Distal Humerus Fracture — ABOS Oral Boards Preparation

A 67-year-old right-hand-dominant woman presents to the emergency department after a fall onto her left elbow on an icy sidewalk. She has a history of rheumatoid arthritis treated with methotrexate and low-dose prednisone. She is an avid gardener and otherwise independent in her activities. She reports severe left elbow pain with inability to move the joint. On exam, the elbow is markedly swollen. There is a visible deformity with crepitus on gentle palpation. The skin is intact but tented over the olecranon. Ulnar nerve function is intact — she has normal small finger flexion and intrinsic function. Radial and median nerves are intact. Radial pulse is 2+.

AP and lateral radiographs of the left elbow reveal a comminuted bicolumnar (intercondylar) fracture of the distal humerus (AO 13-C3) with articular comminution and displacement. There is osteopenic bone quality consistent with her rheumatoid arthritis and chronic steroid use. CT scan with 3D reconstruction confirms the bicolumnar pattern with a low, comminuted articular segment.

After discussing the options — including total elbow arthroplasty given her bone quality and inflammatory arthritis — she elected for ORIF. You performed open reduction and internal fixation through a posterior approach with olecranon osteotomy. Dual plating was performed with orthogonal (90-90) plate placement. Articular fragments were reduced and held with small lag screws before column plating. The ulnar nerve was identified, protected, and transposed anteriorly subcutaneously. The olecranon osteotomy was fixed with a tension band construct. Post-operatively, the patient began gentle active motion at 5 days with a progressive protocol.