INTRODUCTION

Dramatic changes have occurred in the treatment of elbow fractures in recent years. This is especially true for distal humerus fractures. Although improvements in fracture-specific fixation devices have occurred, the most important advances can be attributed to a principle-based approach to these fractures.

Recovery of painless and satisfactory elbow function after a fracture of the distal humerus requires anatomic reconstruction of the articular surface, restitution of the overall geometry of the distal humerus and stable fixation of the fracture fragments to allow early and full rehabilitation.^{2,4,5,7–9,14} Although these goals are obvious, the orthopedic community would agree that they may be technically difficult to achieve, especially in the presence of substantial osteoporosis or comminution.¹⁴

The techniques proposed by the AO/ASIF group had been standard for fixation of distal humerus fractures in the past.^8,14 Their recommended technique included fixation of the articular fragments with screws and column stabilization with two plates at a 90-degree angle to one another.^3,8,19 Fracture stability is only as secure as the fixation of the distal fragment to the shaft. Using standard AO/ASIF techniques, different authors have reported unsatisfactory results in 20% to 25% of patients.^2,4,5,7–9

Improvements in the treatment of these fractures recently have been predicated on understanding and overcoming the limitations and reasons for failure of previous techniques. When treatment of severe distal humerus fractures fails, it typically is due to either nonunion at the supracondylar level or stiffness resulting from prolonged immobilization that has been used in an attempt to avoid failure of inadequate fixation.¹⁴ Either way, the limiting factor is fixation of the distal fragments to the shaft. In an effort to increase the yield of excellent and satisfactory results obtained after fixation of distal humerus fractures and to reproducibly obtain stable fixation in the presence of osteoporosis or comminution, I recommend (and have used for two decades) an alternative philosophy and technique based on principles that maximize fixation in the distal fragments and compression at the supracondylar level.^{11–13,15,17} The key to the stability achieved with this fixation construct is that it combines the features and stability of an arch while locking the two columns of the distal humerus together. The stability achieved allows routine commencement of an intensive rehabilitation program postoperatively, including full active motion with no external protection.

The following discussion expands on the general principles of our current approach to these fractures, the specific technical details, the postoperative program, and the potential complications.

PRINCIPLE-BASED FIXATION

PRINCIPLES AND TECHNICAL OBJECTIVES

Before discussing the details of surgical techniques, it is imperative that the treating surgeon understand the principles (Box 22-1) and technical objectives (Box 22-2) that, if followed and achieved respectively, will maximize the likelihood of a successful outcome from treatment of these fractures.

BOX 22-1 Principles of Fracture Fixation Surgery

The principles by which the earlier mentioned goals are achieved, and the technical objectives at the time of surgery for achieving them, are

1. Maximize fixation in the distal fragment.

2. All fixation in distal fragments should contribute to stability between the distal fragments and the shaft.

BOX 22-2 Technical Objective Checklist

Concerning screws in the distal fragments (articular segment):
	1. Each screw should pass through a plate.

2. Each screw should engage a fragment on the opposite side that is also fixed to a plate.

3. An adequate number of screws should be placed in the distal fragments.

EXPOSURE

The operation is performed with the patient in the supine position. A sterile tourniquet is inflated only for dissection of the ulnar nerve, which is transposed anteriorly. The triceps-anconeus reflecting pedicle (TRAP) approach provides adequate exposure for a surgeon experienced with the technique.¹⁰ This technique involves combining the Bryan-Morrey and modified Kocher approaches to reflect the triceps in continuity with the anconeus. However, I believe that an olecranon osteotomy provides even greater exposure and is recommended in the setting of intra-articular comminution. The TRAP approach is indicated if total elbow replacement is necessary.

PRINCIPLE-BASED SURGICAL TECHNIQUE

The surgical technique is performed in five steps:

Stability and function are restored by achieving eight technical objectives (see Box 22-2) derived from the principles of (1) maximizing fixation in the distal fragments, and (2) ensuring that all fixation in the distal segment contributes to stability at the supracondylar level (see Box 22-1) (Fig. 22-1).

FIGURE 22-1 The technical objectives described in this paper are illustrated. The screws in the distal fragments interlock, providing additional stability to the construct by “closing the arch.” Interlocking is best achieved by contact between the screws. The combination of multiple screws criss-crossing in close proximity with bone between them gives a “rebar” (reinforced concrete) type structure.

All eight of these objectives are achieved with the technique of what we term parallel plating. The medial plate is placed on the medial aspect of the medial column, and the lateral plate is placed laterally, rather than posteriorly, on the lateral column. Although we refer to them as parallel, each plate is actually rotated posteriorly slightly out of the sagittal plane such that the angle between them is often in the range of 150 to 160 degrees. This orientation permits insertion of at least four long screws completely through the distal fragments from one side to the other. These screws interdigitate, thereby creating a fixed-angle structure and greatly increasing stability of the construct. Contact between screws is intended to enhance the locking together of the two columns. The plates must be contoured to fit the geometry of the distal humerus if precontoured plates are not available, but the latter facilitate anatomic reconstruction.

Interfragmentary compression is obtained between articular fragments as well as at the metaphyseal level through the use of large bone clamps that provide compression during the insertion of the screws attaching the articular segment to the shaft. In the distal fragments, fully threaded screws inserted in this manner provide maximum thread purchase in the distal fragments. Additional compression at the metaphyseal level results from slight undercontouring of the plates and the use of dynamic compression holes in the plates. The specific steps of the surgical technique are detailed below.

STEP 1. ARTICULAR SURFACE REDUCTION

Once the fracture is exposed, the first step is reassembly of the articular surface. The proximal ulna and radial head can be used as a template for the reconstruction of the distal humerus. The articular fragments are provisionally fixed with smooth Kirschner wires (K wires) (Fig. 22-2). In cases with extensive comminution, fine threaded wires (1 to 1.5 mm) are used, then cut off and left in as definitive adjunctive fixation. K wires permit assembly of the joint surface fragments in a manner that is analogous to the use of dowels in furniture making. It is necessary that these wires be placed close to the subchondral level so as not to interfere with the passage of screws from the plates into the distal fragments; specifically, no screws are placed in the distal fragments until the plates are applied. The articular fragments are fixed in the following order:

1.a. Anterior trochlea and capitellum

1.b. Medial trochlea

1.c. Posterior fragments

FIGURE 22-2 Step 1. Articular reduction. The articular fragments, which tend to be rotated toward each other in the axial plane, are reduced anatomically and provisionally held with 0.035 inches or 0.045 inches smooth Kirchner wires. It is essential that the wires be placed close to the subchondral level, to avoid interference with later screw placement, and away from where the plates will be placed on the lateral and medial columns. One or two strategically placed pins can be used to provisionally hold the distal fragments aligned with the shaft.

The articular surface of the distal humerus should be reconstructed anatomically unless bone is missing. In the event of absent bone, two important principles should be taken into consideration. First, the anterior aspect of the distal humerus is the critical region that needs to be restored in order to have a functional joint; reconstruction of the posterior articular surface of the distal humerus is less critical. Second, stability of the articulation requires the presence of the medial trochlea in combination with either the lateral half of the trochlea or the capitellum; thus, the medial trochlea is essential to obtain a stable and well-aligned joint.

STEP 2. PLATE APPLICATION AND PROVISIONAL FIXATION

We routinely use precontoured medial and lateral plates from the Mayo Congruent Elbow Plate System (Acumed, Hillsboro, OR) (Fig. 22-3). The medial plate can be extended to the articular margin in very distal or comminuted fractures and is contoured to the shape of the medial epicondyle. The ulnar nerve must be transposed if this extended plate is used. The distal end placed more posteriorly to prevent impinging on, or cutting into, the common extensor tendon and lateral collateral ligament complex. Both plates should be slightly undercontoured to provide additional compression at the metaphyseal region when applied. The length of the plates is selected so that at least three screws are placed both medially and laterally proximal to the metaphyseal component of the fracture. These plates are designed so that in any combination they will end at different levels to avoid the creation of a stress riser proximally. The plates are then provisionally applied according to the following steps:

1. Two smooth Steinmann pins (2.0 to 2.5 mm) are introduced at the medial and lateral epicondyles through holes in the plates while they are held accurately against the bone; the most commonly used holes are the second one laterally and the third medially. These pins are left in place until after step 4 (see later). The pins create pilot holes for later replacement with screws, are easy to drill around, and do not interfere as much with placement of the two distal screws, as would be the case if they were replaced by screws earlier.

2. The appropriate reduction of the distal fragments to the humeral shaft at the supracondylar level is confirmed.

3. One cortical screw is loosely introduced into a slotted hole to hold each plate in place. Use of slotted holes for these screws facilitate later adjustments in plate positioning.

FIGURE 22-3 Step 2. Plate application and provisional fixation. Medial and lateral precontoured plates are placed and held apposed to the distal humerus, while one smooth 2 or 2.5 mm Steinmann pin is inserted through hole #2 (numbered from distal to proximal) of each plate, through the epicondyles, and across the distal fragments, to maintain provisional fixation of the plates to the distal fragments. A screw is placed in the slotted hole (#5) of each plate, but not fully tightened, leaving some freedom for the plate to move proximally later during compression. Because the undersurface of each plate is tubular in the metaphyseal and diaphyseal regions, the screw in the slotted hole only needs to be tightened slightly to provide excellent provisional fixation of the entire distal humerus.

STEP 3. DISTAL FIXATION

Once the plates are provisionally applied, medial and lateral screws are introduced distally to provide stable fixation of the intraarticular fragments and rigid anchorage to the plates (Fig. 22-4).

FIGURE 22-4 Step 3. Screws are inserted through hole #1 of the lateral plate and across the distal articular fragments from lateral to medial, and tightened. This step is repeated on the medial side, using hole #3. In young patients, 3.5-mm cortical screws are used (to prevent breakage), whereas long 2.7-mm screws are used in patients with osteoporotic bone. The distal screws should be as long as possible, passing through as many fragments as possible, and engaging the condyle or epicondyle of the opposite column.

1. Two distal screws, one medial and one lateral, are inserted using a targeted drill guide. As stated earlier, the screws should be as long as possible, pass through as many fragments as possible, and engage in the opposite column. Before screw insertion, a large bone clamp is used to compress the intra-articular fracture lines, unless there is a gap in the articular surface. This ensures interfragmentary compression without the need for lag screws.

STEP 4. SUPRACONDYLAR COMPRESSION

The plates are then fixed proximally under maximum compression at the supracondylar level (Fig. 22-5A and B).

FIGURE 22-5 Step 4. A, Using a large tenaculum to provide interfragmentary compression across the fracture at the supracondylar level, the lateral column is fixed first. A screw is placed in dynamic compression mode (inset) in hole #4 of the lateral plate. Tightening it further enhances interfragmentary compression at the supracondylar level (converging arrows) to the point of causing some distraction at the medial supracondylar ridge (diverging arrows). B, The medial column is then compressed in a similar manner using the large tenaculum, and a screw is inserted in the medial plate in dynamic compression mode. If the plates are slightly undercontoured, they can be compressed against the metaphysis with a large bone clamp, giving further supracondylar compression.

1. The slotted proximal screw on one side is backed out, and a large bone clamp is applied distally on that side and proximally on the opposite cortex to eccentrically load the supracondylar region. A second proximal screw is inserted through the plate in compression mode and then the screw in the slotted hole retightened. Care should be taken not to change the varus-valgus or rotational alignment of the articular surface when the bone clamps are applied.

2. The same steps are followed on the opposite side. Following this step the fixation should be stable.

3. The remaining diaphyseal screws are then introduced, providing additional compression as a result of the undercontoured plates being pulled down to the underlying bone. To avoid having the screws strip the bone, this last step is best performed by squeezing the plates against the bone with a large clamp rather than relying on the screws to deform the plates.

STEP 5. FINAL FIXATION

The smooth Steinmann pins are removed, and then the remainder of the screws are inserted (Fig. 22-6). The intraoperative elbow motion should be full unless significant swelling has already developed. One deep and one subcutaneous drain are placed during the closure. The skin should be closed with staples or interrupted sutures.

FIGURE 22-6 Step 5. The smooth Steinmann pins are all removed and the remainder of the screws inserted. The distal screws interdigitate for maximum fixation in the distal articular fragments (as described in Fig. 22-1).

DEALING WITH METAPHYSEAL BONE LOSS

Adequate bony contact with interfragmentary compression in the supracondylar region is necessary to ensure the stability of the construct and eventual fracture union. If metaphyseal bone loss or comminution precludes an anatomic reconstruction with satisfactory bony contact, the humerus can be shortened at the metadiaphyseal fracture site, provided that the overall alignment and geometry of the distal humerus is correct. We refer to this alternative reconstructive technique as supracondylar shortening (Fig. 22-7A to G). This technique is especially useful in cases of combined soft tissue and bone loss. Shortening by 1 cm or less has only a slight effect on triceps strength in terminal extension,⁶ and in cases of severe soft tissue and bone loss, up to 2 cm of shortening can be tolerated without serious disturbance of elbow biomechanics.⁶

FIGURE 22-7 In cases of supracondylar bone loss, and in some cases of severe comminution, anatomic placement of the distal humerus with respect to the shaft would leave a large structural defect in one or other column, and only point contact in the other. In such cases when structural bone graft is not an option, a supracondylar shortening osteotomy can be performed. A, This involves reshaping the distal end of the shaft (dark lines) (never the articular segments) to enhance contact between the distal articular segment and the shaft. Usually, only a small amount of bone is resected from the distal end of the shaft, and sometimes from one side of it as well (for side-to-side apposition and compression). B and C, The limb is shortened through the fracture site to permit interfragmentary compression between the trochlea and the distal shaft, between the capitellum and the distal shaft, and side to side on one or both sides. Once these surfaces have been compressed and fixed with the plates, stability is strong enough to permit immediate motion and rehabilitation. It is acceptable to translate the distal segment medially or laterally, and also slightly anteriorly, provided that rotational and valgus alignment is maintained. D to G, Preoperative and most recent radiographs of a severe distal humerus fracture with substantial bone loss that was treated with shortening. H and I, Elbow range of motion at most recent follow-up was 0 to 150 degrees.

POSTOPERATIVE MANAGEMENT

Immediately after wound closure, the elbow is placed in a bulky noncompressive Jones dressing with an anterior plaster slab to maintain full extension and the upper extremity is kept elevated for 3 days or more, depending on the extent of soft tissue damage. Those fractures with severe soft tissue damage, which include most open fractures and high-energy closed fractures, are immobilized and elevated in elbow extension for 3 to 7 days postoperatively. While elevated, the limb is let down for a few minutes once or twice each hour to permit shoulder movement, to relieve discomfort, and to prevent perfusion disturbance. Closed fractures without severe swelling or fracture blisters are removed from the Jones dressing after 3 days, and a nonconstrictive elastic sleeve is applied over an absorbent dressing placed on the wound. A physical therapy program including active and passive motion is then initiated. All patients are permitted active use of the hand and instructed not to lift (or push or pull) anything heavier than a glass of water or a telephone receiver for the first 6 weeks. No form of external protection, such as casts or braces is needed if the technical objectives have been achieved.

If postoperative motion fails to progress as expected, a program of patient-adjusted static splinting is instituted as soon as the soft tissues are healed. The torque across the elbow applied with such a patient-adjusted splint was low enough to cause discomfort but not pain, and therefore not of concern with regard to the security of the fracture fixation.

Continuous passive motion (CPM) is helpful in speeding the recovery of motion if the soft tissues will tolerate CPM. In cases of severe soft tissue trauma, it may be wise to postpone or avoid using CPM.

STRUCTURAL STABILITY VERSUS FRACTURE STABILITY

I wish to emphasize that this principle-based technique is not just a different method of fracture fixation. It is a whole new concept based on the idea that stability of the distal humerus is achieved by the creation of an architectural structure. The bone fragments rely on their integration with the whole structure for stability, rather than on fixation of each bone fragment by screw threads. The concept is borrowed from modern architecture and the application of civil engineering principles to surgery. The interdigitation of screws within the distal segment rigidly attaches the articular fragments to the shaft by linking the two columns together. This permits stability to be achieved in such cases as low transcondylar (Fig. 22-8A to D) or severely comminuted (Fig. 22-9A to D) fractures.

FIGURE 22-8 Low supraintercondylar fractures through osteopenic bone (A and B) require placement of the plates distal enough to allow secure fixation. Excellent stability can still be obtained with the technique of parallel plating, employing a medial plate that is contoured around the epicondyle onto the medial side of the trochlea along with a lateral plate (C and D).

FIGURE 22-9 A severely comminuted fracture (A and B) that healed uneventfully after open reduction and internal fixation. C and D, Fine-threaded K-wires, fully embedded in the bone, were used to assemble the articular fragments, just as dowels are used when pieces of wood are glued together to make furniture.

The concept follows the architectural principles of an arch, in which two columns are anchored at their base (on the shaft of the humerus) and linked together at the top (long screws from the plates on each side interdigitating within the articular segment). The interdigitation is best achieved by contact between the screws. However, multiple screws separated by small gaps within the bone will function as a “rebar” construct (steel rods inside concrete). Fixation of the bone fragments is thus reliant not on screw purchase in the bone, but on the stability of the hardware framework, in just the same way that a modern building derives its stability from the grid work of steel assembled and bolted or welded together inside its walls and columns.

The screws in the distal segment are converted into fixed angle screws by two of the technical objectives. First, several long screws in the distal fragments lock together by interdigitation. Second, these screws pass through a plate on one side and into a bone fragment on the other side that itself is also anchored by a plate. From an engineering perspective, this technique of creating fixed angle screws enhances fixation in the distal fragments. It also permits rigid linkage and compression between the distal segment and the shaft. The combined use of clamps, strong and slightly undercontoured plates, dynamic compression holes, and selected metaphyseal shortening provides interfragmentary compression at the supracondylar level. The stability of the construct is such that a rehabilitation program can be commenced in the immediate postoperative period without fear of hardware failure.

Role of Locking Screws

Although fixed angle locking plates are available, I prefer to use variable angle locking screws (TAPLOC Acumed, Hillsboro, OR) for the distal segment to prevent the problem of incorrect screw positioning due to the fixed angles predetermined other plate designs. With the use of locking screws, fewer screws are thought necessary. However, based on my experience, and that of colleagues, I do not believe that locking screws are necessary if the principles and technical objectives for structural stability are achieved.

POTENTIAL COMPLICATIONS

The main complications that have been reported after internal fixation of distal humerus fractures are residual decreased range of motion, fixation failure with nonunion or malunion, nerve dysfunction, extensor mechanism dysfunction, post-traumatic degenerative changes, wound and skin problems, and avascular necrosis.^{1,2,4,5,7–9,20} The combination of ischemic skin and a subcutaneous hematoma is an indication for surgical lavage and reclosure of the wound.

With the internal fixation technique described earlier, we have experienced only one case of fixation failure in the past two decades. A 3.5 reconstruction plate experienced fatigue fracture 6 months after surgery in a patient with a severe open injury treated by supracondylar shortening and flap coverage. The lateral column had healed, necessitating only refixation and bone grafting of the medial column, which did result in union. His final range of motion was 20 to 120 degrees.

Decreased range of motion may occur secondary to heterotopic ossification, intra-articular adhesions, or capsular contracture. If heterotopic ossification prevents recovery of motion, the patient may require excision of the heterotopic bone and a capsular release that can be performed 3 to 6 months after the surgery. If the surgery is performed later, the hardware can be removed if the fracture is completely healed. However, if it is removed too early, refracture may occur.

Dysfunction of the extensor mechanism may occur if the triceps tendon fails to heal to the olecranon. Careful attention to reattachment of the extensor mechanism at surgery should help prevent this complication. The reconstruction should be solid enough to allow passive elbow flexion. Weakness does not seem to be a major problem with use of the TRAP approach for distal humerus fractures although it has not been specifically evaluated. Should discontinuity or subluxation of the extensor mechanism occur, it can be surgically treated by primary repair or augmentation with an Achilles tendon allograft. Olecranon nonunion can be treated by plate fixation and bone grafting.

Joint deterioration may be secondary to the cartilage damage sustained at the initial injury or the avascular necrosis secondary to the devascularization of some articular fragments in severely comminuted injuries. We have had one case of severe osteonecrosis in a severe multifragmentary fracture. To minimize the likelihood of this complication, it is necessary to leave all soft tissues attached to the distal fragments during surgery. Some cases of osteonecrosis may actually represent mechanical destruction due to instability of one or more articular fragments. It can be expected that if a fragment is mobile, it will cause progressive bone erosion.

PITFALLS AND TIPS

One pitfall to avoid is the placement of a free screw into the distal fragments prior to application of a plate. Such a screw does not contribute to supracondylar stability (principle #2) and is not as secure as it might have been if it had passed through a plate (principle #1). It also potentially interferes with the passage of the screws through the plate into the distal articular segment. Another pitfall is the inappropriate placement of K-wires for provisional fixation. These should be placed in the subchondral region rather than in the center of the articular segments where the screws will go. They also need to be placed where they will not interfere with the plates. Anticipating where the plates will be positioned on the bone before placing the temporary K-wires avoids this problem. Some surgeons experience difficulty with placement of the distal articular screws through the plates and across to the other side without violating the joint or the olecranon fossa. This maneuver is facilitated by the use of a targeted drill guide and by waiting to replace the 2 or 2.5 mm Steinmann pins in the distal articular segments until after having placed at least one screw through a second hole of each plate. These pins reserve a pathway for screws to be placed across the distal segment from each side. They also are easy to drill past and place a screw past, whereas if they are replaced by screws immediately, the subsequent drilling is rendered more difficult by the larger diameter screw. Moreover, when drilling through the distal segment, a drill bit may be prone to hitting a screw and break. This problem can be avoided by drilling with the drill on reverse or by drilling with a smooth Steinmann pin; the pin will tend to deflect off a screw rather than breaking.

With respect to the soft tissues, a common pitfall and misunderstanding is the assumption that the technique of parallel plating requires additional soft tissue stripping. Although the lateral skin flap must be raised around to the lateral supracondylar ridge and the lateral epicondyle, there is no additional stripping of the deep soft tissues from the lateral column compared to traditional plating of a distal humerus fracture. In all circumstances, the soft tissues should be retained on the articular fragments.

Excessive contouring of the distal end of the lateral plate can cause entrapment of the common extensor origin or lateral collateral ligament complex. This can result in loss of motion and even necrosis of the underlying soft tissues. This is avoided by placing the plate such that it stops at the epicondyle rather than distal to it and by ensuring that the plate does not wrap around the epicondyle and compress the soft tissues. This will give the appearance on the postoperative radiograph of the tip of the plate sitting away from the bone, but this space is required to accommodate the soft tissues under the plate.

The single biggest impediment to successful application of this principle-based technique is the misconception that plates must be applied in two perpendicular planes. Although that used to be true when very weak 3.5 one-third tubular plates were used, it most certainly is not true when strong plates are used. The “parallel” double-plate construct has been shown to provide excellent stability even in the presence of supracondylar gaps.¹⁸ In fact, Schemitsch et al.¹⁸ showed that the combination of a medial reconstruction and lateral DuPont plate in parallel planes was stronger than two reconstruction plates placed in two planes 90 degrees to each other, as is recommended by the AO/ASIF group and currently employed by most surgeons. When failure occurs, it is likely to start in the lateral column. With only one to three short screws into the capitellum, it can pull away from a posteriorly placed plate (Fig. 22-10A to C). We strongly recommend the use of this technique for comminuted distal humerus fractures, and prefer its use routinely for less complex fractures as well, because the stability is such that intensive rehabilitation is possible. However, for noncomminuted fractures in good quality bone, either technique can be used reliably.

FIGURE 22-10 Lateral column failure (varus). A, Failure fixation often occurs in the lateral column through repetitive gravitational forces that apply repetitive varus stress across the elbow. If the anteroposterior radiograph of the elbow is turned horizontally, one can readily appreciate the way in which varus stresses are applied. B, This mechanism of failure can be minimized by placing the lateral column plate in the sagittal plane on the lateral surface and having the screws pass all the way through to the medial side. C, With the elbow flexed to 90 degrees, varus stresses pull the lateral column and capitellum away from the posterior plate on the lateral column. Screw failure is by direct pullout from the soft and/or comminuted bone.

The efficacy of this approach to achieving structural stability was conclusively documented in a series of 32 consecutive complex distal humeral fractures.¹⁶ Twenty-six fractures were AO type C3, and 14 were open. Despite extensive comminution, bone loss, osteoporosis, or open wounds, neither hardware failure nor fracture displacement occurred in any patient. Union of 31 of the 32 fractures was achieved primarily. No patients required surgery to treat elbow stiffness unless heterotopic ossification had formed. There was one deep infection that resolved without hardware removal and did not impede union. At the time of the most recent follow-up, 28 elbows were either not painful or only mildly painful, and the mean flexion-extension arc was 99 degrees.

In summary, this principle-based approach to achieving “structural stability” in distal humerus fractures has many advantages. Complex fractures are able to be fixed with sufficient stability to permit immediate intensive rehabilitation. Some fractures that have been thought to be unfixable have been very satisfactorily fixed by applying the principles outlined herein. More straightforward fractures are easily fixed using the same techniques. In our experience, the stability achieved with this approach is so much greater than that with traditional methods of fixing distal humerus fractures that bone graft has only very rarely been required, despite the severity of injuries so typical of the tertiary referral nature of our practice.