Comminuted fractures of the distal humerus are very difficult to treat. The technical difficulty increases significantly when there is associated bone loss and fractures of the ulna or radius. These injuries are a result of high energy trauma and are often found in young individuals.
Treatment to union with an external fixator with or without repeat debridements in this case would have resulted in severe disability and pain. Immediate reconstruction in a Gustilo / Anderson III injury has significant risk for peri-operative infection. Repeat debridement with delayed reconstruction of the medial column and removal of the capitellum would result in valgus instability and would be doomed to fail.
The best option would be repeat debridement, delayed primary wound closure, and observation until wound healing. Reconstruction of both the medial and lateral column with bone grafting would follow after stabilization of the soft tissues. Osteochondral allografting of the distal humeral lateral column should be seen only as a last resort because of the significant associated morbidity. Autograft reconstruction in addition to reduction of the remaining capitellar fragments of the distal humeral lateral column presents the best initial option for this patient. Failure of this option would not preclude osteochondral allografting at a later date.