Fratura do úmero distal

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview¶

• Reported outcomes for acute distal humerus fractures remain inconsistent across the orthopedic literature, making it difficult for surgeons to retrospectively compare surgical techniques and clinical outcomes across studies [3].
• Internal fixation is generally accepted as the standard of care for the treatment of intra-articular distal humerus fractures [4].
• Rigid anatomic fixation combined with early motion is associated with favorable results for intra-articular distal humerus fractures [4].
• Decision regarding the treatment for intra-articular fractures of the distal humerus should be based on a combination of the best available evidence and preference of the surgeon [10].
• Older patients who underwent ORIF of the distal humerus using a parallel construct demonstrated good functional outcomes [1].
• Older patients who underwent ORIF of the distal humerus using a parallel construct demonstrated similar complications to those in previously reported studies [1].
• For comminuted distal humerus fractures in young patients, ORIF appears to be the preferred surgical option [14].
• For comminuted distal humerus fractures in young patients, ORIF offers superior functional outcomes compared to hemiarthroplasty [14].
• For comminuted distal humerus fractures in young patients, ORIF offers a lower incidence of complications and heterotopic ossification compared to hemiarthroplasty [14].
• Distal humerus hemiarthroplasty is a viable option in the treatment of unreconstructible distal humerus fractures [2].
• Distal humerus hemiarthroplasty is expected to yield good to excellent outcomes for unreconstructible distal humerus fractures [2].
• Distal humeral hemiarthroplasty is a suitable option for unreconstructable distal humeral fractures [11].
• Distal humeral hemiarthroplasty offers good functional outcomes for unreconstructable distal humeral fractures [11].
• Distal humeral hemiarthroplasty offers acceptable complication rates for unreconstructable distal humeral fractures [11].
• Elbow hemiarthroplasty is a viable option for complex distal humeral fractures in select patients [16].
• Elbow hemiarthroplasty offers functional outcomes comparable to total elbow arthroplasty for complex distal humeral fractures [16].
• Elbow hemiarthroplasty potentially avoids complications related to the ulnar component compared to total elbow arthroplasty [16].
• Total elbow arthroplasty provides a successful treatment alternative for selected distal humerus fractures [32].
• Total elbow arthroplasty is particularly indicated for distal humerus fractures in elderly patients with low anticipated physical demands, severe osteopenia, or comminution [32].
• Open reduction and internal fixation with bone grafting is the treatment of choice for nonunion of distal humerus fractures if no excessive damage of the articular surface is present [5].
• A 2021 systematic review represents the largest report of complications and reoperations of intra-articular distal humeral fractures after ORIF in the current literature [8].

Anatomy & Pathophysiology¶

Bony Anatomy¶

• The elbow is a trocho-ginglymoid joint consisting of medial and lateral articulations that provide bony stability [37].
• The medial side features the trochlea articulating with the ulna within the greater sigmoid notch to form the ulnohumeral, hinged, or trochoid portion of the joint [37].
• The ulnohumeral articulation exhibits highly congruent anatomy through almost 180° of articular contact, excluding the bare area of the greater sigmoid notch which lacks cartilage [37].
• The coronoid process possesses medial and lateral facets that buttress the trochlea anteriorly [37].
• The sublime tubercle is located just distal and medial to the coronoid and serves as the attachment site for the anterior bundle of the medial ulnar collateral ligament [37].
• The medial epicondyle is larger and more posteriorly oriented than the lateral epicondyle and serves as the attachment site for the origins of the flexor pronator mass [37].
• Laterally, the capitellum and radial head form the radiocapitellar joint [37].
• The radial head is a concave elliptical structure covered with articular cartilage along the radiocapitellar joint and approximately 270° of the articular margin [37].
• The radial head articulates with both the capitellum and the lesser sigmoid notch of the ulna [37].
• The radius is held in close approximation to the ulna at the proximal radioulnar joint by the annular ligament [37].
• The distal humeral articulation is angled 30° from the longitudinal axis of the humerus [37].
• The anterior humeral line should pass through the center of the axis of rotation to avoid loss of flexion or extension during reconstructive efforts [37].
• The axis of rotation is angulated 5° to 7° in the coronal plane relative to the epicondylar axis, with the medial side positioned more distal than the lateral side [37].
• This coronal angulation accounts for the change from a valgus carrying angle to a more varus position as the elbow flexes [37].
• The ulna medially bends approximately 8° at 8 cm from the tip of the olecranon [37].
• The articulation to the tip of the coronoid is approximately 30° from the long axis of the ulna in the sagittal plane [37].
• The central area of the distal humerus comprises a coronoid fossa and an olecranon fossa, which is thin to allow extensive range of motion but acts as a weak point for complex fractures [9].
• The medial column holds the medial epicondyle and medial portion of the humeral trochlea and appears continuous with the humeral shaft axis when viewed from the side [9].
• The lateral column is flexed relative to the humeral shaft, placing the capitellum ahead of the trochlea [9].
• The epiphyseal section of the distal humerus containing the trochlear and capitellum articular surfaces is in 4–8° valgus relative to the shaft [9].
• The epiphyseal section of the distal humerus is externally rotated by 3–8° relative to the metaphysis [9].
• The epiphyseal section of the distal humerus is flexed 40° relative to the shaft [9].
• The radial head should line up with the capitellum at all arm positions on all radiographic views [38, 39].
• Tensile forces are present at the medial elbow, while compressive forces are present at the lateral elbow [38, 39].

Ligaments and Soft Tissue¶

• Elbow stability is conferred by bony articular anatomy and ligamentous structures on the medial and lateral sides [25].
• The primary stabilizers of the elbow are the ulnohumeral articulation, the medial ulnar collateral ligament (MUCL), and the lateral ulnar collateral ligament (LUCL) complex [25].
• The secondary stabilizers of the elbow are the radiocapitellar articulation, the common flexor tendon, the common extensor tendon, and the joint capsule [25].
• The medial ulnar collateral ligament is the primary valgus stabilizer of the elbow [38, 39].
• The anterior bundle of the medial ulnar collateral ligament is the most important component for stability [38, 39].
• The posterior bundle of the medial ulnar collateral ligament undergoes the greatest change in length and becomes taut at flexion beyond 120 degrees [38, 39].
• The lateral ulnar collateral ligament acts as the posterolateral stabilizer of the elbow [38, 39].
• Osborne’s ligament stabilizes the ulnar nerve in the cubital tunnel [38, 39].
• The ligament of Struthers is a variant anatomy arising from the supracondylar process to attach to the medial epicondyle and is a potential site of median nerve compression [38, 39].
• The joint capsule allows maximum distension at approximately 70 to 80 degrees of flexion [38, 39].
• The anterior capsule attaches at a point approximately 6 mm distal to the tip of the coronoid [38, 39].
• The coronoid tip is an intraarticular structure that is visualized during elbow arthroscopy [38, 39].

Muscles¶

• The brachialis is the strongest elbow flexor and attaches to the coronoid 11 mm distal to the tip [38, 39].
• The biceps brachii inserts at the ulnar margin of the radial tuberosity and acts as a powerful supinator of the forearm [38, 39].
• The triceps is the primary elbow extensor and inserts on the olecranon process [38, 39].
• The mobile wad consists of the brachioradialis, extensor carpi radialis longus, and extensor carpi radialis brevis [38, 39].
• The flexor-pronator mass consists of the pronator teres, flexor carpi radialis, palmaris longus, flexor carpi ulnaris, and flexor digitorum superficialis [38, 39].

Pathophysiology and Biomechanics¶

• The normal elbow has a range of motion from 0° to 140° from extension to flexion [25].
• The normal elbow has a range of motion of 75° in pronation and 85° in supination [25].
• A functional arc for the elbow is 100° for flexion and extension and forearm rotation [25].
• Injury to primary or secondary stabilizers causes elbow instability [25].
• Malunion is a common complication after distal humerus fractures influenced by biology, reduction, fixation methods, and mechanical failure [6].
• Normal function of the distal humerus is difficult to restore if the joint is deformed by malunion or stiffened by heterotopic ossifications or capsular and ligament contractures [9].
• Coronal shear fractures of the distal humerus can involve the capitellum, the trochlea, or both [56].
• Capitellum fractures account for 1% of all elbow fractures and 6% of distal humeral fractures [56].
• A potential mechanism for coronal shear fracture involves a direct axial load transmitted to the capitellum by the radial head following a fall onto an outstretched hand [56].
• A second mechanism for coronal shear fracture involves lateral collateral ligament complex failure, posterolateral subluxation, and shearing of the capitellum and trochlea by the radial head and coronoid during forearm reduction [56].
• Posterior shear fractures of the distal humerus mostly involve the posterior aspect of the capitellum and are often associated with elbow dislocation [50].
• The inherent complexity of the distal humerus makes a single treatment method unrealistic [24].

Classification¶

• The AO/OTA classification scheme for distal humerus fractures categorizes type A fractures as extraarticular metaphyseal, transcondylar, and apophyseal [19].
• The AO/OTA classification scheme for distal humerus fractures categorizes type B fractures as partial articular [19].
• The AO/OTA classification scheme for distal humerus fractures categorizes type C fractures as complete articular [19].
• Distal humerus fractures are classified using the AO/OTA classification system [20].
• The Dubberley classification is utilized for describing coronal shear fractures of the distal humerus and selecting the surgical approach [52].
• Outcomes for capitellum fractures are unclear due to the use of multiple classification systems [55].

Clinical Presentation¶

• Fractures of the distal humerus account for approximately 0.5% of all fractures in adults [20].
• The incidence of distal humerus fractures is approximately 5.8/100,000 people reported over 1 year in a high volume trauma centre [20].
• The distribution of distal humerus fractures by age is unimodal with a low risk in young adults that increases from the age of 50 years and rises markedly in those over 80 years [20].
• There is a higher incidence of distal humerus fractures in the female population [20].
• Distal humerus fractures are osteoporotic fractures [20].
• The number of distal humerus fracture cases is thought to be increasing in developed nations due to the ageing population [20].
• The age-adjusted incidence of distal humerus fractures may be consistent or falling slowly [20].
• Approximately 3000 distal humerus fractures in adults and children are treated surgically every year in France [9].
• An orthopaedic surgeon in France sees an average of five distal humerus fractures per year [9].
• In older adults with isolated distal humerus fractures, mortality at 1 and 2 years is substantial [17].
• In older adults with isolated distal humerus fractures, mortality is strongly predicted by comorbidity burden and preinjury ambulation [17].

Investigations¶

Imaging Modalities¶

• Plain radiographs remain the hallmark and best screening test for elbow evaluation [25].
• Standard radiographic views include AP, lateral, and oblique projections [43].
• Computed tomography (CT) is helpful for assessing malunion architecture and the location and pattern of osteophytes or loose bodies [43].
• Three-dimensional CT is used to check for heterotopic ossification [43].
• CT is not necessary when elbow stiffness is entirely soft-tissue related [43].
• CT is beneficial if any joint incongruity or abnormal bony anatomy is present [43].
• Magnetic resonance imaging (MRI) can be used to evaluate ligaments and tendons but is rarely indicated for elbow stiffness [43].
• CT Hounsfield Unit (HU) measurements in the coronal plane may identify patients with poorer bone quality at higher risk for postoperative mechanical complications following distal humerus fracture fixation [23].

Physical Examination¶

• The physical examination of the elbow is directed by history and the location of the patient's pain in the anterior, posterior, medial, or lateral aspect [25].
• Stability of the elbow is conferred by bony articular anatomy and ligamentous structures on the medial and lateral sides, which should be the focus of physical examination [25].
• The normal elbow has a range of motion of 75° and 85° in pronation and supination, respectively [25].
• Elbow stability is determined by primary stabilizers (ulnohumeral articulation, MUCL, LUCL complex) and secondary stabilizers (radiocapitellar articulation, common flexor tendon, common extensor tendon, joint capsule) [25].
• Active and passive flexion, extension, supination, and pronation should be evaluated using a goniometer for accurate measurement [43].
• If the elbow has less than 90° to 100° of flexion, the posterior bundle of the medial collateral ligament is contracted and must be released to restore flexion [43].
• Pain during the mid-arc of range of motion is more common with intrinsic disease and may not improve with contracture release alone [43].
• The ulnar nerve is of utmost importance in the physical examination due to its anatomic proximity to the elbow [43].
• Electromyography and nerve conduction velocity studies should be performed if there is any question about neurologic dysfunction [43].
• An assessment for ulnar nerve subluxation should be performed, as subluxation is a relative contraindication for an arthroscopic procedure [43].

Diagnostic Considerations¶

• Reported outcomes for acute distal humerus fractures remain inconsistent across the orthopedic literature, making it difficult to retrospectively compare surgical techniques and clinical outcomes [3].
• The treatment process for articular distal humerus fractures consists of determining the injury mechanism, defining diagnostic modalities, and developing a treatment algorithm [9].

Treatment¶

General Principles and Decision Making¶

• The management of distal humeral fractures remains problematic, particularly in elderly patients with osteoporosis and comminution where ORIF may be impossible [21].
• Non-operative treatment is generally reserved for completely undisplaced stable fractures or for patients in whom the risks of surgery outweigh the benefits [20].

Open Reduction and Internal Fixation (ORIF)¶

• Older patients who underwent ORIF of the distal humerus using a parallel construct demonstrated good functional outcomes and similar complications to those in previously reported studies [1].
• Both orthogonal and parallel plating techniques can be used to treat distal humerus fractures with excellent outcomes [15].
• Dual plating provides the most rigid and reliable construct for reduction of the articular surface to allow for early range of motion and physical rehabilitation [24].
• Current evidence indicates that OO, TRA, TS, and TT posterior approaches provide comparable overall clinical outcomes in the management of AO/OTA type C complete intra-articular distal humerus fractures [22].

Arthroplasty¶

• Distal humerus hemiarthroplasty is a viable option in the treatment of unreconstructible distal humerus fractures, with good to excellent outcomes expected [2].
• Distal humeral hemiarthroplasty is a suitable option for unreconstructable distal humeral fractures and offers good functional outcomes with acceptable complication rates [11].
• DHH yields satisfactory functional outcomes and range of motion in complex distal humerus fractures not amenable to fixation, particularly in elderly patients [13].
• Total elbow arthroplasty provides a successful treatment alternative for selected distal humerus fractures, particularly in elderly patients with low anticipated physical demands, severe osteopenia, or comminution [32].
• Total elbow arthroplasty can be considered for the treatment of acute distal humeral fractures when osteosynthesis is not feasible, particularly in physiologically older patients with lower demands on the joint [33].
• The indications for semiconstrained total joint replacement for acute fractures of the distal humerus are limited to a restricted group of patients older than 60-65 years with an extensively comminuted fracture that is not amenable to adequate and stable osteosynthesis [27].
• Salvage TEA represents a viable option for the management of post-traumatic sequelae following the treatment of a distal humeral fracture [12].
• Patients who underwent salvage TEA had a significantly increased rate of complications and significantly inferior functional outcomes compared with those who underwent TEA acutely [12].

Complications¶

Mechanical and Bony Complications¶

• A thorough smoking history and CT HU measurements in the coronal plane may identify patients with poorer bone quality at higher risk for postoperative mechanical complications following distal humerus fracture fixation [23].

Surgical and Implant-Related Complications¶

• The high risk of complications in olecranon osteotomy must be considered in the decision to perform this procedure in the treatment of distal humerus fractures [59].
• Elbow hemiarthroplasty potentially avoids complications related to the ulnar component [16].

Arthroplasty-Related Complications¶

• Patients who underwent salvage total elbow arthroplasty had a significantly increased rate of complications compared with those who underwent total elbow arthroplasty acutely [12].
• Distal humeral hemiarthroplasty offers acceptable complication rates [11].

Mortality¶

• In older adults with isolated distal humerus fractures, mortality at 1 and 2 years is substantial and strongly predicted by comorbidity burden and preinjury ambulation [17].

Recovery¶

Functional Outcomes and Salvage Procedures¶

• Older patients who underwent open reduction and internal fixation (ORIF) of the distal humerus using a parallel construct demonstrated good functional outcomes [1].
• Good to excellent outcomes are expected for distal humerus hemiarthroplasty in the treatment of unreconstructible distal humerus fractures [2].
• Distal humeral hemiarthroplasty offers good functional outcomes with acceptable complication rates for unreconstructable distal humeral fractures [11].
• Distal humerus hemiarthroplasty yields satisfactory functional outcomes and range of motion in complex distal humerus fractures not amenable to fixation [13].
• Distal humerus hemiarthroplasty yields satisfactory functional outcomes and range of motion in complex distal humerus fractures not amenable to fixation, particularly in elderly patients [13].
• Elbow hemiarthroplasty offers functional outcomes comparable to total elbow arthroplasty for complex distal humeral fractures in select patients [16].
• Salvage total elbow arthroplasty (TEA) represents a viable option for the management of post-traumatic sequelae following the treatment of a distal humeral fracture [12].
• Patients who underwent salvage TEA had a significantly increased rate of complications compared with those who underwent TEA acutely [12].
• Patients who underwent salvage TEA had significantly inferior functional outcomes compared with those who underwent TEA acutely [12].
• In the older cohort, intra-articular fractures were consistently and temporally associated with a more than two-fold increased risk of TEA compared with extra-articular fractures at every time point studied [61].
• Nearly 5.5% of patients with intra-articular fractures progressed to TEA by 10 years [61].

Complications and Mortality¶

• Malunion is a common complication after distal humerus fractures [6].
• Malunion after distal humerus fractures is influenced by biology, reduction, fixation methods, and mechanical failure [6].
• In older adults with isolated distal humerus fractures, mortality at 1 and 2 years is strongly predicted by comorbidity burden and preinjury ambulation [17].
• Transposition does not have a protective effect against the development of late ulnar neuropathy after distal humerus fracture repair surgery [62].

Measurement and Risk Factors¶

• Reported outcomes for acute distal humerus fractures remain inconsistent across the orthopedic literature [3].
• The inconsistency in reported outcomes for acute distal humerus fractures makes it difficult for surgeons to retrospectively compare surgical techniques and clinical outcomes across studies [3].

Key Evidence¶

• [L4] Older patients who underwent ORIF of the distal humerus using a parallel construct demonstrated good functional outcomes and similar complications to those in previously reported studies. [1] (10.1016/j.jhsa.2022.01.030)
• [L4] Distal humerus hemiarthroplasty is a viable option in the treatment of unreconstructible distal humerus fractures, with good to excellent outcomes expected. [2] (10.1016/j.jse.2022.02.015)
• [L1] Reported outcomes for acute distal humerus fractures remain inconsistent across the orthopedic literature, making it difficult for surgeons to retrospectively compare surgical techniques and clinical outcomes across studies. [3] (10.1016/j.otsr.2018.08.017)
• [L5] Internal fixation is generally accepted as the standard of care for the treatment of intra-articular distal humerus fractures, with rigid anatomic fixation combined with early motion associated with favorable results. [4] (10.1016/j.hcl.2007.09.001)
• [L5] Open reduction and internal fixation with bone grafting is the treatment of choice for nonunion of distal humerus fractures if no excessive damage of the articular surface is present. [5] (10.1016/j.jisako.2024.07.002)
• [L5] Malunion is a common complication after distal humerus fractures influenced by biology, reduction, fixation methods, and mechanical failure. [6] (10.1016/j.jisako.2024.05.009)
• [L1] This systematic review is the largest report of complications and reoperations of intra-articular distal humeral fractures after ORIF in the current literature. [8] (10.1016/j.jse.2021.02.017)
• [L4] [9] (10.1016/j.otsr.2013.11.002)
• [L5] Decision regarding the treatment for intra-articular fractures of the distal humerus should be based on a combination of the best available evidence and preference of the surgeon. [10] (10.5397/cise.2019.22.2.113)
• [L4] Distal humeral hemiarthroplasty is a suitable option for unreconstructable distal humeral fractures and offers good functional outcomes with acceptable complication rates. [11] (10.1177/17585732211023100)
• [L1] Salvage TEA represents a viable option for the management of post-traumatic sequelae following the treatment of a distal humeral fracture, although patients who underwent salvage TEA had a significantly increased rate of complications and significantly inferior functional outcomes compared with those who underwent TEA acutely. [12] (10.1302/0301-620x.108b1.bjj-2025-0475.r1)
• [L1] DHH yields satisfactory functional outcomes and range of motion in complex distal humerus fractures not amenable to fixation, particularly in elderly patients. [13] (10.1016/j.jseint.2026.101695)
• [L4] For comminuted distal humerus fractures in young patients, ORIF appears to be the preferred surgical option, offering superior functional outcomes and a lower incidence of complications and heterotopic ossification. [14] (10.1016/j.xrrt.2025.07.014)
• [L5] Distal humerus fractures are complex, and both orthogonal and parallel plating techniques can be used to treat these difficult fractures with excellent outcomes. [15] (10.1016/j.hcl.2010.05.008)
• [L4] Elbow hemiarthroplasty is a viable option for complex distal humeral fractures in select patients, offering functional outcomes comparable to total elbow arthroplasty while potentially avoiding complications related to the ulnar component. [16] (10.1177/1758573216640210)
• [L3] In older adults with isolated distal humerus fractures, mortality at 1 and 2 years is substantial and strongly predicted by comorbidity burden and preinjury ambulation. [17] (10.1016/j.jse.2026.02.013)
• [L5] [19] (10.5435/00124635-201001000-00004)
• [L1] [20] (10.1177/17585732251328594)
• [L5] The management of distal humeral fractures remains problematic, particularly in elderly patients with osteoporosis and comminution where ORIF may be impossible. [21] (10.1016/j.jse.2010.11.012)
• [L1] Current evidence indicates that OO, TRA, TS, and TT posterior approaches provide comparable overall clinical outcomes in the management of AO/OTA type C complete intra-articular distal humerus fractures, with most outcome measures showing no statistically significant differences. [22] (10.1186/s13018-026-06739-x)
• [L3] A thorough smoking history and CT HU measurements in the coronal plane may identify patients with poorer bone quality at higher risk for postoperative mechanical complications following distal humerus fracture fixation. [23] (10.5435/jaaos-d-26-00191)
• [L4] Although the inherent complexity of the distal humerus makes a single treatment method unrealistic, dual plating provides the most rigid and reliable construct for reduction of the articular surface to allow for early range of motion and physical rehabilitation. [24] (10.1016/j.jse.2025.12.020)
• [L5] [27] (10.1097/01.blo.0000131485.47685.8c)
• [L4] Total elbow arthroplasty provides a successful treatment alternative for selected distal humerus fractures, particularly in elderly patients with low anticipated physical demands, severe osteopenia, or comminution. [32] (10.1016/j.hcl.2015.06.008)
• [L4] Total elbow arthroplasty can be considered for the treatment of acute distal humeral fractures when osteosynthesis is not feasible, particularly in physiologically older patients with lower demands on the joint. [33] (10.2106/jbjs.d.02871)
• [L4] Posterior shear fractures of the distal humerus mostly involve the posterior of the capitellum and are often associated with elbow dislocation. [50] (10.1016/j.jse.2026.05.003)
• [L4] The study confirms the utility of the Dubberley classification in describing the fracture and selecting the surgical approach. [52] (10.1016/j.jse.2025.05.033)
• [L4] The article summarizes the existing body of evidence on capitellum fractures, noting that outcomes are unclear due to multiple classification systems and a literature consisting of small case series without comparative groups, and proposes areas for future study. [55] (10.1177/1558944719878817)
• [L4] [56] (10.1016/j.hcl.2004.08.001)
• [L2] The high risk of complications in olecranon osteotomy must be considered in the decision to perform this procedure in the treatment of distal humerus fractures. [59] (10.5397/cise.2021.00591)
• [L4] In the older cohort, intra-articular fractures were consistently and temporally associated with a more than two-fold increased risk of TEA compared with extra-articular fractures at every time point studied, with nearly 5.5% of patients progressing to TEA by 10 years. [61] (10.1177/17585732261451863)
• [L1] The authors conclude that transposition does not have a protective effect against the development of late ulnar neuropathy after distal humerus fracture repair surgery. [62] (10.1016/j.hcl.2017.09.010)

References¶

[1] The Outcomes of Intra-Articular Distal Humerus Open Reduction and Internal Fixation Using Parallel Precontoured Plates in the Elderly. The Journal of Hand Surgery. 2023. DOI: 10.1016/j.jhsa.2022.01.030

[2] Distal humerus hemiarthroplasty for trauma: a systematic review of the outcomes and complications. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2022.02.015

[3] Outcomes of distal humerus fractures: What are we measuring?. Orthopaedics & Traumatology: Surgery & Research. 2018. DOI: 10.1016/j.otsr.2018.08.017

[4] Distal Humerus Fractures. Hand Clinics. 2007. DOI: 10.1016/j.hcl.2007.09.001

[5] Nonunion of distal humeral fractures: Current concepts. Journal of ISAKOS. 2024. DOI: 10.1016/j.jisako.2024.07.002

[6] Malunion of distal humeral fractures: Current concepts. Journal of ISAKOS. 2024. DOI: 10.1016/j.jisako.2024.05.009

[8] Complications of articular distal humeral fracture fixation: a systematic review and meta-analysis. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2021.02.017

[9] Articular fractures of the distal humerus. Orthopaedics & Traumatology: Surgery & Research. 2014. DOI: 10.1016/j.otsr.2013.11.002

[10] Surgical Treatment Strategy for Distal Humerus Intra-articular Fractures. Clinics in Shoulder and Elbow. 2019. DOI: 10.5397/cise.2019.22.2.113

[11] Outcomes and complications of distal humeral hemiarthroplasty for distal humeral fractures – A systematic review. Shoulder & Elbow. 2021. DOI: 10.1177/17585732211023100

[12] Total elbow arthroplasty for the management of post-traumatic sequelae of distal humeral fractures. The Bone & Joint Journal. 2026. DOI: 10.1302/0301-620x.108b1.bjj-2025-0475.r1

[13] Distal humerus hemiarthroplasty for complex intra-articular fractures in elderly or nonfixable patients: a meta-analysis of clinical and functional outcomes. JSES International. 2026. DOI: 10.1016/j.jseint.2026.101695

[14] Hemiarthroplasty vs. open reduction and internal fixation for comminuted distal humerus fractures in patients under 65 years: a systematic review. JSES Reviews, Reports, and Techniques. 2025. DOI: 10.1016/j.xrrt.2025.07.014

[15] Use of Orthogonal or Parallel Plating Techniques to Treat Distal Humerus Fractures. Hand Clinics. 2010. DOI: 10.1016/j.hcl.2010.05.008

[16] Elbow hemiarthroplasty for the management of distal humeral fractures: current technique, indications and results. Shoulder & Elbow. 2016. DOI: 10.1177/1758573216640210

[17] Predictors of mortality after isolated distal humerus fractures in older adults. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2026.02.013

[19] Current Treatment Strategies for Bicolumnar Distal Humerus Fractures. American Academy of Orthopaedic Surgeon. 2010. DOI: 10.5435/00124635-201001000-00004

[20] A systematic review, and meta-analysis of pain outcomes following total elbow replacement and hemi-replacement for unreconstructible acute distal humerus fractures in adults. Shoulder & Elbow. 2025. DOI: 10.1177/17585732251328594

[21] Distal humeral fractures: fixation versus arthroplasty. Journal of Shoulder and Elbow Surgery. 2011. DOI: 10.1016/j.jse.2010.11.012

[22] Comparative efficacy and safety of different posterior surgical approaches for Intra-articular distal humerus fractures. Journal of Orthopaedic Surgery and Research. 2026. DOI: 10.1186/s13018-026-06739-x

[23] Can Computed Tomography Hounsfield Units Predict Distal Humerus Fracture Mechanical Complications?. Journal of the American Academy of Orthopaedic Surgeons. 2026. DOI: 10.5435/jaaos-d-26-00191

[24] Outcomes of intra-articular distal humerus open reduction and internal fixation based on severity of articular comminution. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2025.12.020

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[32] Total Elbow Arthroplasty for Distal Humerus Fractures. Hand Clinics. 2015. DOI: 10.1016/j.hcl.2015.06.008

[33] Distal Humeral Fractures Treated with Noncustom Total Elbow Replacement. Journal of Bone and Joint Surgery. 2005. DOI: 10.2106/jbjs.d.02871

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