This study reviews the early results of Distal Humeral Hemiarthroplasty(DHH) for distal humeral fracture and proposed a treatment algorithm incorporating the use of this technique in the overall management of distal humeral fractures. DHH was performed on 30 patients (mean 65 years; 29-91) for unreconstructable fractures of the distal humerus or salvage of failed internal fixation. A triceps on approach was used in six and an olecranon osteotomy in 24. A Sorbie Questor prosthesis (Wright Medical Technology) was used in 14 patients and a Latitude (Tornier) in 16. Clinical review at a mean of 25 months (3–88) included the American Shoulder and Elbow Surgeons elbow outcomes instrument (ASES), Mayo Elbow Performance Index (MEPI) and radiological assessment. At follow up of 28 patients mean flexion deformity was 25 degrees, flexion 128 degrees, range of pronosupination 165 degrees, mean ASES 83, MEPI 77 and satisfaction 8/10. Acute cases scored better than salvage cases. Re- operation was required in 16 patients (53%); two revisions to a linked prosthesis for periprosthetic fracture and aseptic loosening at 53 and 16 months, 12 metalwork removals and four ulnar nerve procedures. Posterolateral rotatory instability was present in one elbow, four had laxity and mild pain on loading (two with prosthesis or pin loosening), four had laxity associated with column fractures (two symptomatic) and 10 had asymptomatic mild laxity only. The triceps on approach had worse instability and clinical scores. Uncomplicated union occurred in all olecranon osteotomies and 86% of column fractures. One elbow had an incomplete cement mantle and seven had lucencies >1 mm; one was loose but acceptable. Five prostheses were in slight varus. Two elbows had early degenerative changes and 15 developed a medial spur on the trochlea. This is the largest reported experience of DHH. Early results of DHH show good outcomes after complex distal humeral fractures, despite a technically demanding procedure. Better results are obtained for treatment in the acute setting and with use of an olecranon osteotomy. As a result of this experience anatomical and clinical pre-requisites and advise on technique are outlined. An algorithm for use of DHH in relation to total elbow arthroplasty and ORIF for the treatment of complex intra-articular distal humeral fractures with or without column fractures is proposed

This paper reports our experience of revision open reduction, internal fixation and bone grafting of distal humeral fracture non-unions and in addition looks specifically at factors that may predispose to the development of non-union. Between 1993 and 2003 18 patients with distal humeral fracture non-unions underwent revision surgery with bone grafting and rigid internal fixation. Two patients were lost to follow-up leaving a study group of 16 patients. The patients’ age, sex, mechanism of injury, AO classification of the initial fracture and the primary treatment method were analysed with respect to possible factors predisposing to non-union. All revision procedures were performed by the senior author. The non-union site was debrided, bone grafted and rigidly internally fixed. Clinical assessment was performed using the Mayo Elbow Performance Score and radiographs were reviewed for evidence of bony union. The Mayo elbow performance scores were excellent in 11, good in 2, fair in 2 and poor in 1. Our results indicate that age, sex and mechanism of injury are not important in the development of non-union. Twelve patients (75%) however were considered to have undergone inadequate management of the original fracture. Our experience would suggest that to reduce the risk of non-union following distal humeral fractures appropriate consideration must be given to the established and well proven surgical techniques. If adequate fixation is considered beyond the experience of the treating surgeon we would strongly advise referral to a specialist unit

This study reviews the early results of elbow hemiarthroplasty for distal humeral fracture. Elbow hemiarthroplasty was performed on 30 patients (mean 65 years; 29–91) for unreconstructable fractures of the distal humerus or salvage of failed internal fixation. A ‘triceps on’ approach was used in 6 and an olecranon osteotomy in 24. A Sorbie Questor prosthesis (Wright Medical Technology) was used in 14 patients and a Lattitude (Tornier) in 16. Clinical review at a mean of 25 months (3 – 88) included the American Shoulder and Elbow Surgeons elbow outcomes instrument (ASES), Mayo Elbow Performance Index (MEPI) and radiological assessment. At follow up of 28 patients, mean flexion deformity was 25 degrees, flexion 128 degrees, range of pronosupination 165 degrees, mean ASES 83, MEPI 77 and satisfaction 8/10. Acute cases scored better than salvage cases. Re-operation was required in 16 patients (53%); 2 revisions to a linked prosthesis for periprosthetic fracture and aseptic loosening at 53 and 16 months, 12 metalwork removals and 4 ulnar nerve procedures. Posterolateral rotatory instability was present in one elbow, 4 had laxity and pain on loading (2 with prosthesis or pin loosening), 4 had laxity associated with column fractures (2 symptomatic) and 10 had asymptomatic laxity only. The triceps on approach had worse laxity and clinical scores. Uncomplicated union occurred in all olecranon osteotomies and 86% of column fractures. One elbow had an incomplete cement mantle and 7 had lucencies > 1 mm; one was loose but acceptable. 5 prostheses were in slight varus and 2 were flexed. 2 elbows had early degenerative changes and 15 an osteophytic lip on the medial trochlea. Elbow hemiarthroplasty has good early results after complex distal humeral fractures, despite a demanding procedure, metalware removal in 40%, symptomatic laxity in 12% and column non-union in 8%. Better results are obtained for treatment in the acute setting and with use of an olecranon osteotomy

Introduction. Although the majority of adult distal humeral fractures are successfully treated with ORIF, the management in frail patients, often elderly with multiple co-morbidities and osteoporotic bone, remains controversial. Elbow replacement is frequently recommended if stable internal fixation cannot be achieved, especially in low, displaced, comminuted fractures. The “bag-of-bones” method ie early movement with fragments accepted in their displaced position, is rarely considered as there has been little in the literature since 10 successful cases were reported by Brown & Morgan in 1971 (JBJS 53-B(3):425–428). We present the experience of three units in which conservative management has been actively adopted in selected cases. Methods. 44 distal humeral fractures were initially treated conservatively - 2004–2010. Mean age 73.9 yrs (40–91) and 34 F: 10 M. Clinical and radiological review at a mean follow-up of 2 years (1–6). Results. There were 18 AO Type A, 7 B and 19 C fractures. The range of elbow movement was extension/flexion 38/124, and pronation/supination 75/76 at their last follow-up. Using the Oxford elbow score (0 = worst/4 best result), the mean pain score was 2.44 (range 1–4), 2.26 (0–4) for function, and 2.04 (0–4) for psycho-social, although several patients had early dementia. Only 5 subsequently underwent replacement out of 44 patients whose residual symptoms have not been sufficient to require surgery. Discussion. We believe that there is a role for initial conservative treatment in selected higher-risk patients, as initial early mobilisation within the limits of discomfort can give good functional results. There is a significant complication rate after fixation or replacement in elderly, frail patients, which includes infection, stiffness and loosening. Unnecessary operations can be avoided in the majority of cases, with replacement of a virgin joint at a later date only if required

Purpose: Distal humeral fractures are often difficult injuries to treat. We hypothesise that more complex distal humeral fractures have unacceptable functional outcomes due to multi-factorial reasons. Methods: 42 patients with AO/ASIF type B and C fractures of the distal humerus who were treated with open reduction and internal fixation over a six year period were included in the study. All patients were from a single district general hospital. 37 (88%) were clinically, radiologically, and functionally assessed for this study, with the remainder either lost to follow-up or expired. Results: There were 21 type B and 16 type C fractures, all managed by open reduction and internal fixation. Various fixation techniques were utilised. These were performed by consultant surgeons in 14 cases and by surgeons in training in 23 cases. Average follow up was 38 months (range 22–54 months). The arc of elbow motion was 94 degrees (range 58–130), with an average extension deficit of 28 degrees (range 20–55) and an average flexion deficit of 32 degrees (range 15–45). The average arc of forearm rotation was 136 degrees (range 45–140), with an average supination of 68 (range 35–85) and an average pronation of 72 (range 45–90). The complications (n=20/37) included superficial skin infection (n=4), ulnar nerve neurapraxia (n=3), non-union of the humerus fracture (n=2), non-union of olecranon osteotomy site (n=1), intra-articular screw placement (n=1), loosened plate (n=1), loose/backed out screw (n=2), fixed flexion deformity (n=4) and mild elbow instability (n=2). Second surgery was performed in 24% (n=9/37), revision of metal work (n=2), bone grafting (n=2), anterior capsulectomy (n=4), and removal of screw (n=1). Conclusions: Fractures of the distal humerus are often more complex than appreciated, and challenging to treat, with respect to fracture union and functional outcome. A generalist practice appears adequate for achieving bony union, but inadequate for obtaining low complication rates and functional outcomes. Our data suggest that such injuries may constitute a fracture group requiring the acute intervention by centres that have specific sub-specialisation and adequate rehabilitation facilities

Aims: The purposes of this study were to design a more useful fracture classiþcation system for distal humeral fractures and to validate it by exactly reproducing methodology from a previous study. Methods: We designed a new fracture classiþcation system based upon our experience of managing these fractures. We tested its validity by reproducing methodology from a study performed in Oxford. Using the same radiographs, we asked 9 independent assessors to classify the fractures, on two separate occasions, according to the Riseborough and Radin, Jupiter and Mehne and AO classiþcation systems as well as our own Ð The Shefþeld Classiþcation. The assessors were unaware that the new system was produced for the purposes of the study. Using the Kappa statistic, the level of interobserver and intraobserver agreement was determined. Results: Amongst all observers, The Shefþeld Classiþcation is a moderately reliable (k=0.603) but substantially reproducible (k=0.713) classiþcation system. The system improves to become substantially reliable (k=0.643) amongst orthopaedic surgeons. The proportion of fractures unclassiþable by the new system is similar to the AO classiþcation (3.7%). Conclusions: By reproducing previous methodology, we have a unique study that validates The Shefþeld Classiþcation. We believe that it can be used in a management algorithm for these complex fractures

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.

The purpose of this study is to describe the use of the PHILOS plate (Synthes) in reverse configuration to treat complex distal humeral non-unions. Non-union is a frequent complication of distal humeral fracture. It is a challenging problem due to the complex anatomy of the distal humerus, small distal fragment heavily loaded by the forearm acting as a long lever arm with powerful forces increasing the chances of displacement. Rigid fixation and stability with a device of high “pull-out” strength is required. The PHILOS plate has been used in reverse configuration to achieve good fixation while allowing central posterior placement of the implant. 11 patients with established non-union of distal humeral fractures were included in this study. No patient in whom this implant was used has been excluded. Initial fixation was revised using the PHILOS plate in reverse configuration and good fixation was achieved. Bone graft substitutes were used in all cases. Patients were followed to bony union, and functional recovery. All fractures united. One required revision of plate due to fatigue failure. Average time to union was 8 months with excellent restoration of elbow function. A reversed PHILOS plate provides an excellent method of fixation in distal humeral non-union, often complicated by distorted anatomy and previous surgical intervention. It has a high “pull-out” strength and may be placed in the centre of the posterior humerus, allowing proximal extension of the fixation as far as is required. It provides secure distal fixation without impinging on the olecranon fossa. It is more versatile and easier to use than available pre contoured plating systems

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

The management of distal humeral fractures in low-demand patients with osteoporotic bone remains controversial. Total elbow arthroplasty (TEA) has been recommended for cases where achieving stable ORIF can be difficult. The ‘bag of bones’ technique, (early movement with fragments accepted in their displaced position), is now rarely considered as it is commonly believed to confer a poor functional result. The aim of this study was to present the short- and medium-term functional outcomes following the primary conservative treatment of distal humeral fractures in elderly and low-demand patients. We carried out a retrospective case note and radiograph review of all patients (n=40) aged 50 years or more, with distal humeral fractures treated conservatively at our institution over a six-year period. Short-term function was assessed using the Broberg and Morrey (B&M) score. Medium term function was assessed by telephone interview (n=20) using the Oxford Elbow Score (OES), QuickDASH and a pain questionnaire. The mean post-injury B&M score improved from 42 points at 6 weeks to 67 points by 3 months. By four years, surviving patients had a mean OES of 30 points, a mean QuickDASH of 38 points, and 95% reported a functional range of elbow flexion. Those with fracture non-union experienced greater pain on repetitive elbow activities, but no difference in rest pain, compared with patients whose fractures had united. The cumulative 1-year rate of fracture union was 53%, while the 5-year mortality approached 40%. Conservative management of distal humeral fractures confers a reasonable functional result to the patient whilst avoiding the substantial surgical risks associated with primary ORIF or TEA

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

This study was designed to answer the question “Is there a difference in outcome following operative management of AO type C distal humerus fractures for patients with associated injuries compared to those with isolated injuries?” Our hypothesis was that patients with associated injuries would have worse outcomes compared to those with isolated injuries. Fifty-eight patients with fifty-eight fractures managed with ORIF were included. Hospital records, clinic notes and radiographs of these patients were retrospectively reviewed. MFA and DASH scores were prospectively obtained after patients were identified (mean 37.4 months post injury, range 6–74 months). Thirty-two patients had isolated distal humeral fractures while twenty-six patients had distal humeral fractures with associated injuries. The mean MFA of patients with isolated injuries was significantly lower than for patients with associated injuries (27.2 vs 41.7, p = 0.01). There was no difference in DASH scores between the two groups (23.7 vs 29.1, p = 0.34). The mean postoperative arc of motion was one hundred and seven degrees for isolated injuries and seventy-five degrees for patients with associated injuries (p=0.006). Surgical release for stiffness was required for two patients (6%) in the isolated group and ten patients (38%) in the associated injuries group (p=0.003). Outcomes for isolated distal humeral fractures in this study were comparable to previously published literature. Patients who sustain associated injuries at the time of distal humeral fracture have more stiffness and a worse outcome on a global outcome score, but a similar outcome on a limb specific outcome score

Abstract. Background/Objectives. The incidence of reverse total shoulder replacement (rTSR) implantation is increasing globally, but apprehension exists regarding complications and associated challenges. We retrospectively analysed the senior author's series of rTSR from a tertiary centre using the VAIOS shoulder system, a modular 4th generation implant. We hypothesised that the revision rTSR cohort would have less favourable outcomes and more complications. Methods. 114 patients underwent rTSR with the VAIOS system, over 7 years. The primary outcome was implant survival. Secondary outcomes were Oxford shoulder scores (OSS), radiographic analysis (scapular notching, tuberosity osteolysis, and periprosthetic radiolucent lines) and complications. Results. There were 55 Primary rTSR, 31 Revision rTSR and 28 Trauma rTSR. Implant survival: Primary rTSR- 0 revisions, average 3.35-year follow-up. Revision rTSR-1 revision (4.17%), average 3.52-year follow-up. Trauma rTSR- 1 revision (3.57%), average 4.56-year follow-up OSS: Average OSS improved from 15.39 to 33.8 (Primary rTSR) and from 15.11 to 29.1 (Revision rTSR). Average post-operative OSS for the Trauma rTSR was 31.4 Radiological analysis and complications: Low incidence of scapular notching One hairline fracture below the tip of stem, noted incidentally, which required no treatment. One periprosthetic fracture after alcohol related fall. Treated non-surgically One joint infection requiring two-stage revision to rTSR. One dislocation noted at 2 year follow up. This patient had undergone nerve grafting within 6 months of rTSR for axillary nerve injury sustained during the original fracture dislocation. One acromial fracture with tibial and distal humeral fracture after a fall. Conclusions. The 4th generation modular VAIOS implant is a reliable option for various indications. The revision rTSR cohort had favourable outcomes with low complication rates. In this series, early-to-medium term results suggest lower revision rates and good functional outcomes when compared to published reports. We plan to monitor long-term implant survivorship and patient reported outcomes. Declaration of Interest. (a) fully declare any financial or other potential conflict of interest

Introduction: Distal humeral fractures represent a constant challenge to the most experienced surgeon. This is the first report of the use of an unlinked prosthesis for the treatment of distal humeral fractures in elderly persons. Materials and Methods: From July 2000 to June 2001, 9 iBP elbow arthroplasties were performed in patients with acute fractures of the distal humerus. The average age of the group was 71 years. The mean interval between injury and TER was 11 days. The follow-up period averaged 12 months (range 5 to 16). Results: Functional outcome was evaluated with patient-completed questionnaires. All patients had a flexion contracture of the elbow ranging from 15 to 30 degrees. All patients were able to perform daily activities, pain relief was satisfactory and patient satisfaction was high. All elbows met the criteria for functional motion and were stable at the latest follow-up examination. There were no major complications such as dislocation, ulnar nerve dysfunction or deep infection. Conclusion: Unlinked non-congruous elbow arthroplasty when combined with a surgical exposure that allows proper soft tissue balance and instrumentation that enables correct positioning of the components can be a successful alternative in the management of acute distal humeral fractures in selected patients when conventional fixation is not a viable option

Introduction: Fractures of the elbow constitute about 7% of adult fractures; distal humerus fractures account for less than half of all elbow fractures. There is evidence, however, that incidence is increasing. Investigators in Finland performed a retrospective review of hospital admission records between 1970 and 1995 and found that the age-adjusted increase in incidence in women older than 60 years had more than doubled. Treatment of intraarticular comminuted distal humeral fractures is a surgical challenge, adequate reduction of the joint surface demands avoidance of residual step or gap of the articular surface and providing a stable fracture fixation. Aim: To evaluate our initial experience in internal fixation by using bioabsorbable screws by treatment of patients suffered from comminuted distal humeral fractures. Material and methods: 5 patients with sever intraarticular comminuted distal humeral fractures were treated using bioabsorbable screws. A standard transolecranon approach was used. Internal fixation was performed using lateral and medial plates. Additional bioabsorbable screws (pins) were used to fix separate intraarticuar fragments of the distal humeral bone. Results: By follow up all fractures were healed with out secondary displacement of fractures. All five patients returned to the preoperative activity, ROM of operated joints was in functional limits. Insertion bioabsorbable screws thorough articular surface allows preserve intraarticular bone fragments on the place until solid consolidation without need in additional operative procedure of removing implanted devices. Conclusion: Our experience suggests that the bioabsorbable screws can serve as useful augmentation in surgical repair of severe intraarticular comminuted fractures of the elbow joint. Future clinical study

The October 2015 Shoulder & Elbow Roundup. 360 . looks at: Culture time important in propionibacterium acnes; Microvascularisation of the cuff footprint; Degenerative cuff tears: evidence for repair; Middle ground in distal humeral fractures?; Haste needed in elbow heterotopic ossification; Iatrogenic frozen shoulder; Salvage of failed humeral fixation

Total elbow arthroplasty (TEA) has been shown to be a treatment option for elderly patients with complex distal humeral fractures and osteoporotic bone. The published results have often included rheumatoid patients who traditionally would be expected to do well from elbow arthroplasty. Only short-term results have been published using this technique in non-rheumatoid patients. The current study contains the largest number and longest follow-up of non-rheumatoid patients whose fractures have been treated with a non-custom TEA. In total there were 26 patients, mean age 72 years, 22 female and 4 male, 25% dominant arm. The mean follow-up was of 5 years. There was 1 case of loosening, 1 radial nerve palsy and 2 cases of heterotrophic ossification. At final review the mean range of flexion/extension was 97.5 degrees and the mean range of pronation/supination was 151.75 degrees. The mean Mayo Elbow Performance score was 92. We would suggest that TEA provides a very satisfactory outcome in elderly patients with complex distal humeral fractures, the benefit of which can be observed at a mean of 5 years

34 adult patients were assessed at an average of 15 years (13–20) after stable internal fixation with early active mobilisation of a distal humeral fracture. 23 were Müller type C, (5 open), 9 type B and 2 type A. Using the Mayo Score, 94% had an excellent/good result and 6% fair. None had a poor outcome. This study is the first to demonstrate that early stable internal fixation of distal humeral fractures by an experienced surgeon, gives excellent long term results with few complications, together with high rates of patient satisfaction and little functional morbidity

Total elbow arthroplasty (TEA) has been shown to be a treatment option for elderly patients with complex distal humeral fractures and osteoporotic bone. The published results have often included rheumatoid patients who traditionally would be expected to do well from elbow arthroplasty. Only short-term results have been published using this technique in non-rheumatoid patients The current study contains the largest number and longest follow-up of non-rheumatoid patients whose fractures have been treated with a non-custom TEA. In total there were 26 patients, mean age 72 years, 22 female and 4 male, 25% dominant arm. All had a minimum of 5 years follow-up. There was 1 case of loosening, 1 radial nerve palsy and 2 cases of heterotrophic ossification. At final review the mean range of flexion/extension was 97.5 degrees and the mean range of pronation/supination was 151.75 degrees. The mean Mayo Elbow Performance score was 92. We would suggest that TEA provides a very satisfactory outcome in elderly patients with complex distal humeral fractures, the benefit of which can be observed for at least 5 years

The aim of management of an adult distal humeral fracture is to restore mobility, stability and pain-free elbow function. Good results are usually achieved in the majority of fractures treated with ORIF, but the management of comminuted fractures in elderly, frail patients with osteoporotic bone remains controversial. The literature focuses on elbow replacement if stable internal fixation cannot be achieved, with “bag-of-bones” management now rarely discussed eg. key-note paper - 10 successful cases reported by Brown RF & Morgan RG in 1971 (JBJS 53-B(3):425-428). We present the experience in two units in which conservative management has been actively adopted in selected cases by consultants with a subspecialty interest in the elbow. All patients over the age of 60 with distal humeral fractures (2007 – 2009) who had been treated conservatively were reviewed clinically and radiologically. Duration of follow-up and outcome, including the Oxford and quick DASH scores, were recorded, with the fractures classified using the AO system. There were 25 patients, 19 female and 6 male. 19/25 patients have been successfully treated conservatively with a mean Range Of Movement: Extension/Flexion: 45/125, Pronation/Supination 74/70. Only 5 underwent subsequent total elbow replacement and one delayed ORIF. There is a significant complication rate following surgical treatment with ORIF or elbow replacement in elderly, frail patients, including infection, painful non-union and/or stiffness. We believe that there is a role for initial conservative treatment in selected patients with low, displaced, comminuted humeral fractures in osteoporotic bone. Initial early mobilisation as pain allows can give good functional results without the risks of operation. It does not preclude future surgery if conservative treatment fails, but this is not required in the majority of cases