High Yield Overview

INTERCONDYLAR DISTAL HUMERUS FRACTURES

Intra-articular Elbow Fracture | Bicolumnar Fixation | Early Motion Essential

AO 13-CClassification category

90°Orthogonal plating angle

2%All fractures, 30% elbow fractures

45°Minimum useful ROM arc

AO/OTA CLASSIFICATION

PatternSimple articular, simple metaphyseal

TreatmentORIF dual plating

PatternSimple articular, comminuted metaphyseal

TreatmentORIF dual plating

PatternComminuted articular

TreatmentORIF or TEA in elderly

Critical Must-Knows

Bicolumnar anatomy: Medial and lateral columns form triangular construct
Dual plate fixation required - single plate inadequate
Orthogonal plating (90°) or parallel plating both effective
Early motion critical - stiffness is the enemy
Olecranon osteotomy provides best articular visualization

Examiner's Pearls

"
Columns diverge distally to support trochlea and capitellum
"
Articular reconstruction priority before column fixation
"
Ulnar nerve must be identified and protected
"
TEA is reasonable option for elderly with comminution

Clinical Imaging

Imaging Gallery

2-panel (A,B) pre and post-operative X-rays showing displaced intercondylar fracture and bicolumnar dual plate fixation.Credit: PMC - CC BY 4.0 via Open-i (NIH) (CC-BY 4.0)

2-panel (A,B) clinical photos showing elbow flexion and extension ROM after fracture surgery.Credit: PMC - CC BY 4.0 via Open-i (NIH) (CC-BY 4.0)

3-panel (A-C) showing different plating configurations - parallel and orthogonal techniques.Credit: PMC - CC BY 4.0 via Open-i (NIH) (CC-BY 4.0)

2-panel (a,b) pre-op comminuted fracture and post-op Y-shaped bicolumnar plating.Credit: PMC - CC BY 4.0 via Open-i (NIH) (CC-BY 4.0)

Intercondylar distal humerus fracture with dual plate fixation — Two-panel comparison of intercondylar distal humerus fracture. (A) Pre-operative AP and lateral X-rays showing displaced intercondylar fracture with loss of column integrity. (B) Post-operative X-rays demonstrating bicolumnar fixation with orthogonal dual plating - the standard technique requiring plates on both medial and lateral columns for stable fixation.Credit: PMC - CC BY 4.0

Critical Intercondylar Fracture Exam Points

Bicolumnar Anatomy

Distal humerus is a triangle: Two columns (medial and lateral) diverge distally to support the articular surface. Fixation must restore BOTH columns for stability. Single plate fixation will fail.

Ulnar Nerve Management

Identify and protect the ulnar nerve in all cases. Options: in situ, transpose subcutaneously, or transpose submuscularly. Most surgeons transpose to avoid hardware irritation.

Early Motion Imperative

Motion is mandatory - elbow stiffness is the most common complication. Start gentle ROM within 1-2 weeks. Stable fixation allows early motion without risking construct.

Plating Strategy

Dual plate fixation required: Either orthogonal (90°) or parallel plating. Minimum 2-3 screws in each distal fragment. Screws should interdigitate in distal fragments for maximum stability.

At a Glance - Management Decision

Fracture Type	Patient	Bone Quality	Treatment
C1 - Simple articular	Any	Good	ORIF dual plating
C2 - Metaphyseal comminution	Any	Good	ORIF dual plating
C3 - Articular comminution	Young/Active	Good	ORIF dual plating with articular reconstruction
C3 - Articular comminution	Elderly/Low demand	Poor	Consider TEA (total elbow arthroplasty)
Severe comminution	Elderly with RA/osteoporosis	Poor	TEA preferred

Mnemonic

COLUMNSDistal Humerus Anatomy

Columns two

Medial and lateral columns support articular surface

Olecranon fossa

Posterior thin bone - not for fixation

Lateral column

Supports capitellum, thicker posterolaterally

Ulnar nerve

Posterior to medial epicondyle - must protect

Medial column

Supports trochlea, thicker posteromedially

Narrow zone

Olecranon and coronoid fossae - thin bone

Spool shape

Trochlea articulates with olecranon

Memory Hook:The COLUMNS support the elbow - remember the bicolumnar anatomy!

Mnemonic

PLATESSurgical Principles

Parallel or Perpendicular

Either 90° or 180° plating acceptable

Long enough screws

Interdigitate in distal fragments

Articular first

Reconstruct joint before fixing to shaft

Two columns

Both columns must be fixed

Early motion

Stiffness is the enemy - move early

Stable fixation

Must allow early mobilization

Memory Hook:PLATES reminds you of the key surgical principles!

Mnemonic

STIFFComplications

Stiffness

Most common complication - prevent with early motion

Tingling

Ulnar nerve symptoms - transpose or protect

Infection

Risk with extensive surgery and hardware

Fixation failure

Usually from inadequate fixation

Fracture nonunion

Risk with comminution and poor fixation

Memory Hook:Don't let your patient become STIFF - move them early!

Overview

Intercondylar fractures of the distal humerus are complex intra-articular injuries that require anatomic reduction and stable fixation to restore elbow function. These fractures disrupt the bicolumnar architecture of the distal humerus and separate the articular surface from the humeral shaft.

Epidemiology

Incidence:

2% of all fractures
30% of elbow fractures
Bimodal distribution: Young adults (high energy), Elderly women (low energy)

Demographics:

Young males: High-energy trauma (MVA, sports)
Elderly females: Low-energy falls, osteoporosis
Increasing incidence in elderly population

Risk Factors:

Osteoporosis
High-energy mechanism
Direct trauma to elbow

Mechanism of Injury

High-Energy Mechanism:

Motor vehicle accidents
Fall from height
Sports injuries
Direct blow to elbow

Low-Energy Mechanism:

Fall onto flexed elbow
Fall onto outstretched hand with elbow flexed
Common in osteoporotic elderly

Force Transmission:

Olecranon driven into trochlea
Splits columns apart
Creates characteristic T or Y pattern

Associated Injuries:

Open fractures (15-20%)
Nerve injuries (ulnar most common)
Vascular injuries (rare)

Anatomy and Pathophysiology

Bicolumnar Architecture

Understanding the unique triangular architecture of the distal humerus is essential for treating these fractures.

Bicolumnar Concept:

Two columns diverge distally from humeral shaft
Forms triangular structure when viewed end-on
Supports articular surface (trochlea and capitellum)

Medial Column:

Supports the trochlea
Medial epicondyle is non-articular
Thicker bone posteriorly and medially
Best plate position: Posteromedial

Lateral Column:

Supports the capitellum
Lateral epicondyle is non-articular
Thicker bone posteriorly and laterally
Best plate position: Posterolateral

Thin Zones:

Olecranon fossa (posterior)
Coronoid fossa (anterior)
Not suitable for screw placement

The bicolumnar anatomy dictates the dual plating strategy.

Bicolumnar Architecture

The distal humerus resembles a triangle when viewed end-on. The two columns form the sides, and the articular surface (trochlea and capitellum) forms the base. Stable fixation requires restoration of both columns.

Classification

Bone: 13 (Distal Humerus)

Type A - Extra-articular:

A1: Avulsion
A2: Simple metaphyseal
A3: Multifragmentary metaphyseal

Type B - Partial Articular:

B1: Sagittal lateral condyle
B2: Sagittal medial condyle
B3: Coronal plane (capitellum/trochlea)

Type C - Complete Articular (Intercondylar):

C1: Simple articular, simple metaphyseal
C2: Simple articular, comminuted metaphyseal
C3: Comminuted articular

Type C fractures are the focus of intercondylar management.

AO Classification Summary

Type	Articular	Metaphyseal	Treatment Challenge
C1	Simple	Simple	Standard - good prognosis
C2	Simple	Comminuted	Moderate - metaphyseal reconstruction
C3	Comminuted	Variable	Complex - may need TEA in elderly

Clinical Assessment

History and Physical Examination

History

Mechanism:

Fall onto flexed elbow
Direct blow to elbow
Motor vehicle accident
Fall from height

Energy Level:

High energy: MVA, falls from height
Low energy: Simple falls in elderly

Symptoms:

Severe elbow pain
Inability to move elbow
Swelling
Deformity

Medical History:

Osteoporosis
Rheumatoid arthritis (affects treatment choice)
Previous elbow problems
Functional demands

Energy level and patient factors guide treatment decisions.

Physical Examination

Inspection:

Swelling (often marked)
Deformity
Ecchymosis
Skin integrity (open fractures 15-20%)

Palpation:

Tenderness throughout distal humerus
Crepitus (avoid excessive manipulation)
Olecranon prominence preserved (vs dislocation)

Range of Motion:

Limited by pain and instability
Do not force motion
Document baseline

Neurovascular Examination:

Ulnar nerve function (most commonly injured)
Radial nerve function
Median nerve function
Distal pulses and perfusion

Complete neurovascular examination is mandatory before any treatment.

Soft Tissue Assessment

Open Fractures:

15-20% of intercondylar fractures
Gustilo-Anderson classification
Urgent debridement required

Compartment Syndrome:

Rare but possible
Assess forearm compartments
High index of suspicion with high energy

Skin Condition:

Posterior skin often compromised
Fracture blisters common
May delay surgery

Swelling:

Often severe
May need elevation and ice before surgery
Soft tissue recovery before ORIF

Soft tissue condition may dictate surgical timing.

ALWAYS document ulnar nerve function before any treatment. The ulnar nerve lies posterior to the medial epicondyle and is at risk from both the injury and surgical approach. Pre-operative deficit must be documented.

Investigations

Imaging Studies

Standard Views:

AP of elbow
Lateral of elbow
Oblique views if needed

Key Findings:

Fracture pattern (T, Y, H, Lambda)
Degree of comminution
Articular involvement
Column fractures

Associated Injuries:

Radial head fracture
Coronoid fracture
Olecranon fracture (terrible triad)

Limitations:

Overlapping fragments obscure detail
CT often needed for planning
May underestimate comminution

Plain radiographs provide initial assessment but CT is usually needed.

Special Investigations

CT with 3D reconstruction is the gold standard for surgical planning of intercondylar fractures. It reveals articular comminution that may not be apparent on plain radiographs and helps determine if ORIF or TEA is more appropriate.

Management Algorithm

Treatment Decision Making

Non-operative Management:

Reserved for non-ambulatory patients
Severe medical comorbidities precluding surgery
"Bag of bones" technique (historical, poor outcomes)

Operative Management:

Standard of care for displaced fractures
Options: ORIF or Total Elbow Arthroplasty

ORIF Indications:

Young/active patients
Good bone quality
Reconstructable fracture pattern
High functional demands

TEA Indications:

Elderly low-demand patients
Severe osteoporosis
Unreconstructable articular comminution
Pre-existing arthritis or RA

Most intercondylar fractures require operative treatment.

ORIF - Best For

Ideal Candidates:

Young active patients
Good bone quality
Reconstructable pattern
High demand lifestyle

Expected Outcomes:

ROM: 100-110° arc
Function: Good to excellent in 75-80%
Return to activities: Yes

TEA - Best For

Ideal Candidates:

Elderly (over 65-70)
Osteoporotic bone
Severe comminution
Low demand lifestyle

Expected Outcomes:

ROM: 100-120° arc
Pain relief: Excellent
Restrictions: Lifelong 5kg limit

Surgical Technique

Operative Procedures

Indications:

Best articular visualization
Most intercondylar fractures
Complex articular patterns

Technique:

Posterior midline incision
Identify and mobilize ulnar nerve
Chevron or transverse osteotomy
Pre-drill for fixation before osteotomy
Elevate olecranon with triceps attached
Direct visualization of trochlea

Advantages:

Best articular visualization
Direct access to both columns
Allows anatomic reduction

Disadvantages:

Creates additional fracture
Risk of nonunion (2-5%)
Hardware prominence

Olecranon osteotomy provides best visualization for complex fractures.

Different plating configurations for distal humerus fractures — Three-panel comparison (A-C) demonstrating various plating configurations for intercondylar distal humerus fractures. Different views show parallel and orthogonal plating techniques with varying plate designs. Both configurations can provide stable fixation when proper principles are followed: minimum 2-3 screws in each distal fragment with interdigitating screws for maximum stability.Credit: PMC - CC BY 4.0

Olecranon Osteotomy Technique

The olecranon osteotomy provides the best visualization of the articular surface. Use a chevron osteotomy for rotational stability and pre-drill the screw hole before performing the osteotomy to ensure accurate reduction.

Articular Reconstruction

Step 1 - Articular Reconstruction:

Identify key articular fragments
Reduce trochlea first (medial to lateral)
Provisional K-wire fixation
Lag screws for articular fragments

Step 2 - Column Reconstruction:

Reduce articular block to medial column
Reduce articular block to lateral column
Restore column length and alignment

Step 3 - Plate Application:

Apply first plate (usually medial)
Apply second plate
Final tightening
Check ROM intraoperatively

Sequence: Articular first, then columns, then plates.

Complications

Potential Complications

Most Common Complication:

Incidence: 20-40%
Worse with prolonged immobilization
Worse with heterotopic ossification

Prevention:

Early motion (within 1-2 weeks)
Stable fixation
Consider indomethacin for HO prophylaxis

Treatment:

Aggressive physiotherapy
Dynamic splinting
Manipulation under anesthesia
Arthroscopic or open release

Functional ROM:

30-130° arc adequate for most ADLs
Loss of terminal extension common
Loss of flexion more functionally limiting

Early motion is the key to preventing stiffness.

Elbow stiffness is the most common complication of intercondylar fractures. Prevention through stable fixation and early motion is essential. Start gentle ROM within 1-2 weeks of surgery.

Postoperative Care

Rehabilitation Protocol

Goals:

Protect fixation
Begin early ROM
Control swelling

Week 0-2:

Posterior splint at 90° flexion
Elevation
Active finger, wrist, shoulder motion

Week 1-2:

Begin active-assisted elbow ROM
Remove splint for exercises
Gravity-assisted flexion
Extension stretching

Week 2-6:

Progress ROM exercises
Active motion all planes
May use hinged brace for protection
Continue to avoid loading

Early motion is critical - begin within 1-2 weeks.

Outcomes

Expected Results

Functional Results:

Good to excellent: 75-85%
Fair: 10-15%
Poor: 5-10%

Range of Motion:

Average arc: 100-110°
Extension loss: 20-30° common
Flexion usually 120-130°

Complications:

Stiffness: 20-40%
Ulnar nerve symptoms: 10-20%
Hardware removal: 15-25%
Nonunion: 2-10%

Factors Affecting Outcome:

Fracture complexity (C1 better than C3)
Quality of reduction
Early motion protocol
Patient compliance

ORIF outcomes are generally good with proper technique and rehabilitation.

Evidence Base

Key Studies

McKee et al. - ORIF vs TEA in Elderly

McKee MD, et al. • JBJS Am (2009)

Key Findings:

RCT comparing ORIF vs TEA in patients over 65
TEA had better DASH scores at 2 years
TEA had fewer complications
TEA recommended for elderly with comminuted fractures

Clinical Implication: This level I evidence supports choosing TEA over ORIF for elderly patients (over 65) with comminuted intercondylar fractures, particularly those with osteoporosis or low functional demands.

Frankle et al. - Parallel vs Perpendicular Plating

Frankle MA, et al. • J Shoulder Elbow Surg (2006)

Key Findings:

Biomechanical comparison of plating configurations
No significant difference in construct stiffness
Both techniques provide adequate stability
Surgeon familiarity may guide choice

Clinical Implication: This biomechanical study validates that surgeons can choose either orthogonal (90°) or parallel (180°) plating configurations based on their preference and fracture geometry, as both provide equivalent stability.

Sanchez-Sotelo et al. - Results of ORIF

Sanchez-Sotelo J, et al. • JBJS Am (2007)

Key Findings:

Review of 340 intercondylar fractures treated with ORIF
Good-excellent results in 83%
Complication rate 26%
Early motion correlated with better outcomes

Clinical Implication: This large case series establishes realistic outcome expectations for ORIF (83% good-excellent results) and emphasizes the critical importance of early motion protocols in achieving optimal functional outcomes.

Ring et al. - Olecranon Osteotomy

Ring D, et al. • J Hand Surg Am (2004)

Key Findings:

Review of olecranon osteotomy complications
Nonunion rate 2-5%
Hardware removal rate higher with tension band
Plate fixation recommended for osteotomy

Clinical Implication: When performing olecranon osteotomy for exposure, plate fixation is preferred over tension band wiring to reduce hardware prominence and subsequent removal rates, though both techniques have acceptable nonunion rates.

Jupiter et al. - Surgical Approach

Jupiter JB, et al. • JBJS Am (1985)

Key Findings:

Established olecranon osteotomy technique
Described bicolumnar fixation principles
Emphasized early motion
Foundation for modern treatment

Clinical Implication: This classic paper established the fundamental principles still used today: olecranon osteotomy for exposure, bicolumnar dual plate fixation, and early motion protocols - forming the foundation of modern intercondylar fracture management.

Exam Viva Scenarios

Practice these scenarios to excel in your viva examination

VIVA SCENARIOStandard

Scenario 1: Young Active Patient

EXAMINER

"A 45-year-old man sustains an AO 13-C2 intercondylar distal humerus fracture in a motorcycle accident. Describe your management."

EXCEPTIONAL ANSWER

**Assessment:** High-energy trauma requires ATLS assessment first. Specific to elbow: Check **ulnar nerve** function and skin integrity (Open fractures common). **Plan:** This requires **ORIF**. He is young and active. **Goal:** Anatomic reduction and early motion. **Surgical Technique:** 1. **Approach:** Posterior approach with **Olecranon Osteotomy** for best articular visibility. 2. **Ulnar Nerve:** Identify and transpose (subcutaneous). 3. **Reduction:** Reconstruct articular surface first (K-wires), then attach to columns. 4. **Fixation:** **Dual Plating** (Orthogonal or Parallel) with interdigitating distal screws. 5. **Post-op:** Immediate early motion.

KEY POINTS TO SCORE

ATLS / High energy context

Olecranon osteotomy for exposure

Dual plating mandatory

Ulnar nerve protection

COMMON TRAPS

✗Using single plate

✗Inadequate articular reduction

✗Missed compartment syndrome

LIKELY FOLLOW-UPS

"Why olecranon osteotomy over TRAP?"

"What is the risk of non-union?"

VIVA SCENARIOStandard

Scenario 2: Elderly C3 Fracture

EXAMINER

"A 78-year-old active female presents after a fall with a comminuted intra-articular distal humerus fracture (AO type 13-C3). She has osteoporosis but lives independently. How do you manage this?"

EXCEPTIONAL ANSWER

**Assessment:** Elderly patient with "bag of bones" comminution. ORIF is prone to failure and stiffness. **Decision:** I would recommend **Total Elbow Arthroplasty (TEA)**. It provides reliable pain relief and creates immediate stability for early motion. ORIF in this group has high failure rate. **Counseling:** Must accept **lifelong 5kg weight restriction**. If she was high demand (e.g., uses walking aid heavily), might reconsider or use specific robust implants, but TEA usually best.

KEY POINTS TO SCORE

Bone quality dictates treatment

TEA superior for elderly C3 (McKee)

Lifelong restrictions (5kg)

Semi-constrained implant used

COMMON TRAPS

✗Attempting heroic ORIF in poor bone

✗Ignoring functional demands (walking aids)

✗High infection risk in RA

LIKELY FOLLOW-UPS

"What is the main complication of TEA?"

"How does RA affect your decision?"

VIVA SCENARIOChallenging

Scenario 3: Post-op Stiffness

EXAMINER

"At your post-operative review 6 weeks after ORIF, your patient has only 30-100 degrees of motion (70 degree arc). What is your approach?"

EXCEPTIONAL ANSWER

**Assessment:** Stiffness is the most common complication. Exclude: Infection, Malreduction, Hardware prominence, HO. **Management:** 1. **X-rays:** Check union and HO. 2. **Physio:** Intensify. Static progressive splinting (Turnbuckle) is gold standard for non-operative management. 3. **Surgery:** If no progress after 6 months and HO mature then **Release** (Open or Arthroscopic). 4. **Manipulation:** Generally contraindicated late (risk of fracture).

KEY POINTS TO SCORE

Rule out mechanical block first

Static progressive splinting

Wait for HO maturity before release

Prevention is key (Early motion)

COMMON TRAPS

✗Forceful manipulation (fracture risk)

✗Operating too early on HO

✗Missing infection

LIKELY FOLLOW-UPS

"When is HO excision indicated?"

"What is the safe arc for ADLs?"

VIVA SCENARIOStandard

Scenario 4: Bicolumnar Anatomy

EXAMINER

"Describe the bicolumnar anatomy of the distal humerus and how this guides your fixation strategy."

EXCEPTIONAL ANSWER

**Anatomy:** Triangle formed by Medial and Lateral columns supporting the articular block. **Tie Arch** concept. **Fixation:** - Requires **Dual Plating** to restore the triangle integrity. - Single plate leaves one column unstable (toggle). - Plates can be **90-90 (Orthogonal)** or **180 (Parallel)**. - Screws must lock the distal fragment (interdigitate).

KEY POINTS TO SCORE

Triangle concept

Dual plating mandatory

Single plate fails

Interdigitating screws

COMMON TRAPS

✗Placing plates on thin bone (fossae)

✗Single column fixation

✗Inadequate distal purchase

LIKELY FOLLOW-UPS

"Where is the bone thickest?"

"Describe the screw configuration"

MCQ Practice

High-Yield Exam Facts

Dual Plate Fixation

Q: Why is dual plate fixation mandatory for intercondylar fractures? A: The distal humerus has a bicolumnar architecture where medial and lateral columns diverge distally to support the articular surface. Both columns must be stabilized for adequate fixation; single plate fixation will fail.

AO Classification Guide

Q: What are the AO/OTA 13-C subtypes and how do they guide treatment? A: C1 (simple articular, simple metaphyseal) - standard ORIF; C2 (simple articular, comminuted metaphyseal) - ORIF with possible bone graft; C3 (comminuted articular) - ORIF in young patients or TEA in elderly. Treatment selection depends on fracture complexity, patient age, and bone quality.

Plating Configuration

Q: Compare orthogonal vs parallel plating configurations. A: Both are biomechanically equivalent. Orthogonal (90°) positions plates posteromedially and posterolaterally at 90° to each other. Parallel (180°) positions both plates on the posterior surface. Both require minimum 2-3 screws in each distal fragment with interdigitating screws for stability.

TEA Indications

Q: When is TEA preferred over ORIF for intercondylar fractures? A: TEA is preferred in elderly patients (over 65-70) with severe osteoporosis and unreconstructable articular comminution (C3 fractures). Level I evidence (McKee 2009) shows better DASH scores and fewer complications than ORIF in this population.

Stiffness Prevention

Q: What is the most common complication and how is it prevented? A: Elbow stiffness (20-40% incidence) is most common. Prevention requires stable fixation allowing early motion within 1-2 weeks. The functional ROM arc needed for ADLs is 30-130° (100° total arc). Early aggressive physiotherapy is critical.

Ulnar Nerve Management

Q: How should the ulnar nerve be managed during surgery? A: Ulnar nerve identification is mandatory in all cases - it runs posterior to the medial epicondyle. Most surgeons transpose the nerve (subcutaneously or submuscularly) to prevent late ulnar neuritis from hardware irritation, though in situ management is an option.

Self-Assessment Questions

Question 1: What is the primary reason dual plate fixation is required for intercondylar distal humerus fractures?

A. To increase stability against rotational forces
B. Because of the bicolumnar anatomy requiring both columns to be stabilized
C. To allow placement of more screws
D. Because single plates are not strong enough
E. To facilitate hardware removal

Answer: B - The distal humerus has a bicolumnar architecture with medial and lateral columns supporting the articular surface. Both columns must be stabilized for adequate fixation, requiring dual plates.

Question 2: Which surgical approach provides the best visualization of the articular surface in intercondylar fractures?

A. Medial approach
B. Lateral approach
C. Olecranon osteotomy
D. Bryan-Morrey approach
E. Paratricipital approach

Answer: C - The olecranon osteotomy provides the best direct visualization of the articular surface (trochlea), allowing anatomic reduction of complex articular fractures.

Question 3: What is the most common complication following ORIF of intercondylar fractures?

A. Infection
B. Nonunion
C. Stiffness
D. Ulnar nerve injury
E. Hardware failure

Answer: C - Elbow stiffness is the most common complication, occurring in 20-40% of cases. Prevention through early motion is essential.

Question 4: In which patient would TEA be preferred over ORIF for an intercondylar fracture?

A. 35-year-old manual laborer with C1 fracture
B. 80-year-old with RA and C3 fracture with severe comminution
C. 50-year-old with C2 fracture
D. 25-year-old athlete with C3 fracture
E. 60-year-old with C1 fracture and good bone quality

Answer: B - TEA is appropriate for elderly, low-demand patients with osteoporosis or RA and unreconstructable articular comminution (C3). Young active patients should have ORIF attempted regardless of complexity.

Question 5: When performing dual plating, what is the recommended minimum number of screws in each distal fragment?

A. 1
B. 2-3
C. 4-5
D. 6
E. As many as possible

Answer: B - A minimum of 2-3 screws in each distal fragment is recommended. Screws should interdigitate between the two plates for maximum stability.

Australian Context

Intercondylar fractures of the distal humerus in Australian practice require consideration of patient demographics, healthcare access, and rehabilitation resources.

The bimodal distribution of these fractures is evident in Australia, with young males sustaining high-energy injuries in motor vehicle accidents, workplace incidents, and sports, while elderly females present after low-energy falls in the setting of osteoporosis. The aging Australian population means an increasing incidence of fragility fractures, making the choice between ORIF and TEA increasingly relevant.

Australian orthopaedic training through the AOA provides comprehensive exposure to both ORIF techniques and elbow arthroplasty. Major metropolitan trauma centers are equipped for complex reconstructive surgery, while regional areas may need to transfer patients for specialized care. The availability of implants including pre-contoured distal humerus plates and elbow prostheses is generally good throughout the public and private hospital systems.

Rehabilitation services are essential for optimal outcomes. Australian public hospital physiotherapy departments and private practitioners provide supervised rehabilitation programs. The importance of early motion cannot be overemphasized, and patients require clear instruction and access to regular therapy sessions. Some patients may benefit from inpatient rehabilitation in the early post-operative period, particularly elderly patients after TEA.

WorkCover and third-party compensation schemes cover work-related and motor vehicle accident injuries. The potential for prolonged disability and the need for rehabilitation means case management is often required. Permanent impairment assessment following these injuries commonly documents loss of range of motion, which affects compensation calculations under the various state guidelines.