This approach is chosen as it gives adequate exposure for these fractures, avoids disruption to the extensor mechanism and can still be converted to an olecranon osteotomy if greater exposure of the articular surface becomes required. At our institution, for management of an extra-articular fracture (AO type A) or limited articular involvement (type B1/B2), we utilise the triceps sparing approach. Bryan and Morrey described a triceps reflecting technique that spares the triceps mechanism by reflecting from medial to the lateral direction and has the advantage of avoiding damage to the extensor mechanism. The triceps splitting approach was first described by Campbell but has the potential to result in triceps weakness. In addition, an olecranon osteotomy carries the risk of non-union, future need for the removal of metalwork and potentially limiting any future arthroplasty. Despite the olecranon osteotomy providing the greatest exposure of the distal articular surface, 40% of the anterior surface remained unvisualised. Stanley demonstrated that the trans-olecranon approach gave the best articular exposure the median percentages of visible distal humeral articular surface for the triceps splitting, triceps reflection, and olecranon osteotomy approaches were 35%, 46% and 57%, respectively. Numerous surgical approaches to the distal humerus have been described, each conferring differing advantages in terms of exposure and soft tissue disruption. This review will cover the anatomy and classification of distal humerus fractures, investigations and the treatment options for distal humerus fractures including discussion surrounding these controversial areas. Currently controversy exists over several issues of operative management including the optimal surgical approach, plate orientation, management of the ulnar nerve and the role of elbow arthroplasty. The goals of surgical treatment are to restore articular congruity and bone alignment whilst providing rigid, stable fixation that enables early active motion. In an elderly population, internal fixation has been reported to result in better function than those managed non-operatively. Operative fixation has been shown to give satisfactory results with long term follow up demonstrating good or excellent outcome in 86%. Evolution in implant design and surgical technique has led to improved outcomes in operatively treated patients and has resulted in fixation being the current standard of care. Historically, these injuries have been treated non-operatively although most studies report this management to be associated with significant functional impairment.
Treatment of these injuries is challenging due to fracture comminution, poor bone quality and difficulty in restoring the complex anatomy of the distal humerus. Loss of this movement can severely affect activities of daily living and lead to a loss of independence in the elderly population. Treatment is aimed at restoring a functional elbow, which Morrey described as requiring 30 to 130 degree range of motion. reported a 5 fold increase in distal humerus fractures between 19. Although relatively rare, the incidence of these fractures is rising as Pavlanen et al. The injuries are distributed in a bi-modal fashion with the first peak being seen in the young resulting from high-energy trauma and the second peak being seen in the elderly osteoporotic population. Distal humerus fractures constitute 2% of all fractures in the adult population.
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