^{PATIENT HISTORY AND PHYSICAL FINDINGS}

 

^{Distal humerus fractures occur in two age groups:}

 

 

 

^{Younger patients who sustain high-energy trauma Older patients with underlying osteopenia}

 

^{Comminution is the dominant feature of supracondylar and intercondylar fractures and complicates internal fixation. The complicated skeletal geometry of the distal humerus also contributes.}

 

^{The goals of the initial evaluation are to}

 

 

^{Understand the fracture pattern}

 

 

 

^{Determine the existence of previous symptomatic elbow pathology Determine the extent of associated soft tissue (open fractures) Identify associated musculoskeletal or neurovascular injuries}

^{IMAGING AND OTHER DIAGNOSTIC STUDIES}

 

^{Elbow radiographs in the anteroposterior and lateral planes are the first imaging studies obtained and should be carefully scrutinized to identify the fracture lines and fragments as well as the extent of comminution. It is also important to look for associated injuries in the proximal radius and ulna.}

 

^{A complete understanding of the fracture pattern is difficult to obtain based only on simple radiographs because of the complex geometry of the distal humerus and fragment overlapping (FIG 1A,B).}

 

^{Computed tomography (CT) with three-dimensional reconstruction is extremely helpful, especially in the more complex cases. It allows the surgeon to look for specific fractured fragments at the time of fixation, facilitating accurate fracture reduction (FIG 1C,D).}

 

 

 

^{FIG 1 • A,B. Anteroposterior (AP) and lateral radiographs showing a comminuted intra-articular supraintercondylar fracture of the distal humerus. The complexity of the fracture is difficult to appreciate fully because of the geometry of the distal humerus, fracture comminution, and fragment overlapping. C,D. The use of CT with three-dimensional reconstruction and surface rendering helps understand the fracture configuration and anticipate the surgical findings.}

 

 

^{Traction radiographs obtained in the operating room with the patient under anesthesia just before surgery also can be helpful, especially if a CT scan is not available.}

 

^{SURGICAL MANAGEMENT}

 

 

^{Internal fixation is the treatment of choice for most fractures of the distal humerus. Modern fixation techniques seem to benefit from the following:}

 

 

^{Fixation strategies designed to improve the mechanical stability of the construct Use of precontoured periarticular plates}

 

^{Use of screws locked to the plates}

 

^{Elbow arthroplasty should be considered in elderly patients with previous elbow pathology or in very low comminuted fractures in patients with osteopenia.12, 14 However, internal fixation can be successful even in low transcondylar fractures.18}

 

^{The goal of the internal fixation technique is to achieve a construct stable enough to allow immediate unprotected motion without fear of redisplacement.15, 16 This can be attained in most distal humerus fractures—even the most complex—provided the following principles are}

^{adhered to the following ( FIG 2):}

 

 

^{Plates used for internal fixation are applied so that fixation in the distal fragments is maximized.}

 

 

²⁴⁴

 

 

 

^{FIG 2 • A. Internal fixation using two parallel medial and lateral plates allows maximal fixation of the plates in the distal fragments and increased stability at the supracondylar level. B. This postoperative AP radiograph shows anatomic reduction of a complex distal humerus fracture and stable fixation using the principles and technique described in this chapter. The olecranon osteotomy was fixed with a plate. (A: Copyright Mayo Clinic.)}

 

 

^{Distal screw fixation contributes to stability at the supracondylar level, where true interfragmentary compression is achieved.}

 

^Approaches

 

^{Adequate exposure is necessary to achieve satisfactory reduction and fixation.}

 

^{The management of the ulnar nerve is controversial; some surgeons favor routine subcutaneous transposition, whereas others prefer to leave the nerve in its anatomic location at the end of the procedure. A number of patients will develop a transitory or permanent ulnar neuropathy, mostly sensitive, regardless of nerve management; preoperative counseling is important in this regard.}

 

 

^{Most fractures require mobilization of the extensor mechanism of the elbow through an olecranon osteotomy, triceps reflection, or triceps split. Simple fractures occasionally may be addressed working on both sides of the triceps without mobilization of the extensor mechanism.}

 

^{Olecranon osteotomy is the preferred surgical approach for internal fixation for most distal humerus fractures.13}

 

 

^Advantages

 

 

^{Provides excellent exposure}

 

 

^{Offers the potential of bone-to-bone healing, thereby limiting the risk of triceps dysfunction Disadvantages}

 

 

^{Complications: nonunion, intra-articular adhesions Hardware removal may be needed.}

 

 

^{Limits the ability for intraoperative conversion to elbow arthroplasty May devitalize the anconeus muscle}

 

^{The proximal ulna cannot be used as a template to judge reduction and motion.}

 

 

^{Triceps reflection and triceps split9 allow preservation of the intact ulna.}

 

 

^{Avoid complications related to olecranon osteotomy.}

 

^{Facilitate intraoperative conversion to total elbow arthroplasty.}

 

^{Allow use of the proximal ulna as a template for reduction of the distal humerus articular surface.}

 

^{Allow assessment of extension deficit after fracture fixation, which is especially useful in fractures requiring metaphyseal shortening.}

 

^{Bilaterotricipital approach1}

 

 

^{Goals and indications}

 

 

^{The goal is to provide adequate exposure for fracture fixation without violating the extensor mechanism.}

 

^{This approach is used only for the more simple fracture patterns (eg, extra-articular or simple intra-articular distal humerus fractures [AO/OTA A, C1, C2]) or when elbow arthroplasty is being considered.}

 

^Advantages

 

 

 

^{This approach avoids complications related to the extensor mechanism. No postoperative protection is needed.}

 

 

^{Surgical time is decreased. Disadvantage}

 

^{The procedure provides limited exposure of the articular surface.}

 

^TECHNIQUES

• ^{Surgical Approach}

  ^{Olecranon Osteotomy}

   

  ^{Chevron osteotomy provides increased stability (TECH FIG 1A).}

   

   

  ^{The distal apex of the chevron osteotomy is centered with the bare area of the olecranon articular surface. The anconeus is divided with electrocautery in line with the lateral limb of the osteotomy.}

   

  ^{Alternatively, the anconeus may be preserved by dissecting it free on its distal aspect and reflecting it proximally attached to the proximal ulnar fragment.2}

   

  ^{Start the osteotomy with a thin oscillating saw; use of a thick saw blade removes bone excessively, which may make it more difficult to obtain interfragmentary compression at the time of olecranon osteotomy fixation and thus increase the risk of olecranon osteotomy nonunion.}

   

  ^{Complete the osteotomy with an osteotome.}

   

  ^{Decreases risk of damage to the articular cartilage on ulna and humerus}

   

   

  ^{Creates irregularities at the opposing cut surfaces, which may increase interdigitation Mobilize the fragment to facilitate exposure (TECH FIG 1B).}

   

  ^{Fixation (TECH FIG 1C)}

   

  ^{Some biomechanical studies support the combination of a 7.3-mm cancellous screw and tension band over either a screw alone or K-wires plus tension band; others have found no differences.}

   

  ²⁴⁵

   

   

   

  ^{TECH FIG 1 • Olecranon osteotomy provides an excellent exposure for distal humerus fracture fixation. A. A chevron osteotomy is initiated with a microsagittal saw and completed with an osteotome. Drilling and tapping before performing the osteotomy facilitates fixation of the osteotomy if screw fixation is selected. B. Proximal mobilization of the osteotomized fragment and triceps allows ample exposure of the articular surface and columns. C. Fixation may be performed with a cancellous screw and tension band, wires and a tension band, or a plate.}

   

  ^{The author's preferred method uses K-wires plus a tension band in patients with good bone quality and plate fixation in patients with osteopenia.}

   

  ^{If screw fixation is planned, drill and tap the ulna before performing the osteotomy.}

   

  ^{Plate fixation provides improved fixation, but the risk of wound complications is increased.}

   

  ^{There is substantial interest in the development of intramedullary fixation devices locked proximally and distally; they would combine the benefits of stability and intramedullary location, which could lead to a decreased rate of wound complications and painful hardware requiring removal.}

  ^{Triceps Reflection and Triceps Split}

   

  ^{Bryan-Morrey triceps-sparing approach (TECH FIG 2)}

   

   

  ^{The triceps is elevated from the medial intermuscular septum and the posterior aspect of the humeral shaft. The forearm fascia and periosteum are incised just lateral to the flexor carpi ulnaris.}

   

  ^{The triceps, forearm fascia, and anconeus are elevated in continuity from medial to lateral.}

   

  ^{When this approach is used for fracture fixation, the anterior bundle of the medial collateral ligament and the lateral ulnar collateral ligament must be preserved to avoid postoperative instability.}

   

  ^{Mayo-modified extensile Kocher approach}

   

   

  ^{The triceps is elevated from the lateral intermuscular septum and the posterior aspect of the humeral shaft. The triceps and anconeus are elevated in continuity from lateral to medial.}

   

  ^{As noted earlier, the anterior bundle of the medial collateral ligament and the lateral ulnar collateral ligament must be preserved to avoid postoperative instability.}

  ^{Bilaterotricipital Approach}

   

  ^{The triceps is elevated from the medial and lateral intermuscular septae.}

   

  ^{Lateral dissection can be extended anterior to the anconeus muscle (TECH FIG 3).}

   

  ^{The arthrotomy is performed posterior to the medial collateral ligament and lateral collateral ligament complex.}

   

   

   

  ^{TECH FIG 2 • The extensor mechanism (ie, triceps, anconeus, and forearm fascia) may be elevated off the ulna subperiosteally in continuity from medial to lateral (Bryan-Morrey approach) or from lateral to medial (Mayo-modified extensile Kocher approach).}

   

   

  ²⁴⁶

   

   

  ^{TECH FIG 3 • Fractures with no or limited articular involvement may be fixed working on both sides of the triceps. As shown in this image, the extensor mechanism is left mostly undisturbed.}

• ^{Internal Fixation}

  ^{Technical Objectives}

   

   

  ^{Screws in the distal fragments (articular segment) should be placed according to the following principles: Every screw should pass through a plate.}

   

  ^{Each screw should engage a fragment on the opposite side that also is fixed to a plate.}

   

   

  ^{As many screws as possible should be placed in the distal fragments. Each screw should be as long as possible.}

   

  ^{Each screw should engage as many articular fragments as possible.}

   

  ^{The screws should lock together by interdigitation within the distal segment, thereby rigidly linking the medial and lateral columns together, creating an architectural structure similar to that of an arch or dome.}

   

   

   

  ^{TECH FIG 4 • A. Anatomic reduction of the articular surface is maintained provisionally with fine wires placed so that they will not interfere with plate and screw application. B. The medial and lateral plates are held in place provisionally with two distal 2.0-mm pins (which later will be replaced by screws) and two proximal screws through an oval hole to allow small adjustments in plate positioning. (Copyright Mayo Clinic.)}

   

  ^{Plates are used for fixation.}

   

  ^{Plates should be applied such that compression is achieved at the supracondylar level for both columns.}

   

  ^{Plates must be strong enough and stiff enough to resist breaking or bending before union occurs at the supracondylar level.}

  ^{Provisional Assembly of the Articular Surface and Plate Placement}

   

  ^{Reduce the articular surface fragments anatomically.}

   

  ^{The proximal ulna and radial head may be used as templates.}

   

  ^{Rotational alignment should be carefully assessed.}

   

   

  ^{Use smooth K-wires to maintain the reduction provisionally (TECH FIG 4A).}

   

   

  ^{Two 2.0-mm smooth wires introduced at the medial and lateral epicondyles facilitate provisional placement of the plates and can be replaced by screws later.}

   

  ^{Fine-threaded wires, absorbable pins or very small screws may be used for definitive fixation of small fracture fragments.}

   

  ^{Medial and lateral plates are placed so that one of the distal holes of each plate slides over the medial and lateral 2.0-mm smooth wires introduced at the medial and lateral epicondyles (TECH FIG 4B).}

   

  ²⁴⁷

   

  ^{One cortical screw is loosely introduced into a slotted hole of each plate to hold the plates in place; use of slotted holes for these screws facilitates later adjustments in plate positioning.}

  ^{Articular and Distal Fixation}

   

  ^{Two or more distal screws are inserted through the plates medially and laterally. As noted, the screws should be as long as possible and engage fragments on the opposite column.}

   

  ^{Before screw application, a large bone clamp is used to compress the articular fracture lines, unless there is comminution of the articular surface.}

   

  ^{The two 2.0-mm smooth pins may be replaced with distal screws without previous drilling to avoid accidental breakage of the drill when contacting the other screws. Usually, these last screws will interdigitate with the previously applied distal screws, thereby increasing the stability of the construct (TECH FIG 5).}

  ^{Supracondylar Compression and Proximal Plate Fixation}

   

  ^{The proximal screw on one side is backed out, and a large bone clamp is applied distally on that side and proximally on the opposite side to apply maximum compression at the supracondylar level. Compression is maintained by application of one proximal screw in the compression mode (TECH FIG 6A,B).}

   

   

   

  ^{TECH FIG 5 • Maximal distal plate anchorage is then achieved by insertion of multiple long screws through the plates and into the distal fragments. Usually, the screws from the medial and lateral directions will engage, creating an interlocked structure that increases fracture stability. (Copyright Mayo Clinic.)}

   

   

  ^{TECH FIG 6 • A,B. Supracondylar compression is achieved with the use of a large clamp, insertion of screws in the compression mode, and slight undercontouring of the plates. The same technique is applied laterally and medially. (continued)}

   

  ^{The same steps are followed on the opposite side.}

   

  ^{The remaining diaphyseal screws are then introduced, providing additional compression as they push the undercontoured plates to gain intimate contact with the underlying bone (TECH FIG 6C).}

   

   

  ^{Small posterior fragments can be fixed with threaded wires or absorbable pins. Provisional wires are removed.}

   

  ^{The elbow is put through range of motion. Motion should be smooth. If extension is limited, part of the tip of the olecranon may be removed.}

   

   

  ²⁴⁸

   

   

   

  ^{TECH FIG 6 • (continued) C. Internal fixation of a complex distal humerus fracture. (A,B: Copyright Mayo Clinic.)}

• ^{Supracondylar Shortening}

 

^{In cases with supracondylar comminution (ie, bone loss), compression at the supracondylar level cannot be achieved unless the humerus is shortened into a nonanatomic reduction that will provide adequate bone contact (TECH FIG 7A,B).}

 

^{The humerus may be shortened between a few millimeters and 2 cm with only minor losses in extension strength.10}

 

^{Bone is trimmed from the diaphysis to ensure adequate bone contact with the distal fragments. The distal fragments are typically already small, and further removal from these distal fragments should be avoided.}

 

^{TECH FIG 7 • In cases of severe supracondylar comminution, adequate interfragmentary contact and compression takes priority over anatomic reduction. The humerus may be shortened anywhere from a few millimeters to 2 cm by trimming the bony spikes of the diaphysis (A), advancing the distal segment proximally and anteriorly, and fixing it in a nonanatomic fashion (B). C. The olecranon fossa is recreated in this case by removing bone from the posterior aspect of the diaphysis with a burr. (A,B: Copyright Mayo Clinic.)}

^{The distal fragments are translated proximally and anteriorly. Anterior translation is necessary to create room for the radial head and the coronoid in flexion.}

^{The fracture is fixed in the desired position using the technique described previously.}

^{A new deep and wide olecranon fossa is created by removing bone from the distal and posterior aspect of the diaphysis (TECH FIG 7C). Otherwise, extension will be restricted.}

 

^Olecranon

^osteotomy

• ^{Position the apex of the osteotomy distally.}

• ^{Use a thin oscillating saw to minimize bone loss.}

• ^{If plate fixation is preferred, consider drilling the holes for the plate before beginning the osteotomy. This facilitates plate fixation of the osteotomy at the conclusion of the surgery.}

• ^{Similarly, if tension band fixation with an intramedullary screw is preferred, predrill and tap the screw hole.}

^{Triceps reflection}

^{and triceps split}

• ^{Subperiosteal detachment of the extensor mechanism is critical to preserve its thickness and facilitate a strong}

  ^{reattachment.}

• ^{Reproduce anatomic reattachment of the extensor mechanism.}

• ^{Use heavy, nonabsorbable suture (no. 5 Ethibond [Ethicon, Inc., Somerville, NJ] or no. 2 FiberWire [Arthrex, Inc., Naples, FL]) through bone.}

• ^{Protect extension against resistance for 6 weeks.}

^{Bilaterotricipital}

^approach

• ^{Separate the triceps from the underlying medial and lateral joint capsules.}

• ^{Resect the posterior capsule and fat pad to improve visualization.}

 

 

²⁴⁹

 

^{PEARLS AND PITFALLS}

 

 

^{POSTOPERATIVE MANAGEMENT}

 

^{After closure, the elbow is placed in a bulky, noncompressive dressing with an anterior plaster splint to maintain the elbow in extension, and the upper extremity is kept elevated.}

 

^{In patients with severe swelling, open fractures or compromised soft tissues consideration should be given to an incisional or standard vacuum-assisted closure device.}

 

^{Motion is initiated according to the extent of soft tissue damage. Motion usually can be initiated on the first or second postoperative day, but it may be necessary to wait for several days in the case of open fractures or severe soft tissue damage.}

 

^{Most patients benefit from a program of continuous passive motion for the first week or two after fixation; some may benefit from a longer period of passive motion.}

 

^{When postoperative motion fails to progress as expected, a program of patient-adjusted static flexion and extension splints is implemented.}

 

 

 

 

 

 

 

^{Treatment with indomethacin or single-dose radiation to the soft tissues shielding the fracture site may be considered for patients with high risk of heterotopic ossification, such as those with associated head or spinal trauma as well as those who require several surgeries in a short period of time. However, failure to shield the fracture site or the olecranon osteotomy seems to lead to a higher rate of nonunion.}

 

^OUTCOMES

^{The results of internal fixation for fractures of the distal humerus using modern techniques are summarized in Table 1.}

^{The results of the different studies are difficult to interpret because the severity of the injuries included cannot be compared, and there may be variations in the accuracy of range-of-motion measurements.}

^{Improvements in fixation techniques have resulted in a decreased rate of hardware failure and nonunion, but range of motion is not reliably restored in every patient. In addition, other complications remain relatively common8 as detailed below.}

 

 

COMPLICATIONS Infection Nonunion Stiffness, with or without heterotopic ossification Need for removal of the hardware used for fixation of the olecranon osteotomy Ulnar neuropathy Posttraumatic osteoarthritis or avascular necrosis requiring interposition arthroplasty or elbow replacement     250

Table 1 Results of Internal Fixation for Distal Humerus Fractures Affecting the Humeral Columns     Mean Fracture Mean Age Follow- Type (no.) Degrees (Range) up (AO ROM Overall Complications Reoperations Study No. (y) (mo) Classification) Open (range) results (no.) (no.)     Jupiter et 34 57 (17- 70 (25- C1 (13) 14 76% 79% Nonunion (2) Hardware al5 79) 139) C2 (2) (41%) achieved satisfactory* Refracture (1) removal (24) C3 (19) at least Olecranon Capsulectomy 30-120 osteotomy (3) nonunion (2) HO removal Class II HO (1) (1) Nerve Ulnar decompression neuropathy (4) (4) Median neuropathy (1)     Henley et 33 32 (15- 18.3 C1 (23) 14 Mean 92% Hardware Repeat ORIF al4 61) C2 (8) (42%) extension, satisfactory* failure (5) (2) C3 (2) 19; mean (only 25 Infection (2) TBW removal flexion, patients Olecranon (6) 126 evaluated) osteotomy Olecranon nonunion (2) osteotomy Class II HO repeat (2) ORIF (2)     Sanders 17 51 (12- >24 C1 (4) 7 108 (55- 76% Delayed Hardware et al17 85) C2 (3) (41%) 140) satisfactory* union (2) removal (3) C3 (10) Infection (2) Ulnar nerve Pulmonary decompression embolism (1) (1) Ulnar neuropathy

 

								(1)
McKee et	25	47 (19-	37 (18-	C (25)	None	108 (55-	Mean	Ulnar neuritis	TBW removal
al (closed		85)	75)			140)	DASH: 20	(3)	(3)

^fractures)7

^(0-55)

^Transient

^{Repeat ORIF}

								radial nerve palsy (1) Nonunion (1) Malunion (1)	(1) Elbow release (2)
McKee et	26	44 (17-	51 (10-	C1 (5)	100%	97 (55-	Mean	Septic	Repeat ORIF
al (open		78)	141)	C2 (13)		140)	DASH: 23.7	nonunion (1)	(3)
fractures)6				C3 (8)			(0-57.5) 60%	Delayed union (4)
							satisfactory	Transient
							MEPS	radial nerve
								palsy (1)
Pajarinen	21	44 (16-	24 (10-	C1 (6)	5	107 (98-	56%	Deep	Repeat ORIF

^{et al11}

⁸¹⁾

⁴¹⁾

^{C2 (12)}

^(24%)

¹¹⁶⁾

^satisfactory

^{infection (1)}

⁽²⁾

				C3 (3)			OTA	Nonunion (2) Traumatic nerve injuries (3)
								Olecranon
								osteotomy
								nonunion (1)
Gofton et	23	53 (16-	45 (14-	C1 (3)	7	122	Mean	Deep	Olecranon

^al3

⁸⁰⁾

⁸⁹⁾

^{C2 (11)}

^(30%)

^(extension

^{DASH: 12}

^{infection (1)}

^osteotomy

				C3 (9)		loss, 19 ±	(0-38)	Olecranon	repeat
						12;	Subjective	osteotomy	ORIF (2)
						flexion,	satisfaction:	nonunion (2)	Elbow release
						142 ± 6)	93% 87%	Class II HO	(3)
							satisfactory	(3)	Capitellar
							MEPS	Avascular	ORIF (1)
								necrosis (1)
								Reflex
								sympathetic
								dystrophy (1)
								Capitellar
								nonunion (1)
Soon et	15	43 (21-	12 (2-	B (3)	None	109 (45-	86%	Transient	Total elbow
al19		80)	27)	C1 (4) C2 (4)		145)	satisfactory MEPS	ulnar neuritis (2)	arthroplasty (1) Repeat ORIF
				C3 (4)				Hardware	(3)
								failure (3)	Elbow
								Nonunion (1)	manipulation
									or release (4)
Sanchez-	32	58 (16-	24 (12-	A3 (3)	13	Mean	83%	Delayed	Wound
Sotelo et		99)	60)	C2 (4)	(44%)	extension:	satisfactory	union (1)	débridement or
al15				C3 (25)		26 (0-55) Mean	MEPS	Ulnar neuropathy	coverage (4) Bone grafting
						flexion:		(6)	(1)
						124 (80-		Class II HO	HO removal
						150)		(5)	(4)
								Infection (1)	HO removal
									and distraction
									arthroplasty (1)
									Triceps
									reconstruction
									(1)

 

 

 

	ROM, range of motion; Class II HO, heterotopic ossification restricting motion; ORIF, open reduction and internal fixation; TBW, tension band wiring; DASH, Disabilities of the Arm, Shoulder and Hand questionnaire; MEPS, Mayo Elbow Performance Score; OTA, Orthopaedic Trauma Association.   *According to the Jupiter rating system.

 

 

 

 

^REFERENCES

²⁵¹

1. ^{Alonso-Llames M. Bilaterotricipital approach to the elbow. Its application in the osteosynthesis of supracondylar fractures of the humerus in children. Acta Orthop Scand 1972;43:479-490.}

    

    

2. ^{Athwal GS, Rispoli DM, Steinmann S The anconeus flap transolecranon approach to the distal humerus. J Orthop Trauma 2006;20: 282-285.}

    

    

3. ^{Gofton WT, Macdermid JC, Patterson SD, et al. Functional outcome of AO type C distal humeral fractures. J Hand Surg Am 2003;28:294-308.}

    

    

4. ^{Henley MB, Bone LB, Parker B. Operative management of intra-articular fractures of the distal humerus. J Orthop Trauma 1987;1:24-35.}

    

    

5. ^{Jupiter JB, Neff U, Holzach P, et al. Intercondylar fractures of the humerus. An operative approach. J Bone Joint Surg Am 1985;67:226-239.}

    

    

6. ^{McKee MD, Kim J, Kebaish K, et al. Functional outcome after open supracondylar fractures of the humerus. The effect of the surgical approach. J Bone Joint Surg Br 2000;82(5):646-651.}

    

    

7. ^{McKee MD, Wilson TL, Winston L, et al. Functional outcome following surgical treatment of intra-articular distal humeral fractures through a posterior approach. J Bone Joint Surg Am 2000;82-A(12): 1701-1707.}

    

    

8. ^{Lawrence TM, Ahmadi S, Morrey BF, et al. Wound complications after distal humerus fracture fixation: incidence, risk factors and outcome. J Shoulder Elbow Surg 2014;23(2):258-264.}

    

    

9. ^{Morrey BF. Anatomy and surgical approaches. In: Morrey BF, ed. Joint Replacement Arthroplasty. Philadelphia: Churchill-Livingstone, 2003:269-285.}

    

    

10. ^{O'Driscoll SW, Sanchez-Sotelo J, Torchia ME. Management of the smashed distal humerus. Orthop Clin North Am 2002;33:19-33.}

     

     

11. ^{Pajarinen J, Björkenheim JM. Operative treatment of type C intercondylar 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.}

     

     

12. ^{Popovic D, King GJ. Fragility fractures of the distal humerus: what is the optimal treatment? J Bone Joint Surg Br 2012 94(1):16-22.}

     

     

13. ^{Ring D, Gulotta L, Chin K, et al. Olecranon osteotomy for exposure of fractures and nonunions of the distal humerus. J Orthop Trauma 2004;18:446-449.}

     

     

14. ^{Sanchez-Sotelo J. Distal humeral fractures: role of internal fixation and elbow arthroplasty. J Bone Joint Surg Am 2012;94(6):555-568.}

     

     

15. ^{Sanchez-Sotelo J, Torchia ME, O'Driscoll SW. Complex distal humeral fractures: internal fixation with a principle-based parallel-plate technique. J Bone Joint Surg Am 2007;89(5):961-969.}

     

     

16. ^{Sanchez-Sotelo J, Torchia ME, O'Driscoll SW. Principle-based internal fixation of distal humerus fractures. Tech Hand Upper Extremity Surg 2001;5:179-187.}

     

     

17. ^{Sanders RA, Raney EM, Pipkin S. Operative treatment of bicondylar intraarticular fractures of the distal humerus. Orthopedics 1992;15: 159-163.}

     

     

18. ^{Simone JP, Streubel PN, Sanchez-Sotelo J, et al. Low transcondylar fractures of the distal humerus: results of open reduction and internal fixation. J Shoulder Elbow Surg 2014;23(4):573-578.}

     

     

     

     

19. ^{Soon JL, Chan BK, Low CO. Surgical fixation of intra-articular fractures of the distal humerus in adults. Injury 2004;35:44-54.}