Elsevier

The Journal of Hand Surgery

Volume 48, Issue 2, February 2023, Pages 177-186
The Journal of Hand Surgery

Current Concepts
Controversies in the Management of Bicolumnar Fractures of the Distal Humerus

https://doi.org/10.1016/j.jhsa.2022.10.006Get rights and content

Bicolumnar fractures of the distal humerus pose numerous treatment challenges for upper-extremity surgeons. Although open reduction and internal fixation demonstrates advantages compared with nonsurgical treatment, restoration of osseous anatomy can be difficult, particularly for comminuted, intra-articular fractures. Despite well-recognized complications, total elbow arthroplasty remains an option for elderly patients with fractures not amenable to fixation. Although indications remain controversial, distal humerus hemiarthroplasty has emerged as a potential alternative to total elbow arthroplasty in carefully selected patients with nonreconstructable fractures. Numerous controversies remain with respect to the management decisions for these complex injuries, including the optimal surgical approach, management of the ulnar nerve, and ideal fixation constructs for open reduction internal fixation. Our purpose is to review the management of bicolumnar distal humerus fractures in adult patients and discuss current controversies related to treatment.

Section snippets

Anatomy and Biomechanics

The anatomy of the distal humerus lends to the complexity of treatment. The medial and lateral condyles serve as support (“columns”) for the articular surface. Each column has a nonarticulating and articulating segment. These columns are the location of the strongest bone in the distal humerus and are often targeted for plate fixation.7 The articular surface serves as an architectural conduit between the 2 columns, forming an inverted roman arch (Fig. 2).7

The restoration of this anatomical

Diagnosis

In patients with a DHF, a detailed neurovascular examination of the entire extremity is important. Associated nerve injuries are reported in up to 23% of cases and most commonly involve the ulnar nerve.10 A careful inspection of the skin is necessary to rule out associated open fractures, which can be subtle. Segmental, ipsilateral, and extremity injuries need to be ruled out on both clinical and radiographic examinations as these increase the risk of compartment syndrome.

A standard orthogonal

Role of advanced imaging

Traction views can aid in understanding complex fracture patterns, including those with significant shortening, rotation, and comminution (Fig. 3). Computed tomography imaging can also add additional information compared with standard radiographic assessments. However, indications for both traction views and CT scans are not completely defined. A recent multicenter study comparing interobserver and intraobserver reliability found that both traction views and CT scans provided important yet

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