Abstract. Introduction. Intra-articular distal humerus OTA type C fractures are challenging to treat. When osteosynthesis is not feasible one can choose to do a primary arthroplasty of elbow or manage non-operatively. The indications for treatment of this fracture pattern are evolving. Objectives. We present our outcomes and complications when this cohort of patients was managed with either open reduction internal fixator (ORIF), elbow arthroplasty or non-operatively. Methods. Retrospective study to include OTA type C2 and C3 fracture distal humerus of 36 patients over the age of 50 years managed with all the three modalities. Patient's clinical notes and radiographs were reviewed. Results. Between 2016 and 2022, 21 patients underwent ORIF – group 1, 10 patients were treated with arthroplasty – group 2 and 5 were managed conservatively- group 3. The mean age of patients was 62 years in group 1, 70 years in group 2 and 76 years in group 3. The mean range of movement (ROM) arc achieved in the group 1 & 2 was 103 while group 3 was 68. At least follow up was 6 months. 5 patients in group 1 underwent metalwork removal and 2 patients in group 3 under arthroplasty. Conclusion. The outcomes of arthroplasty and ORIF are comparable, but reoperation rates and stiffness were higher in ORIF and conservative group. Surgeon choice and patient factors play important role in decision towards choosing treatment modality. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Introduction. The epicondylar axis of the elbow is a surface anatomical approximation of the true flexion-extension (F-E) axis used in the application of an external fixator/elbow arthroplasty. We hypothesise that the epicondylar axis coincides with the true F-E axis in terms of both angular displacement and position (ie. offset). This suggests that it can serve as a good landmark in total dynamic external fixator application and elbow arthroplasty. Methods. Three-dimensional elbow models were obtained through manual segmentation and reconstruction from 142±40 slices of CT scans per elbow in 15 cadeveric specimens. Epicondylar axis was defined to be the axis through the 2 epicondyles manually identified on the elbow models. F-E axis was defined to be the normal of a circle fitted on 20 points identified on the trochlear groove. The long axis of the elbow was identified through a line fit through the center of the distal humerus on several slices along the elbow CT. Angle between the long axis and epicondylar axis was measured. Angular deviation of the epicondylar axis and the F-E axis was calculated in reference to the long axis. All axes were projected onto the orthogonal planes on the elbow CTs and all measurements were repeated. Angular differences in the axial, saggital and coronal planes are described in internal/external rotation, flexion/extension and valgus/varus respectively. Offset in the axial and coronal planes are described in the following directions respectively: proximal/distal and anterior/posterior respectively. Comparisons between angles were performed using student's t-test. Results. Angle between the long axis and the epicondylar axis in our study (85.9±5.30) was not significantly different when compared to an existing study (87.3±2.80) (p=0.327). The epicondylar axis deviates from the true F-E axis by 1.9±4.50 (p=0.523) in flexion, 2.1±3.40 (p=0.442) varus, and 0.5±2.70 (p=0.851) in external rotation with an overall angular deviation of 2.2±4.80 (p=0.204). There was no statistical significance difference in the angle deviations mentioned. The offset between the epicondylar axis and the F-E axis was 15.6±3.4 mm anterior and 9.4±2.9 mm distal with an overall offset of 17.6±2.5 mm. Discussion. Our study demonstrated small and statistically insignificant angular difference between the epicondylar axis and the F-E axis. However, offset between the axes exists and may be clinically significant. When the epicondylar axis is used as an approximation to the natural F-E axis, this offset may introduce a moment on elbow flexion resulting in additional strain on the elbow collateral ligaments and dynamic external fixators. Implications of this as well as ligament balancing and implant stress-strain patterns in elbow arthroplasty merit further research with potential modification of technique and jigs. Significance. Although the angular difference between between the epicondylar and F-E axes was not statistically significant, an offset between the axes exist. Further research is required to elucidate its impact and the need for modification on elbow implants and external fixators

The aim of management of an adult distal humeral fracture is to restore mobility, stability and pain-free elbow function. Good results are usually achieved in the majority of fractures treated with ORIF, but the management of comminuted fractures in elderly, frail patients with osteoporotic bone remains controversial. The literature focuses on elbow replacement if stable internal fixation cannot be achieved, with “bag-of-bones” management now rarely discussed eg. key-note paper - 10 successful cases reported by Brown RF & Morgan RG in 1971 (JBJS 53-B(3):425-428). We present the experience in two units in which conservative management has been actively adopted in selected cases by consultants with a subspecialty interest in the elbow. All patients over the age of 60 with distal humeral fractures (2007 – 2009) who had been treated conservatively were reviewed clinically and radiologically. Duration of follow-up and outcome, including the Oxford and quick DASH scores, were recorded, with the fractures classified using the AO system. There were 25 patients, 19 female and 6 male. 19/25 patients have been successfully treated conservatively with a mean Range Of Movement: Extension/Flexion: 45/125, Pronation/Supination 74/70. Only 5 underwent subsequent total elbow replacement and one delayed ORIF. There is a significant complication rate following surgical treatment with ORIF or elbow replacement in elderly, frail patients, including infection, painful non-union and/or stiffness. We believe that there is a role for initial conservative treatment in selected patients with low, displaced, comminuted humeral fractures in osteoporotic bone. Initial early mobilisation as pain allows can give good functional results without the risks of operation. It does not preclude future surgery if conservative treatment fails, but this is not required in the majority of cases