Intra-articular Distal Humerus Fractures in Adults: Current Concepts in Diagnosis, Preoperative Planning, and Surgical Treatment. Are We Moving Away From Olecranon Osteotomy?

Abstract

Intra-articular distal humerus fractures remain a frequent source of debate among orthopaedic trauma surgeons. Different interpretations of the same problem are common, and treatment strategies may be markedly divergent. Nevertheless, the objective of treatment is consistent: anatomical reconstruction of the articular surface, stable bicolumnar fixation, preservation of soft-tissue biology, and early elbow mobilization. A narrative review of the literature was performed, including clinically relevant studies on epidemiology, imaging, surgical approaches, fixation, ulnar nerve management, arthroplasty, complications, and rehabilitation. Olecranon osteotomy has historically provided broad posterior exposure of the articular surface and remains valuable, particularly in AO/OTA 13-C3 fractures, very distal fractures, trochlear comminution, and patterns associated with coronal shear components. However, with the evolution of diagnostic imaging and a more detailed understanding of distal humeral biomechanics, the paratricipital approach without osteotomy has gained increasing acceptance. Anatomical articular reductions can be achieved while avoiding an additional surgical insult to an important structure of the elbow: the olecranon. In addition, the evolution of implants, including anatomical parallel or orthogonal plates, has contributed to improved treatment success rates, demonstrating that good outcomes can be achieved when the principles of distal humerus fracture fixation are respected. Routine anterior transposition of the ulnar nerve is not consistently supported by comparative evidence; careful decompression, nerve protection, and selective transposition are favored. Total elbow arthroplasty is a reasonable option in selected elderly, low-demand patients with non-reconstructible articular comminution, poor bone quality, and the ability to comply with permanent activity restrictions. Current evidence supports a selective, fracture-pattern-based approach rather than either abandonment or routine use of olecranon osteotomy. Olecranon osteotomy should remain an important tool, but its indication should be individualized according to fracture morphology, the visualization required, patient physiology, bone quality, and surgeon experience.