Total elbow arthroplasty for a neglected malunited distal humerus fracture using a diamond pop-up approach – a case report

Introduction: Neglected distal humeral fractures in elderly patients often progress to painful malunion, advanced osteoarthritis, and profound loss of elbow function. When anatomical reconstruction is not feasible due to osteoporosis and chronic deformity, total elbow arthroplasty (TEA) serves as a reliable salvage option. Case presentation: We report a challenging case of a 68-year-old female who presented with left elbow pain and severe post-traumatic combined contracture 5 months after injury. She had initially been treated by a non-professional with above-elbow plaster immobilization in full extension for 6 weeks, followed by massage therapy. Examination revealed a fixed elbow in terminal extension with no flexion and severe pain on attempted movement. Radiographs demonstrated a malunited distal humeral fracture with complete separation and fibrosis of the condylar region, accompanied by end-stage post-traumatic osteoarthritis. The patient underwent cemented linked TEA through a triceps-on diamond pop-up approach. At 1-year follow-up, she demonstrated excellent radiological alignment and functional recovery. Discussion: Neglected distal humeral fractures are difficult to manage, especially in elderly osteoporotic patients. TEA has been widely shown to provide reliable outcomes when anatomic reconstruction is not feasible. The diamond pop-up approach offers extensile exposure without olecranon osteotomy while preserving triceps integrity, facilitating early rehabilitation and minimizing extensor complications. Conclusion: Cemented linked TEA using a diamond pop-up triceps preserving approach is a safe and effective strategy for elderly patients with neglected distal humeral malunion and fixed elbow stiffness.