3

1 2

C C1 C2 C3

Figure 4 AO/OTA classification for the distal humerus.

3 4

Figure 3 Riseborough and Radin classification.

of motion in the majority of the cases. Proper pre-operative im-
aging and templating is a useful prerequisite to anatomical
fracture fixation.
Displaced intra-articular fractures in which the articular in-
congruity exceeds 2 mm are best treated by internal fixation.
Other indications for surgery include open fractures, fractures
with neurovascular injuries or compartment syndrome and frac-
tures in multiple injury patients.
Operative Technique
Patient may be positioned either in lateral decubitus position
with shoulder and arm flexed at 90° and placed on an arm rest;
or in prone position with arm placed abducted on a side table.
Pneumatic tourniquet is used to provide a clear operative field

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 Intercondylar humerus fractures: current concepts and controversies

Table 1 Various classification systems for intercondylar fractures of humerus.

Riseborough and Radin classification AO classification/Müller’s classification Jupiter and Mehne

1. Type I: Undisplaced fracture
2. Type II: Mild displacement. Trochlea and
capitellum displaced but not rotated
3. Type III: Moderate displacement. Trochlea
and capitellum are both displaced and rotated
4. Type IV: Severe comminution. Type III with
significant intracondylar comminution
1. Type C1: Classic bicondylar fractures “T” or 1. Grade I: Intra-articular fractures.
“Y” type, simple with no comminution. 2. Grade II: Extra-articular,
2. Type C2: C1 with supracondylar communition. intracapsular fractures.
3. Type C3: C1 or C2 with intracondylar comminution. 3. Grade III: Extracapsular fractures.
Intracapsular fractures are
subdivided into:
A: Single column
B: Bicolumnar
C: Capitellar
D: Trochlear

and minimize blood loss. Tourniquet should be deflated after

60–90 minutes to minimize the chances of tourniquet palsies.
No surgical approach to distal humerus fracture is perfect.
Visualization of the distal humerus articular surface comes at
the cost of sacrificing important bony or tendinous structures
that may be associated with long term complications or difficult
postoperative rehabilitation.
Olecranon osteotomy is the most commonly used approach
for the fixation of these fractures. It provides extensive exposure
of the articular surfaces and precise assessment of fracture anat-
omy. It is advisable to make it an intra-articular chevron osteot-
omy starting about 2 cm distal to the tip, with the apex directed
distally, to facilitate its further reduction and fixation. It is fixed
with tension band wiring with double tightening loops or by
using screws with predrilling.17 Dorsal midline longitudinal in-
cision is used, starting well proximal to the olecranon depending
upon the level of supracondylar extension, to end in midline
about 5 cm distal to the tip of olecranon. The incision curves
slightly laterally over the prominence of the elbow to avoid
wound complications. Midline approach provides the best ex-
posure of the distal humerus and preserves more cutaneous
nerves than the medial or lateral incisions.
Olecranon osteotomy may lead to denervation of anconeus
muscle. Anconeus act as a stabilizer of the lateral side of
the elbow preventing varus and posterolateral instability. To
avoid this complication, Athwal et al described anconeus flap
trans-olecranon approach which preserves anconeus from
denervation.20
The anconeus flap trans-olecranon approach involves dis-
section through the Kochers interval (between the anconeus
and the extensor carpi ulnaris), and raising the anconeus off
the olecranon. An apex distal chevron osteotomy of the ole-
cranon is combined with this proximally based flap of the an-
coneus muscle. This leaves the anconeus attached to the
triceps and the proximal olecranon preserves its innervation
and the blood supply.
To gain distal exposure in the triceps splitting approach the
split is extended distally along the triceps insertion raising full
thickness medial and lateral sleeves from the olecranon, maintain-
ing continuity with the flexor carpi ulnaris and anconeus. Al-
though originally debated, it is now clear that there is no difference
A B
Figure 5 Outline of the TRAP Approach: The line (A) showing the outline
of the flap reflecting the triceps along with a sleeve of periosteum and
the anconeus muscle (B).
in terms of articular exposure and functional outcomes whether
a triceps splitting approach or an olecranon osteotomy is per-
formed.20,21 Triceps splitting approach is also used in cases
where primary prosthetic total elbow replacement is kept as an
alternative to fixation, especially in grossly comminuted frac-
tures.22 It also avoids complications related to the union of os-
teotomy site. Also, the unfractured olecranon may be used as
template to re-assemble the fragments of trochlea. Triceps split-
ting approach can be extended distally with olecranon osteotomy
and reflection of the olecranon medially with intact medial soft
tissue attachments.23
Triceps reflecting anconeus pedicle (TRAP) approach com-
bines features of Kochers and Bryan-Morreys24 exposure by re-
flecting the triceps tendon and anconeus medially to laterally,
thus skeletonizing the olecranon and gaining exposure to the
articular surface (Figure 5). The anconeus is released from its
attachment on lateral epicondyle while maintaining its fascial
continuity with the triceps. This is less extensive exposure avoid-
ing complications of olecranon osteotomy and stripping of the
ligament support on the lateral aspect of the elbow joint.25–30
TRAP approach is also friendlier as regard the future total elbow
arthroplasty. Triceps tendon needs to repair back to the olecra-
non at the end of the repair. The disadvantage of this approach

JCOT Vol 1 No 2 59
 Trikha and Goyal
includes prolonged rehabilitation, and chances of triceps weak-
ening or failure of repair.
Triceps sparing (paratricipital) approach provides limited ex-
posure of the distal articular surface of the humerus. Its use is
thus limited to type A fractures and some type C1 and C2 frac-
tures. An advantage of this approach is that it can be easily con-
verted to olecranon osteotomy approach, in cases where the
exposure is found to be inadequate.
Radial nerve may be at risk of damage by undue proximal
extension of the triceps splitting approach.31 Fractures extend-
ing high up to mid or proximal shaft, or segmental humerus
shaft fracture associated with distal humerus fracture will require
olecranon osteotomy combined with triceps splitting approach
for adequate exposure.25,32 Alternately a combined olecranon
osteotomy, lateral paratricipital sparing, deltoid insertion split-
ting approach may be used.33
Transposition of Ulnar Nerve
Identification of ulnar nerve at the time of surgery is important
to prevent inadverant injury but may lead to perineural scar-
ring.9,12,34 Dissection and anterior transposition of ulnar nerve is
mandatory in cases where pre-operative damage extends to the
nerve trunk, or there is intra-operative contusion or retraction
injury, when there is anticipation that the implants will cause
mechanical impingement on the nerve or may require future
removal, cases where medial column plate is applied on the pos-
terior surface of the column, and in cases of mal-union or non-
union where there is risk of tardy ulnar nerve palsy. Evidence in
favor of routine transposition of ulnar nerve is lacking.35,36
The ulnar nerve is first localized proximally where it emerges
beneath the triceps tendon from the medial intermuscular sep-
tum. It is important to release the ulnar nerve proximally up
to the level of medial intramuscular septum and arcade of
Struthers, the cubital tunnel is then divided completely and
distally the aponeurosis between the humeral and ulnar origins
of the flexor carpi ulnaris is enlarged. The nerve is followed for
at least 7 cm after the flexor pronator mass is entered, up to
its first motor branch, to avoid the chances of failure and devel-
opment of postoperative compressive ulnar neuropathy. If
ulnar neuritis is present pre-operatively, in addition to the ex-
tensive release of the soft tissue, ulnar neurolysis should also
be carried out.
Wang et al and several other authors recommended routine
subcutaneous anterior transposition of ulnar nerve.14 In their
20 cases they reported no case of ulnar compression syndrome.
Helfet and Schmeling reported a 7% incidence of ulnar neurop-
athy when routine transposition of ulnar nerve in not performed.
Subperiosteal elevation of the ulnar nerve combined with ole-
cranon osteotomy may avoid risk of ulnar nerve damage due to
lack of exposure and risk of perineural fibrosis secondary to its
isolation.37,38 Chen et al in their study comparing 89 patients in
whom anterior transposition was done with 48 patients in whom
anterior transposition was not done, found that there was a four
times higher risk of ulnar neuritis when ulnar nerve transposition
was done (p < 0.0003).35 Additionally they found that the place-
ment of medial implant does not mandate anterior transposition.
JCOT Vol 1 No 2
Placement of Plates
Placement of plates is one of the most controversial topics in the
treatment of the distal humerus fractures. Some authors have
recommended orthogonal placement of plates (at 90° to each
other), one on medial column, and the other posterolaterally.7,39,40
Others have recommended parallel placement of plates on the
medial and lateral columns respectively.41,42 There is no clear
biomechanical superiority of one plate design over the other.
The plates are best applied according to the fracture configura-
tion. The orthogonal placement of plates is advantageous in low
type fractures and coronal fractures since the lateral plate can
be placed far more distally. The plate applied on the medial
column (in sagittal plane) also avoids ulnar nerve fiddling.
Disadvantages of placing plates on the columns includes addi-
tional subperiosteal stripping that is required along the supra-
condylar ridges, with its potential complications such as damage
to the blood supply of the distal fragments and increased risk of
non-union or delayed union. Also, it needs greater deal of tem-
plating of the plates in two planes. Thus, it may be convenient
to use pelvic reconstruction plates, especially for the medial
column. They have less strength as compared to dynamic com-
pression plates but do not alter mechanics of the medial col-
umn. Lateral column plates require less templating and the
stronger dynamic compression plates can be easily used.
Placing the two plates at right angle to each other was initially
said to enhance stability.7,13 AO/ASIF group recommends or-
thogonal placement of plates for fracture fixation.22,27 O’Driscoll
in his review paper concluded that the parallel is stronger than
or at least as strong as perpendicular placement of the plates.27
He pointed out that most common mode of failure is the non-
union of the fragments at the supracondylar level. Based on his
findings he laid down several technical objectives to be achieved
during parallel plating to maximize the potential for union. He
emphasized maximization of fixation in the distal fragment by
screws put through the plate along with good supracondylar
metaphyseal contact to achieve union.
Sanders et al used dynamic compression plate in the sagittal
plane for the fixation of the lateral column for primary stability
followed by the fixation of the medial column by reconstruc-
tion plates placed posteriorly in coronal plane.13 Sanchez-Sotelo
et al treated 34 patients with complex distal humeral fractures
with two parallel plates both applied in sagittal plane. They em-
phasized that this principle of parallel plating maximizes fixa-
tion in the articular fragments and stability at the supracondylar
level.43
Plate is applied first to the lateral column followed by the fix-
ation of the medial column. The thicker lateral column, where
plate requires less templating as compared to the medial column,
provides ideal site for primary fixation.
Thus, placement of the plates on the columns can be in part
dictated by the fracture patterns (Figures 6–13). Whereas in the
simple T type intercondylar split with large fragment it may be
easier to apply the plates on the posterior aspects of both the
columns, or one on the medial column and second plate poste-
rolaterally. In low types of fractures, and in those with more com-
minution it is more useful to proceed with more stripping of the
60
 Intercondylar humerus fractures: current concepts and controversies
tissue from the supracondylar ridges and place the plates on
the medial and lateral columns in order to reach more distally.
In low fracture configurations plates may be given a perpendic-
ular bend at the distal end to place long screws from the medial
or lateral epicondyles through the medial and lateral columns.
Stoffel et al used locking plates for the stabilization of these
fractures. They concluded that the parallel placement of plates to
be superior to perpendicular placement in terms of stability.44
This arrangement is especially helpful while using two locking
plates.40
A B
Figure 6 High intercondylar fracture humerus.
A B
Figure 7 Follow-up radiographs after triceps - reflecting anconeus pedi-
cle (TRAP) approach and bicolumnar plating.
A B
Figure 8 Clinical follow-up of the same patient showing good range of motion (ROM).
JCOT Vol 1 No 2
One–third tubular plates are not recommended for use in fix-
ation due to higher incidences of implant failure. Locking plates
or pre-contoured distal humeral plates are perhaps more stable
implants in osteoporotic bones or in a setting of metaphyseal
communition.27,40,45,46
It is imperative to restore intercondylar distance as well as
distal humeral length even in face of gross intracondylar commu-
nition. Highly comminuted fractures where bone loss precludes
the anatomical stabilization of trochlea, its reconstruction using
autologous bone graft is recommended to restore elbow stability.
In such cases, the screws should not provide interfragmentary
compression to prevent the collapse at fracture site.
Open fractures are best managed by thorough debridement
and irrigations, followed by stable internal fixation, within
6 hours of injury. In grossly contaminated fractures, those with
massive soft tissue cover loss or open fractures reporting late, it
is prudent to do internal fixation as a secondary procedure
once the wound is free of infection.44
Patients with non-union and mal-union of these types of
fractures require rigid internal fixation of the fracture fragments
after removal of interposing fibrous tissues, and possibility of
bony gaps reconstruction using autologous bone graft. These are
followed by aggressive elbow joint arthrolysis and soft tissue
release, depending upon joint contractures. Significant improve-
ment in range of motion and joint stiffness can be expected
A B
Figure 9 Pre-operative radiographs.
61
 Trikha and Goyal
A B
Figure 10 Bicolumnar plating using olecranon osteotomy.
A B
Figure 11 Follow-up radiographs of intercondylar humerus.
A B
Figure 12 Pre-operative radiographs.
following these procedures.47 Rigid internal fixation in these
cases consistently results in union of delayed or mal-unions.
Intra-operative specimens for culture are helpful in these patients
to rule out chances of infection. Active infection is a contrain-
dication to such procedures. In cases of non-unions rendered
non-salvageable due to excess comminution, bone loss or poor
bone quality total elbow replacement is best alternative espe-
cially in low demand or in elderly.48
JCOT Vol 1 No 2
A B
Figure 13 Postoperative radiographs with 90–90 plating.
Postoperatively, the elbow should be moved actively through-
out its range of motion to rule out any impingement of hard-
ware, confirm stability of the construct and to define the goals of
postoperative physiotherapy. If full extension is limited due to im-
pingement by the olecranon a portion of its tip may be excised.
Rehabilitation and Outcome
Early postoperative rehabilitation is recommended to avoid the
formation of intra-articular adhesions and peri-articular fibro-
sis that will make elbow stiff. Aitken et al in their retrospective
study concluded that the most important indicator of end result
is the starting point of physiotherapy.11 Usually postoperatively
the limb is rested in a dorsally applied above elbow splint. After
the postoperative pain has subsided in about a two days time,
active and active assisted range of motion for elbow flexion/
extension and supination/pronation should be started. This is
initially started in horizontal plane to eliminate the effect of
gravity. No passive flexion is allowed at this time and up to
6 weeks to allow fracture healing and reduce chances of hetero-
topic bone formation. Passive gravity assisted extension is com-
menced at the end of 1 week. With stable fixation splint may be
discarded after 1 week. Strengthening begins at 10 weeks. Active
range of motion is regained during the first 2 months. Addi-
tional flexion and extension may be gained for up to 5 months
62
 Intercondylar humerus fractures: current concepts and controversies

postoperatively. Works requiring strenuous efforts should be
avoided for 10 weeks.
Most patients may feel some sense of easy fatigability and
exercise intolerance many years after surgery, as full recovery
of flexor and extensor muscle strength is not achieved in most
cases despite adequate physiotherapy. Union is anticipated by
3 months. Loss of extension strength is reported to be around
25% irrespective of the surgical approach. But this is not as re-
markably perceived by a sedentary or a light worker as is the im-
proved range of pain free motion provided by the surgery.14
Various scoring systems are used for the grading of results,
such as those by Cassebaum,49 Jupiter,22 Aitken,11 and
Krishnamoorthy.15 Most commonly used is that of Jupiter which
uses loss of extension, range of flexion, pain, and disability in
its criteria. Most authors report good to excellent results in
about 75% of the patients.11,13,17,30,34,47,49–51
Ulnar nerve injury is the most common nerve involved in this
type of fractures.35,36 It may present at the time of injury, post-
operatively or late in the postoperative period. Associated risk
factors include wide fracture displacement, long tourniquet time,
and poor soft tissue handling during surgery and mal-union or
non-union.
Normal range of motion is uncommon after such injuries.
But most of the studies have reported good to excellent outcomes
in more than three–fourth of their patients (Table 2) (based on the
functional outcome criteria used by Jupiter et al or Cassenbaum
et al).13 Incidences of restriction of supination and pronation
are low.1,3,34,48,52
Other significant complications associated with these fractures
include joint osteoarthrosis, complications related to olecranon os-
teotomy including non-union, heterotropic ossification, hardware
removal for prominence, avascular necrosis, and elbow instability.

Complications Newer Options for Treatment

The average rate of non-union following bicolumnar fractures
is rated at 6%.3,39,52,53 It is more common in low fracture config-
urations, unstable internal fixation or failure of internal fixation.
It is assessed after 6 months of postoperative period. It generally
requires revision surgery with repeat internal fixation and elbow
release procedures to improve range of motion.3,51 Non-union
in most cases involves the supracondylar part of the fracture
whereas the intercondylar part usually unites well.27
Deep infections are uncommon occurring on an average in
3% of patients.8 Risk factors include open fractures with massive
contamination and devascularized segments of bone and soft
tissues. Urgent debridement is mandatory. In refractory cases and
those with failure of fixation, removal of implant is required.
Recently locked compression plates have been popularized that
utilize fixed angle screws that are believed to provide superior fix-
ation in osteopenic bones.46 They have an additional advantage
of unicortical screw placement that avoids risk of screw tips
projecting into the joints. Pre-contoured plates have also been
made available for the medial and lateral columns. These locked
compression plates and distal humerus plates are more useful
in patients with osteoporotic bones, metaphyseal comminution,
or very low type of intra-articular fractures.40,61,62
Illizarov fixation has been proposed as an option for the in-
fected non-unions of distal radius.63 It may be studied as a pri-
mary modality in the setting of grossly comminuted or infected
open injuries.

Table 2 Review of literature regarding the functional results after intercondylar humerus fractures.

Author (year) No. of Plate placement Average Outcome assessment % with excellent
fractures follow-up followed and good
(months) outcomes
Jupiter (1985)22 34 Not specified 70 Jupiter 79
Gabel (1987)54 10 Not specified 26 Gabels 90
Henley (1987)39 24 Not specified 19 Jupiter and Cassebaum 92
Holdsworth (1990)50 38 Lateral plate—posterior 37 Jupiter 76
Medial plate—saggital
Sanders (1992)13 13 Plates placed posteriorly on both columns > 24 Cassebaum 92
Papaioannou (1995)55 54 Not specified 48 Cassebaum 78
Kundel (1996)3 99 Lateral plate—posterior 40 Cassebaum 52
Medial plate—saggital
Pajarinen (2002)56 18 Not specified 25 OTA 56
Ozdemir (2002)57 34 Not specified 82 Jupiter 62
Gupta (2002)2 55 Plates placed posteriorly on both columns 48 Aitken 93
Aslam (2004)58 26 Not specified 35 Broberg/Morrey 70
Ahmed (2006)59 20 Lateral plate—posterolaterally 31 Broberg/Morrey 72
Medial plate—saggital
Clement (2006)60 28 Plates placed posteriorly on both columns 56 DASH, Mayo, and physical SF–36 87

OTA: Orthopedic Trauma Association; DASH: Disabilities of arm, shoulder and hand score; SF-36: Medical Outcomes General Health Survey (SF-36).

JCOT Vol 1 No 2 63
 Trikha and Goyal
Total elbow arthroplasty has recently gained popularity for
the treatment of distal humerus fractures. It appears prudent to
assess the fracture pre-operatively with the view of achieving a
stable construct depending upon the fracture con and bone qual-
ity. Elderly low demand patients with comminuted osteoporotic
are the best candidates for total elbow arthroplasty. Presently
the scope of primary elbow arthroplasty is limited by the limited
longevity of the construct. It is being more commonly used in
osteoporotic fractures in elderly population. If longevity of these
implants can be improved they can cater to younger population
with complex comminuted fractures.1,64–66
CONCLUSIONS
Pre-requisites for successful outcomes are anatomical reduction,
stable internal fixation, and early mobilization. Unless a stable
construct is obtained it is not possible to achieve mobilization
without loss of anatomical accuracy. Early mobilization is the
key to best postoperative outcomes in terms of range of motion
and patient comfort and level of activity. Comminution of the
fragments, osteopenia, delicate articular anatomy of the distal hu-
merus, deficient bone stock available in the olecranon fossa for
implant placement, further complicate the situation. Bicolum-
nar fixation provides a stable construct on which early mobiliza-
tion can be initiated. Excellent to good results can be expected
at least in 75% of the patients. Improved range of motion and
stable union can also be achieved following surgery in cases of
non-unions.
We affirm that we have no financial affiliation (including research
funding) or involvement with any commercial organization
that has a direct financial interest in any matter included in
this manuscript. There is no conflict of interest. ♦ liminary report. J Trauma 2005;58:70–5.
REFERENCES
1. Helfet DL, Schmeling GJ. Bicondylar intra-articular fractures of the
distal humerus in adults. Clin Orthop Relat Res 1993;292:26–36.
2. Gupta R, Khanchandani P. Intercondylar fractures of the distal humerus
in adults: a critical analysis of 55 cases. Injury 2002;33:511–5.
3. Kundel K, Braun W, Wieberneit J, Rüter A. Intra-articular distal
humerus fractures. Factors affecting functional outcome. Clin Orthop
Relat Res 1996;332:200–8.
4. Robinson CM, Hill RM, Jacobs N, Dall G, Court-Brown CM. Adult distal
humeral metaphyseal fractures: epidemiology and results of treat-
ment. J Orthop Trauma 2003;17:38–47.
5. Rose SH, Melton LJ III, Morrey BF, Ilstrup DM, Riggs BL. Epidemiologic
features of humeral fractures. Clin Orthop Relat Res 1982;168;24–30.
6. McCarty LP, Ring D, Jupiter JB. Management of distal humerus frac-
tures. Am J Orthop 2005;34:430–8.
7. Agarwal S, Abbas M, Sherwani MK, Huda N, Azom Q, Hashmat A.
Management of type C intercondylar fractures of lower end humerus
in adults: a clinical study. J Indian Med Assoc 2006;104:322–4.
8. Huang TL, Chiu FY, Chuang TY, Chen TH. The results of open reduction
and internal fixation in elderly patients with severe fractures of the
JCOT Vol 1 No 2
distal humerus: a critical analysis of the results. J Trauma 2005;
58:62–9.
9. John H, Rosso R, Neff U, Bodoky A, Regazzoni P, Harder F. Operative
treatment of distal humeral fractures in the elderly. J Bone Joint
Surg Br 1994;76:793–6.
10. Kannus P, Niemi S, Parkkari J, Palvanen M, et al. Why is the age-
standardized incidence of low-trauma fractures rising in many elderly
populations? J Bone Miner Res 2002;17:1363–7.
11. Aitken GK, Rorabeck CH. Distal humeral fractures in the adult. Clin
Orthop Relat Res 1986;207:191–7.
12. Ilyas AM, Jupiter JB. Treatment of distal humerus fractures. Acta Chir
Orthop Traumatol Cech 2008;75:6–15.
13. Sanders RA, Raney EM, Pipkin S. Operative treatment of bicondylar
intra-articular fractures of the distal humerus. Orthopedics 1992;
15:159–63.
14. Wang KC, Shih HN, Hsu KY, Shih CH. Intercondylar fractures of the
distal humerus: routine anterior subcutaneous transposition of the
ulnar nerve in a posterior operative approach. J Trauma 1994;36:770–3.
15. Krishnamoorthy S, Bose K, Wong KP. Treatment of old unreduced dis-
location of the elbow. Injury 1976;8:39–42.
16. Perry CR, Gibson CT, Kowalski MF. Transcondylar fractures of the dis-
tal humerus. J Orthop Trauma 1989;3:98–106.
17. Ring D, Gulotta L, Chin K, Jupiter JB. Olecranon osteotomy for expo-
sure of fractures and non-unions of the distal humerus. J Orthop
Trauma 2004;18:446–9.
18. Alcid JG, Ahmad CS, Lee TQ. Elbow anatomy and structural bio-
mechanics. Clin Sports Med 2004;23:503–17.
19. Bryce CD, Armstrong AD. Anatomy and biomechanics of the elbow.
Orthop Clin North Am 2008;39:141–54.
20. Athwal GS, Rispoli DM, Steinmann SP. The anconeus flap transolecranon
approach to the distal humerus. J Orthop Trauma 2006;20:282–5.
21. Ziran BH, Smith WR, Balk ML, Manning CM, Agudelo JF. A true triceps-
splitting approach for treatment of distal humerus fractures: a pre-
22. Jupiter JB, Neff U, Holzach P, Allgöwer M. Intercondylar fractures of
the humerus. An operative approach. J Bone Joint Surg Am 1985;67:
226–39.
23. Zlotolow DA, Catalano LW III, Barron OA, Glickel SZ. Surgical expo-
sures of the humerus. J Am Acad Orthop Surg 2006;14:754–65.
24. Bryan RS, Morrey BF. Extensive posterior exposure of the elbow.
A triceps-sparing approach. Clin Orthop Relat Res 1982;166:188–92.
25. Ebraheim NA, Andreshak TG, Yeasting RA, Saunders RC, Jackson WT.
Posterior extensile approach to the elbow joint and distal humerus.
Orthop Rev 1993;22:578–82.
26. Ek ET, Goldwasser M, Bonomo AL. Functional outcome of complex
intercondylar fractures of the distal humerus treated through a triceps-
sparing approach. J Shoulder Elbow Surg 2008;17:441–6.
27. O’Driscoll SW. Optimizing stability in distal humeral fracture fixation.
J Shoulder Elbow Surg 2005;14:186S–94S.
28. Ozer H, Solak S, Turanli S, Baltaci G, Colakoglu T, Bolukbasí S.
Intercondylar fractures of the distal humerus treated with the triceps-
reflecting anconeus pedicle approach. Arch Orthop Trauma Surg
2005;125:469–74.
29. Schildhauer TA, Nork SE, Mills WJ, Henley MB. Extensor mechanism-
sparing paratricipital posterior approach to the distal humerus.
J Orthop Trauma 2003;17:374–8.
64
 Intercondylar humerus fractures: current concepts and controversies
30. Signoret F, Feron JM, Lemseffer M, Guincestre JM. Posterior approach to
the elbow preserving the extensor apparatus. Its value in the osteo-
synthesis of humerus plate fractures. J Chir (Paris) 1986;123:746–8.
31. Uhl RL, Larosa JM, Sibeni T, Martino LJ. Posterior approaches to the
humerus: when should you worry about the radial nerve? J Orthop
Trauma 1996;10:338–40.
32. Archdeacon MT. Combined olecranon osteotomy and posterior tri-
ceps splitting approach for complex fractures of the distal humerus.
J Orthop Trauma 2003;17:368–73.
33. Lewicky YM, Sheppard JE, Ruth JT. The combined olecranon osteot-
omy, lateral paratricipital sparing, deltoid insertion splitting approach
for concomitant distal intra-articular and humeral shaft fractures.
J Orthop Trauma 2007;21:133–9.
34. Doornberg JN, van Duijn PJ, Linzel D, Ring DC, et al. Surgical treat-
ment of intra-articular fractures of the distal part of the humerus.
Functional outcome after twelve to thirty years. J Bone Joint Surg Am
2007;89:1524–32.
35. Chen RC, Harris DJ, Leduc S, Borrelli JJ Jr, Tornetta P III, Ricci WM. Is ulnar
nerve transposition beneficial during open reduction internal fixation
of distal humerus fractures? J Orthop Trauma 2010;24:391–4.
36. Vazquez O, Rutgers M, Ring DC, Walsh M, Egol KA. Fate of the ulnar
nerve after operative fixation of distal humerus fractures. J Orthop
Trauma 2010;24:395–9.
37. Krkovic M, Bosnjak R. Subperiosteal elevation of the ulnar nerve—
anatomical considerations and preliminary results. Injury 2008;39:
761–7.
38. Krkovic M, Kordas M, Tonin M, Bosnjak R. Subperiosteal elevation of
the ulnar nerve during internal fixation for fractures of the distal
humerus assessed by intra-operative neurophysiological monitoring.
J Bone Joint Surg Br 2006;88:220–6.
39. Henley MB, Bone LB, Parker B. Operative management of intra-articular
fractures of the distal humerus. J Orthop Trauma 1987;1:24–35.
40. Korner J, Diederichs G, Arzdorf M, Lill H, et al. A biomechanical evalu-
ation of methods of distal humerus fracture fixation using locking
compression plates versus conventional reconstruction plates.
J Orthop Trauma 2004;18:286–93.
41. Schemitsch EH, Tencer AF, Henley MB. Biomechanical evaluation of
methods of internal fixation of the distal humerus. J Orthop Trauma
1994;8:468–75.
42. Self J, Viegas SF, Buford WL Jr, Patterson RM. A comparison of double-
plate fixation methods for complex distal humerus fractures. J Shoulder
Elbow Surg 1995;4:10–6.
43. Sanchez-Sotelo J, Torchia ME, O’Driscoll SW. Complex distal humeral
fractures: internal fixation with a principle-based parallel-plate technique.
Surgical technique. J Bone Joint Surg Am 2008;90(Suppl 2):31–46.
44. Chaudhary S, Patil N, Bagaria V, Harshavardhan NS, Hussain N. Open
intercondylar fractures of the distal humerus: Management using a
mini-external fixator construct. J Shoulder Elbow Surg 2008;17:465–70.
45. Greiner S, Haas NP, Bail HJ. Outcome after open reduction and angu-
lar stable internal fixation for supra-intercondylar fractures of the
distal humerus: preliminary results with the LCP distal humerus sys-
tem. Arch Orthop Trauma Surg 2008;128:723–9.
46. Stoffel K, Cunneen S, Morgan R, Nicholls R, Stachowiak G. Com-
parative stability of perpendicular versus parallel double-locking
plating systems in osteoporotic comminuted distal humerus fractures.
J Orthop Res 2008;26:778–84.
47. Helfet DL, Kloen P, Anand N, Rosen HS. ORIF of delayed unions and
non-unions of distal humeral fractures. Surgical technique. J Bone
Joint Surg Am 2004;86-A(Suppl 1):18–29.
JCOT Vol 1 No 2
48. McKee MD, Wilson TL, Winston L, Schemitsch EH, Richards RR.
Functional outcome following surgical treatment of intra-articular
distal humeral fractures through a posterior approach. J Bone Joint
Surg Am 2000;82-A:1701–7.
49. Cassebaum WH. Operative treatment of T and Y fractures of the lower
end of the humerus. Am J Surg 1952;83:265–70.
50. Holdsworth BJ, Mossad MM. Fractures of the adult distal humerus.
Elbow function after internal fixation. J Bone Joint Surg Br 1990;72:
362–5.
51. Södergård J, Sandelin J, Böstman O. Postoperative complications of
distal humeral fractures. 27/96 adults followed up for 6 (2–10) years.
Acta Orthop Scand 1992;63:85–9.
52. Kinik H, Atalar H, Mergen E. Management of distal humerus fractures
in adults. Arch Orthop Trauma Surg 1999;119:467–9.
53. Ring D, Jupiter JB. Complex fractures of the distal humerus and their
complications. J Shoulder Elbow Surg 1999;8:85–97.
54. Gabel GT, Hanson G, Bennett JB, Nobel PC, Tulos HS. Intra-articular
fractures of the distal humerus in the adult. Clin Orthop Relat Res
1987;216:99–108.
55. Papaioannou N, Babis GC, Kalavritinos J, Pantazopoulos T. Operative
treatment of type C intra-articular fractures of the distal humerus: the
role of stability achieved at surgery on final outcome. Injury 1995;
26:169–73.
56. Pajarinen J, Björkenheim JM. Operative treatment of type C inter-
condylar fractures of the distal humerus: results after a mean follow-up
of 2 years in a series of 18 patients. J Shoulder Elbow Surg 2002;
11:48–52.
57. Ozdemir H, Urgüden M, Söyüncü Y, Aslan T. Long-term functional
results of adult intra-articular distal humeral fractures treated by open
reduction and plate osteosynthesis. Acta Orthop Traumatol Turc
2002;36:328–35.
58. Aslam N, Willett K. Functional outcome following internal fixation of
intra-articular fractures of the distal humerus (AO type C). Acta
Orthop Belg 2004;70:118–22.
59. Wafai AM, Tank GG, Holdsworth BJ. Outcome of primary internal fixa-
tion of (type C) distal humerus fractures in the elderly. Eur J Orthop
Surg Traumatol 2006;16:114–9.
60. Werner CML, Ramsier LE, Trentz O, Heinzelmann M. Distal humeral
fractures of the adult. Eur J Trauma 2006;32:264–70.
61. Korner J, Lill H, Müller LP, Rommens PM, Schneider E, Linke B. The
LCP-concept in the operative treatment of distal humerus fractures—
biological, biomechanical and surgical aspects. Injury 2003;
34(Suppl 2):B20–30.
62. Schuster I, Korner J, Arzdorf M, Schwieger K, Diederichs G, Linke B.
Mechanical comparison in cadaver specimens of three different
90-degree double-plate osteosyntheses for simulated C2-type distal
humerus fractures with varying bone densities. J Orthop Trauma
2008;22:113–20.
63. Athwal GS, Goetz TJ, Pollock JW, Faber KJ. Prosthetic replacement for
distal humerus fractures. Orthop Clin North Am 2008;39:201–12.
64. Brinker MR, O’Connor DP, Crouch CC, Mehlhoff TL, Bennett JB. Ilizarov
treatment of infected non-unions of the distal humerus after failure of
internal fixation: an outcomes study. J Orthop Trauma 2007;21:178–84.
65. Kamineni S, Morrey BF. Distal humeral fractures treated with non-
custom total elbow replacement. Surgical technique. J Bone Joint
Surg Am 2005;87(Suppl 1):1–50.
66. Müller LP, Kamineni S, Rommens PM, Morrey BF. Primary total elbow
replacement for fractures of the distal humerus. Oper Orthop
Traumatol 2005;17:119–42.
65