Columnar Buttress Plating after a Comminuted Distal Humerus Fracture in the Elderly: an Alternative to the “Bag-of-bones” Technique, a Method and Case Series

Introduction: Intra-articular, comminuted distal humerus fractures are common injuries in the elderly. Treatment is challenging secondary to osteoporotic bone, poor wound-healing, co-morbidities, and limited functional reserve. Operative management typically entails detailed anatomic articular reduction, columnar plate fixation, and often olecranon osteotomy. In geriatric patients with severe intra-articular comminution, or those who are unable to tolerate surgery, non-operative management with immobilization and early range of motion of the elbow—the “bag of bones” approach—has been advocated. However, this method is associated with poor functional outcomes, distorted distal humerus geometry, and joint dysfunction.

Methods: We describe an “enhanced bag of bones” (EBB) technique, in which buttress plate fixation with minimal intra-articular reduction allows for reconstruction of the overall distal humeral architecture with shorter operative times and decreased risk of wound complications as compared with ORIF involving olecranon osteotomy. EBB technique only provides columnar support and relies on an intact olecranon to allow functional remodeling of a highly comminuted trochlea.

Results: 26 patients were treated with EBB technique and compared with 32 age matched controls using ORIF with olecranon osteotomy.

Conclusion: In our case series, EBB technique appears to offers slightly improved ROM, fewer complications, and less need for additional surgery than ORIF with olecranon osteotomy. EBB involves less surgery, preservation of the extensor mechanism for future total elbow arthroplasty if ever needed, and anecdotally results in higher patient satisfaction for a challenging fracture pattern in a frail population.