Standard fixation for intra-articular distal humerus fracture is open reduction and internal fixation (ORIF). However, high energy fractures of the distal humerus are often accompanied with soft tissue injuries and or vascular injuries which limits the use of internal fixation. In our report, we describe a highly complex distal humerus fracture that showed promising healing via a ring external fixator. A 26-year-old man sustained a Gustillo Anderson Grade IIIB intra-articular distal humerus fracture of the non-dominant limb with bone loss at the lateral column. The injury was managed with aggressive wound debridement and cross elbow stabilization via a hinged ring external fixator. Post operative wound managed with foam dressing. Post-operatively, early controlled mobilization of elbow commenced. Fracture union achieved by 9 weeks and frame removed once fracture united. No surgical site infection or non-union observed throughout follow up. At 2 years follow up, flexion - extension of elbow is 20°- 100°, forearm supination 65°, forearm pronation 60° with no significant valgus or varus deformity. The extent of normal anatomic restoration in elbow fracture fixation determines the quality of elbow function with most common complication being elbow stiffness. Ring fixator is a non-invasive external device which provides firm stabilization of fracture while allowing for adequate soft tissue management. It provides continuous axial micro-movements in the frame which promotes callus formation while avoiding translation or angulation between the fragments. In appropriate frame design, they allow for early rehabilitation of joint where normal range of motion can be allowed in controlled manner immediately post-fixation. Functional outcome of elbow fracture from ring external fixation is comparable to ORIF due to better rehabilitation and lower complications. Ring external fixator in our patient achieved acceptable functional outcome and fracture alignment meanwhile the fracture was not complicated with common complications seen in ORIF. In conclusion, ring external fixator is as effective as ORIF in treating complex distal humeral fractures and should be considered for definitive fixation in such fractures

The aim of this abstract is to show that acute osteomyelitis is one of the most feared complication of orthopedic surgery. A rapid and aggressive treatment is mandatory in order to avoid significant bone loss, joint destruction and, in most cases, salvage of the limb. After apparent cure of the infection, sequelae must be addressed. In this case, the joint destruction was important, so reconstruction procedures where impossible. In a superficial and relatively small joint such as the elbow, it is preferred to do an arthrodesis than an arthroplasty because the risk of reactivation of the infection with implant involvement is very important.

We present a case report of a 69 years old woman, who had a supra-intra-condylar fracture (AO 13-C1) of the right humerus. She was treated with open reduction and internal fixation with 2 internal lag screws and 2 external lag screws. After 6 weeks, she was admitted with a dislocated elbow associated with pain, loss of limb function, cubita nerve palsy and a purulent discharge from the surgical wound. She started vancomycin and was submitted to surgery with debriment, hardware removal and fixation with an external fixator was used. The local signs of infection disappeared progressively. After normalization of the laboratory parameters of infection, the patient was submitted to an elbow arthrodesis using a posterior contour plate.

The elbow achieved solid fixation and infection was eradicated, at least for the time being, allowing the patient to use the upper limb in her daily live activities.

The treatment of post operative acute osteomyilits is challenging, In this case, after apparent solution of the infection, a solid fixation of the elbow was achieved, allowing the use of the upper limb in the patient daily activities.

Objectives. Distal humerus fractures in elderly population are often comminuted and presents multiple challenges. When managed with fixation the results are often complicated with stiffness, pain, and reduced function while total elbow replacement is fraught with lifelong restrictions on load bearing which can significantly affect elderly patients who rely assistive devices for ambulation. Elbow hemiarthroplasty however, presents a viable alternative in these cases. This series evaluates the results of the distal humerus hemiarthroplasty in a single centre. Designs and methods. Data was collected retrospectively. Comprehensive case reviews were done to collect demographic, intra-operative and post-operative data. Fractures were classified as per AO classification. The primary outcome was functional outcome and range of motion (ROM). The secondary outcomes were complications and patient satisfaction. Results. 22 cases were included in this study from 2016 – 2023 majority being females (n=18). Mean age was 74years (SD −11.2). Majority fractures were AO type C3 (n=15) with two A2 type fractures managed for non-union. Pre-existing bone on bone arthritis was present in 3 cases and CT scan was done for 12 patients to assess fracture configuration. Excluding those treated for non- union the median time between fracture and surgery was 8.5 days. Follow-up of more than 6 months was available for 16 patients with median follow-up of 18 months. ROM was available for 17 patients with 13 (50%) patients having functional ROM. No patients had full extension and there was a mean lag of 20. 0. Mean flexion was 118.2. 0. Nearly 2/3. rd. patients (73%- n=16) were satisfied with the surgery with no problems in activity of daily living. Complications seen were ulnar neuropathy (n=3), heterotopic ossification(n=2) and periprosthetic fracture (n=1). Conclusion. This single centre study suggests good outcomes following distal humerus hemiarthroplasty. It is a reasonable alternative to fixation and total elbow arthroplasty in complex fractures

Advancements in treating distal humerus fractures. We will review and discuss approaches to the elbow to treat different types of fractures. We will discuss the role of soft tissue structures and how they affect elbow function. During this session, we will review the latest techniques for treating the complex articular fractures of the distal humerus to include capitellar and trochlear fractures. Techniques presented will address fixation, reconstruction, and salvaging of complex distal humerus fractures

Olecranon Osteotomy is a common approach used in the management of intraarticular distal humerus fractures. Significant complication rates have been associated with this procedure, including non-union rates of 0–13% and implant removal rates between 12–86%. This study is a multicentre retrospective study involving the largest cohort of olecranon osteotomies in the literature, examining implant fixation types, removal rates and associated complications. Patients were identified between 2007 and 2017 (minimum one year follow-up) via Canadian Classification of Health Interventions (CCI) coding and ICD9/10 codes by our health region's data information service. CCI intervention codes were used to identify patients who underwent surgery for their fracture with an olecranon osteotomy. Reasons for implant removal were identified from a chart review. Our primary outcome was implant removal rates. Categorical data was assessed using Chi square test and Fischer's Exact test. Ninety-nine patients were identified to have undergone an olecranon osteotomy for treatment of a distal humerus fracture. Twenty patients had their osteotomy fixed with a plate and screws and 67 patients were fixed with a tension band wire. Eleven patients underwent “screw fixation”, consisting of a single screw with or without the addition of a wire. One patient had placement of a cable-pin system. Of patients who underwent olecranon osteotomy fixation, 34.3% required implant removal. Removal rates were: 28/67 for TBW (41.8%), 6/20 plates (30%), 0/1 cable-pin and 0/11 for osteotomies fixed with screw fixation. Screw fixation was removed less frequently than TBW p<.006. TBW were more commonly removed than all other fixation types p<.043. Screws were less commonly removed than all other fixation types p<.015. TBW were more likely to be removed for implant irritation than plates, p<.007, and all other implants p<.007. The average time to removal was 361 days (80–1503 days). A second surgeon was the surgeon responsible for the removal in 10/34 cases (29%). TBWs requiring removal were further off the olecranon tip than those not removed p=.006. TBWs were associated with an OR of 3.29 (CI 1.10–9.84) for implant removal if implanted further than 1mm off bone. Nonunion of the osteotomy occurred in three out of 99 patients (3%). K-wires through the anterior ulnar cortex did not result in decreased need for TBW removal. There was no relation between plate prominence and the need for implant removal. There was no association between age and implant removal. The implant removal rate was 34% overall. Single screw fixation was the best option for osteotomy fixation, as 0/11 required hardware removal, which was statistically less frequent than TBW at 28/67. Screw fixation was removed less frequently than TBW and screw fixation was less commonly removed than all other fixation types. Only 6/20 (30%) plates required removal, which is lower than previously published rates. Overall, TBW were more commonly removed than all other fixation types and this was also the case if hardware irritation was used as the indication for removal. Nonunion rates of olecranon osteotomy were 3%

Purpose of the study. To evaluate the outcome of the Modified French osteotomy for the correction of cubitus varus resulting from a supracondylar distal humerus fracture in children. Description of methods. A retrospective review of 90 children, aged 3 to 14, who underwent a modified French osteotomy between 1986 and 2012 for the correction of cubitus varus as a result of a supracondylar distal humerus fracture. Case notes and radiographs were reviewed. The carrying angle was measured clinically and radiologically pre-operatively, post-operatively and at latest follow up. Comparison was made with the unaffected side. The outcome was graded as good if the correction of the carrying angle was within 5 degrees of the unaffected side, satisfactory if the correction was more than 5 degrees of the unaffected side but cubitus valgus was restored and poor if there was persistence of cubitus varus post correction. Any intra-operative and post-operative complications were documented. Summary of results. The average age at the time of osteotomy was 8 years. Sixty-two percent of the patients were male. The left elbow was affected 61% of the time. The average delay from time of fracture to osteotomy was 24 months. The average post-operative follow up was 3.5 months. With regard to the correction of the cubitus varus, 83% of patients had a good outcome, 17% had a satisfactory outcome, with no poor outcomes. Post-operative complications were documented in 6 patients, 3 of which required re-operation. Conclusion. The modified French osteotomy has been shown to be a safe and effective treatment for cubitus varus following supracondylar distal humerus fractures in children. NO DISCLOSURES

We aimed to assess the functional outcomes of elderly patients with isolated comminuted distal humerus fractures that were managed non-operatively. Retrospective analysis of patients over 65 years presenting to our unit between 2005–2015 was undertaken. 67 patients were identified, 7 had immediate TEA, 41 died and 5 were lost to follow-up leaving 14 available for review. Mean Follow-up was 55 months(range 17–131) Patient functional outcomes were measured using VAS scores for pain at rest and during activity, and the Oxford Elbow Score (OES). Need for conversion to TEA and complications were recorded. The mean age at injury was 76 years(range 65–90) of which 79%(11/14) were females. The mean score on the OES was 46(range 29 – 48). The mean VAS score at rest was 0.4(range 0–6) and the mean VAS score during activity was 1.3(range 0–9). 93%(13/14) of patients reported no pain (0 out of 10 on the numeric scale for pain) in their injured elbow at rest and 79%(11/14) reported no pain during activity. No patients converted to TEA and there were no complications. Non-operative management of comminuted distal humerus fractures should be considered for elderly patients, avoiding surgical risks whilst giving satisfactory functional outcomes in this low demand group

Our objective was to investigate the adequacy of the antegrade intramedullary nailing for the treatment of proximal and distal humeral fractures. From January 2004 to April 2008, 28 proximal humerus fractures and 9 distal humerus fractures were treated with intramedullary nailing. Mean age of the patients was 69-year-old (39–82). 26 patients were males. All fractures of the first group were treated with closed static intramedullary nailing whereas in the second group closed static intramedullary nailing was achieved in 7 fractures. The clinical and radiological outcomes were evaluated. All the proximal humerus fracture – but one – obtained bone-union at an average of 3 months (from 2 to 4 months). The mean follow up was 22 months (6–40). Functional outcome measured by Constant score showed 22 patients with an excellent and good result and 6 with a poor result. One case with osteonecrosis of the humeral head was recorded. Malunion of the greater tuberosity was recorded in 7 fractures. Only 5 distal humerus fractures united at an average of 5 months (from 4 to 7 months). Functional outcome measured by Burri – Lob score showed 3 patients with an excellent and good result and 6 with a poor result. Failure of the distal locking was noticed in 5 patients and 3 fractures united in valgus position. The antegrade closed intramedullary nailing is an effective treatment method for the proximal humerus fractures. However the role of the nailing for the distal humerus fractures is humeral nail is effective for the treatment of proximal humeral fractures remains

Purpose: To evaluate the functional outcome following internal fixation of bicondylar distal humerus fractures (AO type C) using the ACUMED modified titanium plates. Material-Methods: Fourteen patients (9 male, 5 female) aging 18 to 78 years (av. 54 y.) with bicondylar distal humerus fractures, between September 2002 and May 2004, were included in our study. All of them underwent open reduction and internal fixation. The articular surface was reduced through a transolecranic approach using one or two compression screws and the fractures was then fixated using the modified titanium ACUMED plates. Results: Postoperative follow-up ranged from 6 to 24 months (av. 12 m.). The results were evaluated using the Mayo Clinic Score. The mean range of elbow flexion-extension was 115o. Nine patients had an excellent/good result, 3 had affair and 2 a poor result. One patient underwent a second procedure for symptomatic metalwork. In one case there was soft tissue infection that resolved successfully with antibiotic administration. Conclusion: The internal fixation of bicondylar AO (type C) distal humerus fractures with the ACUMED plates through a transolecranic approach is an extensive but atraumatic operation that offers excellent reduction and a stable osteosynthesis leading to a good functional outcome

Introduction: Treatment and outcome of patients with rheumatoid arthritis and distal humerus fractures is not well established. Methods: Between 1982 and 2002 twenty-four elbows in twenty-two patients (eleven men, eleven women) treated for acute distal humerus fractures were retrospectively reviewed. The average age at time of the fracture was 64 years. Eleven elbows were immediately treated with a total elbow arthroplasty (TEA) type Coonrad-Morrey (CM), six elbows had underwent open reduction and internal fixation (ORIF), and seven elbows were referred to our institution after failed ORIF elsewhere and were revised with an TEA (CM). Results: At an average follow-up of 52 months the Mayo Elbow Performance Score (MEPS) averaged in the eleven elbows with an immediate TEA 96 points and in the six elbows with ORIF 93 points (p=0.79). In the seven elbows with TEA after failed ORIF there was a trend towards a less favorable outcome (MEPS: 86 points) but the differences was not significant compared to immediate TEA (p=0.31) and ORIF (p=0.53). Patients with failed ORIF and a subsequent TEA had an average of 3 operation per elbow with one patient ending in elbow resection after an infected TEA. Patients with immediate TEA had an average of 1.3 operations and patients with successful ORIF 1.2 interventions. Discussion and Conclusion: Distal humerus fractures in patients with rheumatoid arthritis can be treated successfully with an immediate TEA or ORIF. There is a trend towards a poorer clinical outcome in patients with TEA after failed ORIF

Abstract. Objectives. Operative management of distal humerus fractures is challenging. In the past, plates were manually contoured intraoperatively, however this was associated with high rates of fixation failure, nonunion and metalwork removal. Anatomically pre-contoured distal humerus locking plates have since been developed. Owing to the rarity of distal humeral fractures, literature regarding outcomes of anatomically pre-contoured locking plates is lacking and patient numbers are often small. The purpose of this study is to investigate the outcomes of these patients. Methods. We retrospectively identified patients with distal humeral fractures treated at our institution from 2009–2018. Inclusion criteria were patients with a distal humeral fracture, who underwent two-column plate fixation with anatomically pre-contoured locking plates. Clinical records and radiographs were reviewed to elicit outcome measures, including range of motion, complications and reoperation rate. Results. We identified 50 patients with mean age of 55 years (range 17–96 years). Mean length of follow up was 5.2 years. AO fracture classification Type A occurred most frequently (46%), followed by Type B (22%) and Type C (32%). Low energy mechanisms of injury predominated in 72% of patients. Mean time from injury to fixation was seven days. Mean range of motion at the elbow was 13–123o postoperatively. The overall reoperation rate was 22%, the majority of which required subsequent removal of prominent metalwork (18%). The incidence of nonunion, heterotopic ossification, deep infection and neuropathy requiring decompression was 2% each. Fixation failure occurred in only one patient however the fracture went on to heal. Conclusions. Previously reported reoperation rates with manually contoured plates were as high as 44%, which is twice our reported rate. Modern locking plates are no longer subject to implant failure (previously 27% reported metalwork failure rate). Likewise, heterotopic ossification and non-union have also reduced, highlighting that modern plates have significantly improved overall patient outcomes. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Adequate exposure is a prerequisite for treatment of distal humeral fractures. In this study, we compared the clinico-radiological and functional outcome of TRAP approach with that of olecranon osteotomy for distal humerus fractures. 27 patients with distal humerus fractures were randomized into 2 groups: Group 1 (n=14, TRAP approach), Group 2 (n=13, Olecranon osteotomy). All patients were operated with bi-columnar fixation. All patients were mobilized from day 2. Follow-up evaluation was done at 1, 3, 6 and 12 months. All patients achieved union. The mean surgical time was higher in group 1 (120 min) as compared to group 2 (100 min). The final ROM was higher in group 1 (1160) as compared to group 2 (850). Two patients in group 2 needed posterior release. 5 patients in group 2 had hardware complications related to olecranon osteotomy and needed removal. Two patients in Group 1 had transient ulnar nerve paraesthesias. There was no difference in triceps power in both groups. Our results demonstrate that TRAP approach is extensile and safe enough in treating these complex fractures with better final ROM and fewer complications

The primary aim of this study was to identify risk factors for developing neuritis and its impact on outcome following open reduction internal fixation (ORIF) of distal humerus fractures. Patients were identified from a prospective trauma database (1995–2010). All fractures of the distal humerus (OA-OTA Type A, B, C) managed with ORIF were included. Prospective long-term follow up was collected by telephone. Demographic data, fracture classification, intraoperative details (time to surgery, tourniquet, approach, fixation technique, nerve transposition), subsequent surgeries, presence of postoperative nerve palsy, complications and range of motion were collected. The Broberg and Morrey Elbow Score and DASH score were used as functional outcome measures. Eighty-two patients, mean age 50(range, 13–93) were included. 16% (13/82) developed post-operative ulnar neuritis, 7% (6/82) radial neuritis and 5% (4/82) longterm nonspecific dysaesthesia. Short-term (mean 10 months, range 1–120, collected in 82 patients) and long-term (mean 6 years, range 4–18, collected in 45%, 34/75, of living patients) was completed. In patients with nerve complication: average Broberg and Morrey score was 86 (76% good/excellent), average DASH was 24.7(range, 3.3–100) and Oxford Elbow Score was 39.5(range, 18–48). Compared to: 94 (96% good/excellent), 17.7(range, 0–73.3) and 43.8(range, 17–48) in patients without. Mean pain score was 3.7 in patients with nerve complication compared to 2 without. Nerve complications were seen with increased frequency in young, male patients with high energy and Type C injuries. Nerve complication following ORIF of distal humerus fractures is relatively common. They have detrimental impact on functional outcome. Certain groups appear to be at increased risk

Introduction. Adequate exposure is a prerequisite for treatment of distal humeral fractures. In this study, we compared the clinico-radiological and functional outcome of TRAP approach with that of olecranon osteotomy for distal humerus fractures. Material & Methods. 27 patients with distal humerus fractures were randomized into 2 groups: Group 1 (n=14, TRAP approach), Group 2 (n=13, Olecranon osteotomy). All patients were operated with bi-columnar fixation. All patients were mobilized from day 2. Follow-up evaluation was done at 1, 3, 6 and 12 months. Results. All patients achieved union. The mean surgical time was higher in group 1 (120 min) as compared to group 2 (100 min). The final ROM was higher in group 1 (1160) as compared to group 2 (850). Two patients in group 2 needed posterior release. 5 patients in group 2 had hardware complications related to olecranon osteotomy and needed removal. Two patients in Group 1 had transient ulnar nerve paraesthesias. There was no difference in triceps power in both groups. Conclusion. Our results demonstrate that TRAP approach is extensile and safe enough in treating these complex fractures with better final ROM and fewer complications

Introduction. Primary Total Elbow Replacement (TER) is gaining popularity as a primary treatment option for osteoporotic fractures of the elbow, particularly in patients with low demand. The aim of this study was to assess the clinical and functional efficacy of TER as a primary treatment for comminuted distal humerus fractures in the elderly. Methods. We retrospectively reviewed twenty-three patients (22 females and 1 male) who were treated with primary total elbow replacement for complex, intra-articular fractures of the distal humerus in the elderly between March 2000 and January 2010. The average age of the patients was seventy-five years (ranging from 66 to 94 years). Postoperative elbow function was assessed using the Mayo Elbow Performance Score. The radiological assessment was performed using antero-posterior and lateral radiographs done at follow-up appointments. Results. The average duration of follow up was 6 years. Overall, the mean Mayo elbow performance score was 93 points out of 100. The arc of flexion averaged at 94.3degrees. One patient developed blisters at her arm postoperatively but resolved with dressings. Two patients (8.6%) had mild pain at two years post surgery but there was no evidence of implant loosening or evidence of infection. One patient developed superficial infection which was treated with antibiotics. Nineteen (82%) of the twenty-three elbows had neither a complication nor further surgery from the time of TER to the recent follow up. Conclusions. Our review suggests that total elbow replacement as a primary treatment for comminuted distal humerus fractures in the elderly can give good to excellent results both in the short and the long term basis. When osteosynthesis is not a feasible option, especially in older patients who place lower demands on the joint, total elbow replacement can be considered a the primary treatment

Aims: To evaluate the functional outcome following internal fixation of distal humerus intra-articular fractures (AO type C) with a minimum follow up of two years. Methods: Design: Retrospective evaluation and clinical review. Setting: Regional trauma centre Patients and Participants: Twenty six consecutive patients with fractures of the distal humerus were treated over a thirty one month period (June 1993 to December 1995). The mean age was 55years (range,18–82). Clinical review of twenty patients at a mean follow up of more than two years (range 19–48 months). Six patients were lost to follow up. Results: Clinical evaluation of twenty patients was carried out. Fourteen patients (70 percent) had an excellent or good outcome, five patients (25 percent) a fair outcome and one patient (5 percent) had a poor result. Three patients (15 percent) underwent a second procedure for symptomatic metalwork. The mean arc of flexion-extension was 112 degrees (range, 85 to 122 degrees). Fifteen patients (75 percent) were able to return to their pre injury level of occupation and activity. Seventeen patients (85 percent) were satisfied with the final outcome. Conclusion: nternal fixation of intra-articular distal humerus fractures is an effective procedure with an excellent/good functional outcome in most patient age groups. Patients have a high level of satisfaction and return to previous level of activity

Background. Level 1 studies for fracture management of upper extremity fractures remains rare. The influence of these studies on management trends has yet to be evaluated. The purpose of this study was to examine alterations in national trends managing mid-shaft clavicle and intra-articular distal humerus fractures (DHF) surrounding recent Level 1 publications. Methods. We retrospectively reviewed a comprehensive Medicare (2005–2012) and Humana (2007–2014) patient population database within the PearlDiver supercomputer (Warsaw, IN, USA) for DHF and mid-shaft clavicle fractures, respectively. Non-operative management and open reduction internal fixation (ORIF) were reviewed for mid-shaft clavicle fractures. ORIF and total elbow arthroplasty (TEA) were reviewed for DHF. Total use and annual utilization rates were investigated using age limits defined in the original Level 1 studies. Results. A total of 4,929 clavicle patients between 15 and 59 years, and 106,535 DHF patients greater than 65 years of age were coded. There was no significant change in annual volume of mid-shaft clavicle fractures and DHF coded (p=0.078 and p=0.614, respectively). Among clavicle patients there was a significant increase in ORIF utilization following the publication of the Level 1 study (p=0.002), and a strong, positive correlation was evident (p=0.007). No significant change in annual TEA (p=0.515) utilization for DHF was seen. Conclusion. A significant increase in the utilization of ORIF for clavicular fractures was observed following the publication of supporting Level 1 evidence. This was not observed following similar evidence in managing DHF, as no increase in utilization of TEA was observed

The problem of retained drain fragments is a well known but under reported complication in the literature. The authors present the case of a 66 years old male, who suffered a right distal humerus fracture luxation six years ago that was treated conservatively. He went to the emergency service with fever and right elbow purulent drainage. Physical examination showed deformity, swelling and fluctuation of the right elbow with purulent drainage through cutaneous fistula. The x-ray showed instable inveterate pseudarthrosis of the distal humerus. Leucocytosis and neutrophylia with increased CRP were presente in the blood tests and the patient started empiric treatment with Ceftiaxone IV. A MRSA was isolated in cultural exam of the exsudate, and a six weeks treatment with Vancomycin IV was iniciated. Exhaustive surgical cleaning was performed and two plastic foreing bodies (fragmented drains) were removed. At the time of discharge the patient was afebrile, with normal analytical parameters and negative culture tests. The orthopaedic surgeon should considerate the presence of a foreign body in patients with infected abcess and traumatic or surgery previous history

Purpose: In the younger population there is substantial body of evidence that the outcome is better following open reduction and internal fixation of distal humerus fractures. In the elderly however, there is a need to assess the value of internal fixation of these fractures where osteoporosis is almost a rule than exception and poses considerable challenge to even very experienced trauma surgeon. The purpose of this study therefore was to assess the functional outcome of operative fixation of fractures of the distal humerus in a cohort of elderly patients (aged 75 and above). The reproducibility of four different scoring systems is also evaluated. Patients and Methods: Between 1996 and 2000 out 125 patients who were treated in our institution, elderly patients above 75 years of age were studied. Demographic data such as age, sex, associated injuries and the pre-admission elbow function were recorded. All the fractures were classified according to the AO/ASIF system. At final follow up elbow function was analyzed using OTA’s rating system and these results were compared using three other scoring systems (Jupiter’s criteria, Aitkin’s and Rorabeck criteria, and the scoring system of Caja et al). Treatment options, surgical or non surgical was based on the medical condition of the patient and the personality of the fracture. Intra-operative details including ulnar nerve transposition, olecranon osteotomy and quality of fixation were recorded and analysed. Serial radiographs were studied in detail for union, loss of reduction, certain prognostic indicators such as anterior tilt of distal humerus, cubitus angle, any articular step, gap, heterotopic ossification and development of degenerative changes. Radiological analysis was correlated with functional outcome. The minimum follow up was 16 months (range 16–92). Results: Out of 125 patients, 29 (23.2%) were above the age of 75 (5 male). The mean age of the patients was 84.6 years (range 75–100). One patient was lost to follow-up. In total 28 patients were studied with 29 fractures (one bilateral), five open (Gustilo’s grade I). Mechanism of injury included 24 falls and 4 motor vehicle accidents. In seven cases associated injuries (three with ipsilateral upper limb injuries) were noted. Twenty patients (69.8%) had noticeable osteopenia in the x rays. According to the AO/ASIF classification, there were eight type A, eight type B and thirteen type C fractures. Eight patients were treated non-operatively (3 type A, 2 type B, 3 type C) and 21 (5 type A, 6 type B, 10 type C) operatively. The injury-surgery interval ranged from 6hours to 5days. An olecranon osteotomy (chevron type, Jupiter’s technique) was performed in 21 cases, 2 underwent Triceps ‘tongue’ reflection and 7 had triceps splitting. Only one case had anterior transposition of the ulnar nerve and none in the series developed ulnar nerve symptoms. Local complications included one case of deep infection (leading to non-union), three cases of superficial infection treated with antibiotics, 3 non-unions (two affecting the fracture and the other one the site of the olecranon osteotomy). The former patients declined further intervention and the latter patient was asymptomatic. One patient needed removal of olecranon metal ware, one developed olecranon bursitis. Heterotopic ossification was present in one patient with no effect on the elbow function. Overall, the mean loss of extension was 22.5° (range 5–40°) and the mean flexion 98.6° (ranged 40o–132°). In the non-operative group the mean loss of extension and mean flexion achieved were 33.5oand 70.1° respectively whereas in the operative group were 22.7oand 106.6°. OTA grading revealed 3‘excellent’, 9‘good’, 7‘fair’and 2 ‘poor’ results in the operated group whereas in the non-operative group there were no ‘excellent’, 2‘good’, 3‘fair’, 3‘poor’results. It is of note that in the non-operative group there was a 37.5% incidence of poor results significantly higher than the operative group. The number of ‘acceptable’ (excellent + good) results was higher in the surgically treated group (52%) than in the non-surgically treated group (25.0%). The functional outcome was most closely related to anatomical reduction of the fracture (particularly articular step < 2mm) and anterior tilt of the distal humerus and was unaffected by the injury-surgery interval. It was found that the Jupiter score was less rigid for the range of movement but produced similar scores to OTA with less potential inter observer error compared to the two other scoring systems. 18 of the 21(85.7%) the patients had no limitation of rotation. Conclusion & Significance: This study supports the view that the functional outcome following distal humerus fractures is better with operative treatment in patients above the age of 75. Out of the 4 functional assessment scoring systems evaluated only the OTA and Jupiter gave similar results

Introduction: Several studies have compared various plate constructs for distal intra-articular humerus fractures. In our experience osteoporotic bone and fractures that have a transverse component close to the elbow joint have tenuous fixation with traditional plating systems due to, at most, two screws in the distal fragment through the plate. Therefore, the aim of this study was to obtain objective data on the performance of two plating systems used for fixation of intra-articular distal humerus fractures with a low transverse component with only two screws through a 3.5 LC-DCP distally. It was hypothesized that locked plating would be more stable than standard plating after cyclic loading. Methods: Twenty pairs of fresh matched cadaver humeri of patients older than 65 years old were harvested. DEXA scans of the right forearm from each pair were obtained. Osteotomies were performed to simulate comminuted supracondylar humerus fracture with intercondylar split (OTA 13-C2.3). The specimens were then randomly assigned to locking or non-locking plate fixation. Ten paired specimens were tested in simulated extension and the remaining ten were tested axially. Fragment motion relative to the humeral shaft was measured using kinematic analysis at the fracture gap. Differences in resultant fragment translations and rotations between fixation groups were checked for significance (p< 0.05) using a one-tailed paired t-test. Differences in cycles to failure were checked for significance using a Wilcoxon signed rank test. Results: On average, during extension tests, the humeri with locking plate fixation did not survive significantly more cycles (4352) than with non-locking (4755) plate fixation. There was no significant difference in fragment translation between locking (0.8 mm) and non-locking (1.7 mm) plates. However, there was a significant difference in fragment rotation between locking (2.8 degrees) and non-locking (3.9 degrees) fixations. On axial testing, the humeri with locking plates on average survived more loading cycles (4072) than those with non-locking plate fixation (2115), but the difference was not significant. Mean translation for locking plate fixation (3.6 mm) was significantly less than for non-locking plate fixation (5.7 mm) and mean fragment rotation was significantly less for locking plate fixation (13.3 degrees) than for non-locking plate fixation (17.8 degrees). Conclusions: The results of this study demonstrated that the fixed-angle 3.5 mm locking plate constructs for comminuted intercondylar humerus fractures reduced fracture site motion, sometimes significantly so, relative to the non-locking constructs in osteoporotic bone. The potential benefit of increased fixation survivability and decreased fracture site motion in osteoporotic bone needs to be evaluated clinically