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Distal humerus fracture

100 citationsUpdated Sep 2026

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Overview

Distal humerus fractures are complex injuries that present a significant technical challenge, requiring meticulous surgical technique and experience to achieve optimal results [15]. These fractures are associated with a high incidence of complications [8], and reported outcomes for acute injuries remain inconsistent across the orthopaedic literature, making it difficult for surgeons to retrospectively compare surgical techniques and clinical outcomes across studies [16]. Consequently, the decision regarding treatment for intra-articular fractures of the distal humerus should be based on a combination of the best available evidence and the preference of the surgeon [35].

Operative management is dominated by open reduction and internal fixation (ORIF), which remains the predominant treatment choice for most distal humerus injuries, with trade-offs existing between exposure and complication rates for different surgical approaches [69]. In older patients, ORIF using a parallel construct has demonstrated good functional outcomes and similar complications to those in previously reported studies [1], while plate fixation in the elderly yields fairly satisfactory functional recovery despite the difficulty of treatment and appreciable number of complications [3]. 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 compared to hemiarthroplasty [165].

Arthroplasty serves as a viable alternative for unreconstructible or nonreconstructable distal humeral fractures. Distal humerus hemiarthroplasty is a suitable option for these cases, offering good functional outcomes with acceptable complication rates [25] and good long-term outcomes [13]. It may be an effective treatment for certain distal humeral fractures, as suggested by long-term clinical results [9], and is a good option for the surgical management of unreconstructible fractures in selected patients [67]. Elbow hemiarthroplasty offers functional outcomes comparable to total elbow arthroplasty while potentially avoiding complications related to the ulnar component [156]. In young patients, distal humeral hemiarthroplasty has satisfactory clinical outcomes and allows a higher level of function than is generally advised after total elbow arthroplasty, although it is only rarely indicated [66]. Total elbow arthroplasty for distal humerus fractures provided similar clinical and functional outcomes when performed as a primary procedure or after failed internal fixation [39], and primary arthroplasty produces reliable results with regards to revisions and other adverse events [33]. Total elbow joint replacement should be available at the time of surgery for all distal humeral fractures in the elderly patient population [4].

Nonoperative management is associated with acceptable functional outcomes and low rates of delayed surgery in the elderly [2]. Satisfactory outcomes were observed after the nonoperative management of selected distal humeral fractures in lower-demand, medically unwell, or older patients [12]. Nonoperative treatment for comminuted intraarticular distal humerus fractures results in acceptable functional outcome in elderly patients and should be considered when the fracture is not amenable to internal fixation and in lower-demand patients with higher surgical risk [30].

Anatomy & Pathophysiology

Bony Anatomy

The elbow is a trocho-ginglymoid joint, providing trochoid (rotatory) motion through the radiocapitellar and proximal radioulnar joints and ginglymoid (hinge-like) motion through the ulnohumeral joint [88]. The distal humerus consists of an arch formed by two condyles, with the capitellum on the lateral side and the trochlea medial to it [85]. The distal humeral shaft is triangular in cross-section with its apex directed anteriorly, bifurcating into medial and lateral cortical columns as it approaches the distal humerus [88]. The medial column diverges approximately 45 degrees from the humeral shaft in the coronal plane and terminates as the medial epicondyle [88]. The lateral column diverges at approximately 20 degrees from the humeral shaft in the coronal plane [88]. As the lateral column extends distally, it curves anteriorly, creating a 35 to 40 degrees angle with the shaft in the sagittal plane [88]. The complex anatomy of the distal humerus reflects its articulation with both the radius and ulna, allowing a wide range of motion in multiple planes [86].

In the coronal plane, the trochlea is more distal than the capitellum, resulting in a valgus alignment of 4 to 8 degrees [88]. The articular surface of the distal humerus is in 5° to 6° of valgus with respect to the humeral shaft [86]. The overall elbow valgus angle in extension, including the ulna, is 10 to 17 degrees, termed the carrying angle [88]. The normal valgus carrying angle of the elbow is 5 to 10 degrees for men and 10 to 15 degrees for women [83]. The distal humerus articular surface is internally rotated 3 to 8 degrees axially, causing slight varus alignment as the elbow flexes [88]. The distal humeral articulation is angled 30° from the longitudinal axis, and the anterior humeral line should pass through the center of the axis of rotation [77]. The articular surface of the distal humerus is angled 30 degrees anterior to the humeral shaft axis [83]. The articular surface of the distal humerus is in 30° of flexion [86].

The articular surface of the capitellum encompasses an arc of approximately 180 degrees in the sagittal plane [88]. The trochlea is covered by articular cartilage anteriorly, inferiorly, and posteriorly, creating an arc of almost 270 degrees [88]. The trochlea has a 300-degree arc of cartilage [85]. The trochlea is shaped like a spool with a central sulcus that articulates with the central ridge of the greater sigmoid notch of the proximal ulna [88]. There is highly congruent anatomy through almost 180° of articular contact between the trochlea and ulna, with the exception of the bare area of the greater sigmoid notch which is devoid of cartilage [77]. The lateral trochlear ridge contains a portion that is covered with articular cartilage but is non-articulating throughout normal elbow range of motion [111]. The olecranon fossa and coronoid fossa are separated by a thin bony septum, which is occasionally absent [88]. The floor of the olecranon and coronoid fossae is composed of thin cortical bone that articulates with the proximal olecranon in extension and the coronoid process in flexion [86]. The walls of the fossae have thick cortical bone that can be an asset in plate fixation with screws [86]. Screw placement through the olecranon or coronoid fossae should be avoided as it may lead to impingement and decreased elbow range of motion [88]. Screws placed into or across the olecranon fossa can block elbow extension if they impinge against the tip of the olecranon during attempted elbow extension [86]. The posterior aspect of the lateral column is relatively flat and wide, well suited for application of a posterolateral plate [88]. There is a bare area on the posterior aspect of the lateral condyle that permits safe placement of hardware [86].

The proximal ulna contains the olecranon process posteriorly, the coronoid process anteriorly, and the sigmoid or semilunar notch [85]. The olecranon serves as the insertion point of the triceps mechanism, with fibers attaching in an expansive sleeve on its posterior, medial, and lateral surfaces [106]. The triceps sleeve blends into the periosteal tissue of the proximal ulnar shaft [106]. The olecranon forms the posterior wall of the fossa for humeroulnar articulation [106]. The fossa, or semilunar notch, is bounded anteriorly by the coronoid process of the ulna [106]. The major contact forces within the semilunar notch are at four distinct facets, two each on the olecranon and the coronoid [106]. The floor of the sigmoid notch has a thin, bare area along its transverse axis that is devoid of articular cartilage [106]. The coronoid has a medial and lateral facet which buttresses the trochlea anteriorly [77]. The sublime tubercle, located just distal and medial to the coronoid, provides the attachment site of the anterior bundle of the medial ulnar collateral ligament [77]. The ulna medially bends approximately 8° at 8 cm from the tip of the olecranon [77]. The articulation to the tip of the coronoid is approximately 30° from the long axis of the ulna in the sagittal plane [77].

The radial head is a concave elliptical structure covered with articular cartilage along the radiocapitellar joint and approximately 270° of the articular margin [77]. The radial head should line up with the capitellum at all arm positions on all radiographic views [78]. The radial head lines up in its lesser sigmoid, or radial notch, with the annular ligament surrounding it [85]. The area of the ulna which articulates with the margin of the radial head at the proximal radioulnar joint is known as the lesser sigmoid notch [77]. The radius is held in close approximation to the ulna at the proximal radioulnar joint by the annular ligament [77]. The capitellum and radial head form the radiocapitellar joint [77]. The ulnohumeral joint allows flexion-extension of the joint, while the radiocapitellar joint allows forearm rotation [85]. The trochlea articulates with the ulna within the greater sigmoid notch to create the ulnohumeral, hinged or trochoid, portion of the elbow joint [77]. The axis of rotation is 5° to 7° angulated in the coronal plane to the epicondylar axis, with the medial side more distal than the lateral side [77].

The medial epicondyle forms the attachment site for the origins of the flexor pronator mass and is larger and more posteriorly oriented than the lateral epicondyle [77]. The medial epicondyle is the location where the medial collateral ligament and flexor-pronator group of muscles attach [85]. The less prominent lateral epicondyle is the origin of the lateral extensor musculature [77]. The supinator-extensor muscle group attaches to the lateral epicondyle, which is slightly proximal and lateral to the capitellum [85]. With the elbow in 90 degrees of flexion, the medial condyle, lateral condyle, and olecranon form a palpable triangle [85].

Ligamentous Anatomy

Elbow stability is determined by primary and secondary stabilizers [42]. The three primary stabilizers of the elbow are the ulnohumeral articulation, the medial ulnar collateral ligament (MUCL), and the lateral ulnar collateral ligament (LUCL) complex [42]. Secondary stabilizers of the elbow include the radiocapitellar articulation, the common flexor tendon, the common extensor tendon, and the joint capsule [42]. The medial (ulnar) collateral ligament consists of anterior, posterior, and transverse bundles [83]. The medial or ulnar collateral ligament is the primary valgus stabilizer [78]. The anterior bundle of the medial collateral ligament is the most important for stability [78]. The anterior bundle of the medial collateral ligament is the primary restraint to valgus stress within functional elbow ROM [83]. The secondary restraint to valgus stress within functional elbow ROM is the radial head [83]. The medial collateral ligament originates on the posterior medial epicondyle and inserts on the sublime tubercle of the medial coronoid process [83]. The most important portion of the medial or ulnar collateral ligament is the anterior portion, which attaches to a small process on the medial surface of the coronoid [85]. The posterior bundle of the medial collateral ligament has the greatest change and length, becoming taut at flexion beyond 120 degrees [78]. The posterior bundle of the medial collateral ligament is the primary restraint to valgus stress with the elbow in maximal flexion [83]. Stability in full extension is provided by the medial collateral ligament, joint capsule, and ulnohumeral articulation [83]. The medial ulnar collateral ligaments are areas of capsular thickening which provide stability to the medial side of the elbow joint [7].

The lateral collateral ligament complex consists of the radial collateral ligament, the lateral ulnar collateral ligament (LUCL), and the annular ligament [88]. The annular ligament attaches to the anterior and posterior margins of the lesser sigmoid notch [88]. The radial collateral ligament originates from an isometric point on the lateral epicondyle and fans out to attach to the annular ligament [88]. The lateral ulnar collateral ligament arises from the isometric point on the lateral epicondyle and attaches to the crista supinatoris of the proximal ulna [88]. The lateral ulnar collateral ligament is the posterolateral stabilizer [78]. The lateral collateral ligament complex functions as an important restraint to varus and posterolateral rotatory instability [88]. The lateral collateral ligament complex is vulnerable to injury during application of a direct lateral plate [88]. Exposure of the lateral aspect of the distal lateral column should not extend past the equator of the capitellum to avoid injury to the lateral collateral ligament complex [88]. The origin of the lateral ulnar collateral ligamentous complex is located just distal to the lateral epicondyle at the geometric center of the radiocapitellar articulation [77].

Osborne’s ligament stabilizes the ulnar nerve in the cubital tunnel [78]. 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 [78].

Kinematics

The normal range of elbow flexion/extension is 0 to 150 degrees [83]. The normal forearm pronosupination is 80 to 85 degrees in each direction [83]. The functional range of motion for the elbow is 30 to 130 degrees for flexion/extension and 50 degrees for pronosupination [83]. The functional ROM is 30 to 130 degrees for flexion/extension and 50 degrees for pronosupination [84]. In full extension, 60% of axial load is transmitted through the radiocapitellar joint [83]. Tensile forces are present at the medial elbow, while compressive forces are present at the lateral elbow [78]. The capsule allows maximum distension at approximately 70 to 80 degrees of flexion [78].

Soft Tissue & Neural Anatomy

The brachialis is the strongest elbow flexor and attaches to the coronoid 11 mm distal to the tip [78]. The brachialis inserts on the coronoid process and the tuberosity of the ulna anteriorly [85]. The biceps brachii inserts at the ulnar margin of the radial tuberosity, with the long head proximal and short head distal [78]. The biceps brachii is a powerful supinator of the forearm [78]. The primary elbow extensor, the triceps, inserts on the olecranon process [78]. The triceps has a broad tendinous insertion into the olecranon posteriorly [85]. The mobile wad consists of the brachioradialis, extensor carpi radialis longus, and extensor carpi radialis brevis [78]. The flexor-pronator mass consists of the pronator teres, flexor carpi radialis, palmaris longus, flexor carpi ulnaris, and flexor digitorum superficialis [78]. The anterior capsule attaches at a point approximately 6 mm distal to the tip of the coronoid [78]. The coronoid tip is an intraarticular structure that is visualized during elbow arthroscopy [78]. The olecranon allows for a broad attachment site of the triceps posteriorly [77]. The ulnar nerve passes through the cubital tunnel at the medial column of the elbow [85]. The ulnar nerve enters the anterior forearm by traveling between the two heads of the flexor carpi ulnaris [85].

Classification

Epidemiology and Demographics

Distal humerus fractures exhibit a bimodal age distribution with distinct mechanisms and patient characteristics [5]. However, the distribution by age is unimodal, with low risk in young adults that increases from age 50 and rises markedly in those over 80 years [146]. These fractures have a higher incidence in the female population [146]. In adults, distal humerus fractures account for approximately 0.5% of all fractures [146]. The incidence is approximately 5.8/100,000 people reported over 1 year in a high volume trauma centre [146]. The number of cases is thought to be increasing in developed nations due to the ageing population, although the age-adjusted incidence may be consistent or falling slowly [146].

Classification Systems

AO/OTA: The AO/OTA classification system classifies distal humerus fractures into type A (extra-articular), type B (partial articular), and type C (complete articular) [147]. Each type is subdivided into three groups (1, 2, and 3) based on fracture pattern and further into three subgroups (1, 2, and 3) according to the degree of fragmentation [147]. This system results in twenty-seven different potential injury patterns for periarticular fractures [147].

Mehne and Matta: The Mehne and Matta classification divides distal humeral fractures into Grade I (intra-articular), Grade II (extra-articular intracapsular), and Grade III (extracapsular) [147]. Intracapsular fractures are subdivided into four groups: A (single column), B (bicolumnar), C (capitellar), and D (trochlear) [147]. Further selections are determined by the distance from the joint and the direction of the transverse limb of the fracture, resulting in a total of twenty-one subgroups [147].

Copenhagen Classification for Distal Humeral Fractures (CCDHF): The CCDHF demonstrated validity and clinical applicability in classifying distal humeral fractures [62]. It showed a moderate level of agreement among observers [62]. This classification is useful to identify patients who may require hemi- or total elbow arthroplasty [62].

Wrightington: The Wrightington classification system is a reliable and valid method of classifying fracture-dislocations of the elbow [153]. It is a valuable tool for characterizing the majority of elbow-fracture dislocations and guiding surgical interventions [143]. The system has moderate reliability overall and higher reliability when using combined 2D and 3D CT imaging [170].

Other Considerations: A novel classification system based on the humeral capitellum angle (alpha angle) allows for the identification of fracture subtypes that can be successfully managed with simple fixation [102]. The Dubberley classification is useful in describing the fracture and selecting the surgical approach for coronal shear fractures of the distal humerus [172]. Current elbow fracture dislocation classification systems only describe one element of the injury or only include one pattern [50].

Imaging and Diagnostic Accuracy

Two- and three-dimensional computed tomography can be used for the classification and management of distal humeral fractures [147]. Distal humerus fracture lines are characteristic and highly related to the micro-architecture difference of the distal humerus [34]. In a specific series, the majority of distal humerus fractures had 4 or more fragments [173]. Fractures with more fragments had a higher percentage of small, difficult-to-repair fragments [173].

Clinical Application and Decision Making

A clinically applicable fracture classification for distal humeral fractures aids the surgical decision-making process when used in conjunction with a management algorithm [38]. The Dubberley classification of capitellar and trochlear fractures includes types 2A, 2B, 3A, and 3B based on involvement of the capitellum, trochlea, and presence of posterior fracture [154]. Good outcomes can be achieved for complex elbow fracture-dislocations through pattern recognition and management with an anatomically based reconstruction algorithm as described by the Wrightington classification system [166].

Clinical Presentation

Distal humerus fractures represent complex injuries that necessitate a carefully planned approach to restore anatomy and achieve good functional outcomes [24]. Successful management is challenging due to the complex anatomy of the elbow, associated osteopenia, and articular and metaphyseal comminution [18]. Therapeutic decisions are particularly complex in elderly patients with poor bone quality or those sustaining high-energy injuries [5]. The relative magnitude of the clinical burden associated with various types of distal humeral fractures is highlighted by population-based incidence data [17]. In Qatar, the incidence of these fractures is lower than reported in developed countries, likely due to the country's demographic profile [142].

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 [32]. A fragility evaluation can help inform surgical decision-making in patients older than 50 years with distal humerus fractures [21]. Pathologic fractures in the distal humerus are uncommon and are associated with a very high reoperation rate [11].

For pediatric and adolescent patients, most with T-type distal humerus fractures have results better than those of adults but often worse than other elbow fractures in this age group [19]. Management principles for pediatric and adolescent distal humerus fractures focus on restoring the anatomic axis, the triangle of stability, and the articular surface to ensure a stable elbow joint that allows for early motion and full range of motion [26].

Investigations

Plain radiography: Plain radiographs remain the hallmark and best screening test for elbow evaluation [42]. Distal humerus fracture lines are characteristic and highly related to the micro-architecture difference of the distal humerus, which may provide guidance for treatment plan selection and surgical fixation design [34].

CT: In complex distal humerus fracture patterns where the extent of fractures or position of dislocated fragments is unclear on radiography, multidetector computed tomography (MDCT) is a recommended complementary examination [184]. CT is helpful when assessing for malunion architecture and the location and pattern of osteophytes or loose bodies [91]. Three-dimensional CT is used to check for heterotopic ossification [91]. CT is not necessary when elbow stiffness is entirely soft-tissue related [91]. A thorough smoking history and CT Hounsfield Unit measurements in the coronal plane may identify patients with poorer bone quality at higher risk for postoperative mechanical complications following distal humerus fracture fixation [74].

MRI: MRI can be used to evaluate ligaments and tendons, but it is rarely indicated for elbow stiffness [91]. MRI is superior to radiograph in evaluating and diagnosing children's humeral lateral condyle fractures and their stability [177].

Ultrasonography: Ultrasonography can accurately depict radial nerve lesions with coexistent plate fixation of humeral shaft fractures [182]. Elevated posterior fat pad and lipohemarthrosis serve as strong indirect indicators to detect occult elbow fractures and can be detected quickly and reliably by ultrasonography [185].

Physical Examination and Anatomy: The evaluation of the elbow requires an intimate understanding of the anatomy, biomechanics, and diagnostic tests for this complex joint [42]. Elbow stability is conferred by the bony articular anatomy, which is highly congruent, and the ligamentous structures on the medial and lateral sides [42]. The normal elbow has a range of motion from 0° to 140° from extension to flexion and 75° and 85° in pronation and supination respectively [42]. A functional arc in each plane is 100° for flexion and extension and forearm rotation [42]. The three primary stabilizers are the ulnohumeral articulation, the medial ulnar collateral ligament (MUCL), and the lateral ulnar collateral ligament (LUCL) complex [42]. Secondary stabilizers are the radiocapitellar articulation, the common flexor tendon, the common extensor tendon, and the joint capsule [42]. The physical exam is directed by history and location of the patient's pain in the anterior, posterior, medial, or lateral aspect of the elbow [42].

The ulnar nerve is of utmost importance in elbow evaluation because of its anatomic proximity to the elbow [91]. The posterior bundle of the medial collateral ligament (MCL) forms the floor of the cubital tunnel, along the course of the ulnar nerve [91]. Electromyography/nerve conduction velocity studies should be performed if any question about neurologic dysfunction exists [91]. An assessment for ulnar nerve subluxation should be performed [91]. Subluxation of the ulnar nerve is a relative contraindication for an arthroscopic procedure secondary to possible iatrogenic nerve injury [91]. If the elbow has less than 90° to 100° of flexion, the posterior bundle of the medial collateral ligament (MCL) is contracted and must be released to restore flexion [91]. Pain should be assessed during the mid-arc or at the terminal ends of motion [91]. Mid-arc range of motion pain is more common with intrinsic disease and may not improve with contracture release alone [91].

Classification and Risk Stratification: The Copenhagen Classification for Distal Humeral Fractures (CCDHF) demonstrated validity and clinical applicability in classifying distal humeral fractures, showing a moderate level of agreement among observers [62]. The CCDHF is useful to identify patients who may require hemi- or total elbow arthroplasty [62]. A 5-item modified Fragility Index can help inform surgical decision-making in patients older than 50 years with distal humerus fractures [21].

Post-operative Imaging: When experienced and skilled surgeons perform fixation of type C distal humerus fractures, the immediate postoperative radiograph is not predictive of fixation failure [41].

Treatment

Non-Operative

Nonoperative management of distal humerus fractures in the elderly is associated with acceptable functional outcomes and low rates of delayed surgery [2]. Conservative treatment in patients over 65 years of age is safe, allowing continued independence and providing satisfactory clinical results with no severe joint stiffness or elbow instability [14]. However, the non-operative approach to intercondylar distal humerus fractures cannot ensure good reconstruction of the articular surface nor permit early mobilization of the elbow [127].

Operative

Indications: Most intra-articular distal humerus fractures require operative fixation to achieve anatomic reduction and allow for early motion [52]. ORIF remains the predominant treatment choice for most distal humerus injuries [69]. In patients older than 65 years with intra-articular distal humerus fracture, ORIF had better outcomes than total elbow arthroplasty [58]. Osteosynthesis by open reduction and internal fixation is a recommended option for extra-articular distal humeral fractures in patients aged 70 years or older in whom conservative treatment has failed [168]. Total elbow arthroplasty (TEA) provides a successful treatment alternative for selected distal humerus fractures, particularly in elderly patients with low anticipated physical demands, severe osteopenia, or comminution [174]. The indications for semiconstrained total joint replacement for acute distal humerus fractures are limited to patients older than 60-65 years with an extensively comminuted fracture that is not amenable to adequate and stable osteosynthesis [55]. Distal humerus hemiarthroplasty is a viable option for the treatment of unreconstructible distal humerus fractures [6, 13].

Surgical Approach / Technique: Distal humerus fractures present a significant technical challenge requiring meticulous technique and experience to achieve optimal results [15]. Successful outcomes are difficult to achieve due to complex elbow anatomy, associated osteopenia, and articular and metaphyseal comminution [18]. The triceps tongue approach is a safe and effective approach for the treatment of distal humeral fractures [131], and the triceps fascial tongue exposure is a useful approach for surgeons treating distal humerus fractures [23]. ORIF of the distal humerus using a parallel precontoured plate construct in older patients demonstrated good functional outcomes and complication rates similar to previously reported studies [1]. Open reduction and internal fixation of Type C intraarticular distal humerus fractures is safe and effective [60]. Open reduction and plate fixation for distal humeral fractures is a reasonable treatment option with acceptable complication rates and favorable clinical outcomes [120]. The surgical repair of an intra-articular distal humeral fracture through a posterior approach reliably maintains general health status as measured by patient-based questionnaires [54]. Judicious management of extra-articular distal humerus fractures with extraarticular plates has yielded encouraging results [31]. A novel surgical technique using skinny wire and locking plate fixation results in strong, stable fixation of complex intra-articular distal humerus fractures irrespective of bone quality, with all fractures healing and high patient-reported outcome scores [140]. Short-term results demonstrate satisfactory clinical outcomes with low rates of revision for distal humerus fractures fixed with a linking beam [36].

Implant Selection: Total elbow arthroplasty for the treatment of comminuted intra-articular distal humeral fractures resulted in more predictable and improved 2-year functional outcomes compared with ORIF based on the MEPS [136]. Primary total elbow replacement for treatment of complex distal humerus fractures in elderly patients yielded satisfactory short-term outcomes [28]. A semiconstrained total elbow replacement has a role in the treatment of distal humeral fractures in carefully selected cases that are difficult to treat by internal fixation due to osteopenia and comminution [40]. Despite disadvantages including excessive loss of bone stock and mechanical failure, primary TEA is preferred for comminuted and displaced intraarticular fractures of the distal humerus in older women with associated comorbidities [158]. Semiconstrained TEA should be considered as a salvage procedure in young post-traumatic patients with unreconstructible distal humerus fractures [178]. Distal humerus hemiarthroplasty may be an effective treatment for certain distal humeral fractures based on long-term review data [9]. Elbow range of motion and functional use are maintained in patients treated with hemiarthroplasty for distal humeral fractures when compared with short-term studies [7]. Distal humeral hemiarthroplasty has satisfactory clinical outcomes in young patients and allows a higher level of function than is generally advised after total elbow arthroplasty [66].

Other Considerations: Patients treated with total elbow replacement for acute distal humerus fractures must have low physical demands, and subsequent athletics are precluded [55]. Distal humerus fractures treated with plate fixation in patients over 65 years of age achieved fairly satisfactory functional recovery despite a significant number of complications [3]. Low and high body mass index and three or fewer screws in the articular segment are risk factors for non-union of distal humerus fracture in the elderly [176]. Further studies are required to evaluate elbow hemiarthroplasty as a superior treatment for patients with nonreconstructable traumatic distal humerus fractures, though current data support its use in elderly patients with intermediate follow-up [157]. Reported outcomes for acute distal humerus fractures remain inconsistent across the orthopedic literature, making it difficult to retrospectively compare surgical techniques and clinical outcomes [16]. The management of distal humeral fractures remains problematic, particularly in elderly patients with osteoporosis and comminution where ORIF may be impossible [179]. 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 [35]. A clinically applicable fracture classification for distal humeral fractures, used in conjunction with a management algorithm, aids the surgical decision-making process [38].

Complications

General Complication Rates: Complex distal humeral fractures carry a high incidence of complications [8]. In patients over 65 years of age, complications develop in one out of three individuals [10]. These fractures in elderly patients are difficult to treat and are associated with an appreciable number of complications [3]. Malunion is a common complication influenced by biology, reduction, fixation methods, and mechanical failure [61].

Nerve Injury: The incidence of immediately postoperative ulnar nerve dysfunction after open reduction and internal fixation of distal humerus fractures is 10.1% [171]. At final follow-up, the incidence of ulnar nerve dysfunction rises to 16% [171].

Heterotopic Ossification: Heterotopic ossification is a relatively common complication of elbow trauma that can prevent the restoration of a functional arc of movement [22]. Isolating the specific functional implications of heterotopic ossification may be difficult because movement may also be impaired by associated posttraumatic deformity, arthritis, or capsular fibrosis [22].

Fixation Failure and Mechanical Complications: Pathologic fractures in the distal humerus are uncommon and are associated with a very high reoperation rate [11].

Arthroplasty-Related Complications: Distal humeral hemiarthroplasty for unreconstructable distal humeral fractures offers good functional outcomes with acceptable complication rates [25]. Total elbow arthroplasty for comminuted distal humeral fractures in elderly patients reveals excellent long-term implant survival with no patient requiring a late revision [65].

Recovery

Light activity (weeks): The provided evidence does not specify a typical week range for light activity, desk work, driving, or light activities of daily living.

Full activity (months): The provided evidence does not specify a month range for the return to manual work, sport, or full range of motion and strength.

Complete recovery / outcome plateau (months): The provided evidence does not specify a month range for the stabilization of pain, strength, or final functional outcomes.

Rehabilitation protocol: The provided evidence does not detail specific physical therapy phasing, immobilisation duration, weight-bearing or range-of-motion progression schedules, or sling and brace removal timing.

Functional milestones: The provided evidence does not report validated patient-reported outcome measure trajectories or specific benchmark scores for Constant, ASES, or WOMAC scales.

Other Considerations: Conservative treatment of distal humerus fractures in patients over 65 years of age is exceptional but demonstrably safe, allowing continued independence and providing satisfactory clinical results with no severe joint stiffness or elbow instability [14]. Although distal humerus fractures in elderly patients are difficult to treat with an appreciable number of complications, functional recovery following open reduction internal fixation (ORIF) was fairly satisfactory [3]. Surgical repair of intra-articular distal humeral fractures reliably maintains general health status as measured by patient-based questionnaires [54]. Short-term results demonstrate satisfactory clinical outcomes with low rates of revision for distal humerus fractures fixed with a linking beam [36]. When experienced and skilled surgeons perform fixation of type C distal humerus fractures, the immediate postoperative radiograph is not predictive of fixation failure [41]. Long-term data demonstrate the durability of these elbows following ORIF, with radiographic mild to moderate arthritis observed in half of patients at 17-year follow-up [189].

Regarding arthroplasty, data suggest that elbow range of motion and functional use are maintained from comparison with short-term studies [7]. Long-term reviews suggest that distal humerus hemiarthroplasty (DHH) may be an effective treatment for certain distal humeral fractures [9]. DHH offers a treatment option for unreconstructable distal humeral fractures and is associated with a good long-term outcome [13]. Data suggest that elbow range of motion and functional use of the elbow are maintained from comparison with short-term studies [27]. DHH yields modest short-term clinical results for patients with unreconstructible injuries to the distal humerus, and the reoperation rate is not insignificant [188]. Primary total elbow replacement (TER) for treatment of complex distal humerus fractures in elderly patients yielded satisfactory short-term outcomes [28]. Short-term results suggest that a semiconstrained total elbow replacement has a role to play in the treatment of distal humeral fractures in carefully selected cases which are difficult to treat by internal fixation due to osteopenia and comminution [40]. The absence of any infectious complications and satisfactory functional outcomes observed in the current series indicates that total elbow arthroplasty (TEA) is a viable treatment modality for complex open fractures of the distal humerus [59]. TEA is an effective and reliable procedure for comminuted distal humeral fractures in elderly patients, revealing excellent long-term implant survival with no patient requiring a late revision [65]. This study demonstrated similar short-term functional outcomes between elbow hemiarthroplasty (EHA) and ORIF for the treatment of multi-fragmentary intra-articular distal humeral fractures in patients >60 years of age [145]. In patients aged 60 years or older with unreconstructible distal humeral fractures, elbow hemiarthroplasty and total elbow arthroplasty did not differ for function at ≥2 years [148].

Complications develop in one out of three patients over 65 with distal humerus fractures [10]. Data suggest that a fragility evaluation can help inform surgical decision-making in patients older than 50 years with distal humerus fractures [21]. The clear rise in the rate of low-trauma distal humeral fractures in Finnish women 60 years of age and older from 1970 till late 1990s has been followed by stabilized or even decreased fracture rates [75].

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] Nonoperative management of distal humerus fractures in the elderly seems to be associated with acceptable functional outcomes and low rates of delayed surgery. [2] (10.1016/j.xrrt.2021.10.001)
• [L4] Although distal humerus fractures in elderly patients are difficult to treat with an appreciable number of complications, the functional recovery was fairly satisfactory. [3] (10.1016/j.otsr.2013.08.001)
• [L4] This option should therefore be available at the time of surgery for all distal humeral fractures in this patient population. [4] (10.1016/j.injury.2015.08.011)
• [L4] Distal humerus hemiarthroplasty is a viable option in the treatment of unreconstructible distal humerus fractures, with good to excellent outcomes expected. [6] (10.1016/j.jse.2022.02.015)
• [L4] The data suggest that elbow range of motion and functional use are maintained from comparison with short-term studies. [7] (10.1016/j.jse.2016.09.057)
• [L4] Complex distal humeral fractures are difficult to treat and are associated with a high incidence of complications. [8] (10.1007/s12306-011-0132-9)
• [L4] This long-term review suggests that distal humerus hemiarthroplasty may be an effective treatment for certain distal humeral fractures. [9] (10.1016/j.jse.2021.12.027)
• [L4] Complications develop in one out of three patients over 65 with distal humerus fractures. [10] (10.1016/j.otsr.2013.10.002)
• [L4] Pathologic fractures in the distal humerus are uncommon and associated with a very high reoperation rate. [11] (10.1016/j.jse.2011.06.019)
• [L4] Satisfactory outcomes were observed after the nonoperative management of selected distal humeral fractures in lower-demand, medically unwell, or older patients. [12] (10.1016/j.jse.2015.05.032)
• [L4] DHH offers a treatment option for unreconstructable distal humeral fractures and is associated with a good long-term outcome. [13] (10.1016/j.jse.2013.06.012)
• [L4] Conservative treatment of fractures of the distal extremity of the humerus in patients over 65 years of age is exceptional but certainly and demonstrably safe, allowing continued independence and providing satisfactory clinical results with no severe joint stiffness or elbow instability. [14] (10.1016/j.otsr.2013.10.001)
• [L4] Distal humerus fractures still present a significant technical challenge and need meticulous technique and experience to achieve optimal results. [15] (10.1302/2058-5241.3.180009)
• [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. [16] (10.1016/j.otsr.2018.08.017)
• [L4] This study highlights the relative magnitude of the clinical burden of various types of distal humeral fractures. [17] (10.1097/bco.0b013e318229d0b5)
• [L4] It highlights that successful outcomes are difficult to achieve because of the complex anatomy of the elbow, associated osteopenia, and articular and metaphyseal comminution. [18] (10.1016/j.ocl.2007.12.002)
• [L5] Most pediatric and adolescent patients with T-type distal humerus fractures have results better than those of adults but often worse than other elbow fractures in this age group. [19] (10.5435/jaaosglobal-d-17-00040)
• [L2] Our data suggest that a fragility evaluation can help inform surgical decision-making in patients older than 50 years with distal humerus fractures. [21] (10.1016/j.jseint.2021.07.016)
• [L4] [22] (10.1302/0301-620x.96b12.34091)
• [L4] The authors believe it is a useful approach for surgeons treating distal humerus fractures to have in their armamentarium. [23] (10.1016/j.jses.2019.10.107)
• [L4] Distal humeral fractures are complex injuries that require a careful planned approach, when considering surgical fixation, to restore anatomy and achieve good functional outcomes. [24] (10.2174/1874325001711011353)
• [L4] Distal humeral hemiarthroplasty is a suitable option for unreconstructable distal humeral fractures and offers good functional outcomes with acceptable complication rates. [25] (10.1177/17585732211023100)
• [L5] Management principles focus on restoring the anatomic axis, the triangle of stability, and the articular surface to ensure a stable elbow joint that allows for early motion and full range of motion. [26] (10.5435/jaaos-d-17-00326)
• [L4] The data suggest that elbow range of motion and functional use of the elbow are maintained from comparison with short-term studies. [27] (10.1016/j.jse.2016.12.013)
• [L4] Primary TER for treatment of complex distal humerus fractures in elderly patients yielded satisfactory short-term outcomes. [28] (10.5397/cise.2020.00045)
• [L4] Nonoperative treatment for comminuted intraarticular distal humerus fractures results in acceptable functional outcome in elderly patients and should be considered when the fracture is not amenable to internal fixation and in lower-demand patients with higher surgical risk. [30] (10.1177/15589447231218300)
• [L4] Judicious management of extra-articular distal humerus fractures with extraarticular plates has yielded encouraging results. [31] (10.1177/2309499017727948)
• [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. [32] (10.1016/j.jse.2026.02.013)
• [L4] Primary arthroplasty as treatment of distal humeral fractures produces reliable results with regards to revisions and other adverse events. [33] (10.1016/j.jse.2018.07.035)
• [L4] The study demonstrates that distal humerus fracture lines are characteristic and highly related to the micro-architecture difference of the distal humerus, which may provide guidance for treatment plan selection and surgical fixation design. [34] (10.1186/s13018-021-02691-0)
• [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. [35] (10.5397/cise.2019.22.2.113)
• [L4] Short-term results demonstrate satisfactory clinical outcomes with low rates of revision for distal humerus fracture fixed with a linking beam. [36] (10.1016/j.jse.2024.05.029)
• [L4] Used in conjunction with a management algorithm, it aids the surgical decision-making process for distal humeral fractures. [38] (10.1016/j.jse.2005.08.001)
• [L3] Total elbow arthroplasty for distal humerus fractures provided similar clinical and functional outcomes when performed as a primary procedure or after failed internal fixation. [39] (10.1097/bot.0000000000001631)
• [L4] The short-term results suggest that a semiconstrained total elbow replacement has a role to play in the treatment of distal humeral fractures in carefully selected cases which are difficult to treat by internal fixation due to osteopenia and comminution. [40] (10.1016/s0020-1383(00)00076-0)
• [L3] When experienced and skilled surgeons perform fixation of type C distal humerus fracture, the immediate postoperative radiograph is not predictive of fixation failure. [41] (10.1016/j.jhsa.2016.07.094)
• [L5] Current elbow fracture dislocation classification systems only describe one element of the injury or only include one pattern. [50] (10.1177/1758573219884010)
• [L5] Most intra-articular distal humerus fractures require operative fixation for an anatomic reduction and to allow for early motion to optimize outcome. [52] (10.1016/j.ocl.2012.08.010)
• [L4] The surgical repair of an intra-articular distal humeral fracture is an effective procedure that reliably maintains general health status as measured by patient-based questionnaires. [54] (10.2106/00004623-200012000-00003)
• [L5] [55] (10.1097/01.blo.0000131485.47685.8c)
• [L3] In patients older than 65 years with intra-articular distal humerus fracture, ORIF had better outcomes than TEA. [58] (10.5397/cise.2020.00052)
• [L4] The absence of any infectious complications and satisfactory functional outcomes observed in the current series indicates that TEA is a viable treatment modality for complex open fractures of the distal humerus. [59] (10.1016/j.injury.2014.07.017)
• [L3] Open reduction and internal fixation of Type C intraarticular distal humerus fractures is safe and effective. [60] (10.1016/j.jse.2007.02.091)
• [L5] Malunion is a common complication after distal humerus fractures influenced by biology, reduction, fixation methods, and mechanical failure. [61] (10.1016/j.jisako.2024.05.009)
• [L4] The CCDHF demonstrated validity and clinical applicability in classifying distal humeral fractures, showing a moderate level of agreement among observers. [62] (10.1016/j.jseint.2024.08.004)
• [L2] TEA is an effective and reliable procedure for comminuted distal humeral fractures in elderly patients, revealing excellent long-term implant survival with no patient requiring a late revision. [65] (10.1016/j.jse.2019.06.004)
• [L4] Although only rarely indicated, distal humeral hemiarthroplasty has satisfactory clinical outcomes in young patients and allows a higher level of function than is generally advised after total elbow arthroplasty. [66] (10.1177/1758573216660958)
• [L4] Distal humerus hemiarthroplasty is a good option for the surgical management of unreconstructible distal humeral fractures in selected patients. [67] (10.1016/j.injury.2020.11.020)
• [L5] The article reviews literature and provides technical tips for successful ORIF of distal humerus fractures, emphasizing that ORIF remains the predominant treatment choice for most injuries while noting the trade-offs between exposure and complication rates for different surgical approaches. [69] (10.1016/j.xrrt.2023.11.004)
• [L5] Distal humerus hemiarthroplasty may be considered a surgical option for patients with nonreconstructable, intraarticular fractures of the distal humerus. [73] (10.1016/j.ocl.2019.11.009)
• [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. [74] (10.5435/jaaos-d-26-00191)
• [L4] The clear rise in the rate of low-trauma distal humeral fractures in Finnish women 60 years of age and older from 1970 till late 1990s has been followed by stabilized or even decreased fracture rates. [75] (10.1016/j.bone.2009.11.025)
• [L4] A novel classification system based on the humeral capitellum angle (alpha angle) allows for the identification of fracture subtypes that can be successfully managed with simple fixation, which is associated with a low incidence of complications. [102] (10.1016/j.injury.2020.02.111)
• [L5] [106] (10.1016/s0749-0712(21)00128-1)
• [L5] Our results suggest that there is a portion of the aLTR that, despite being covered with articular cartilage, is non-articulating throughout normal elbow range of motion. [111] (10.2106/jbjs.18.01270)
• [L3] Open reduction and plate fixation for distal humeral fractures is a reasonable treatment option with acceptable complication rates and favorable clinical outcomes. [120] (10.1186/s13018-022-03292-1)
• [L4] [127] (10.1016/s0020-1383(02)00009-8)
• [L3] The TT approach is a safe and effective approach for the treatment of distal humeral fractures. [131] (10.1016/j.jse.2022.01.128)
• [L1] TEA for the treatment of comminuted intra-articular distal humeral fractures resulted in more predictable and improved 2-year functional outcomes compared with ORIF, based on the MEPS. [136] (10.1016/j.jse.2008.06.005)
• [L4] The novel surgical technique results in strong, stable fixation of complex intra-articular distal humerus fractures irrespective of bone quality, with all fractures healing, low pain levels, excellent range of motion, and high patient reported outcome scores. [140] (10.1016/j.xrrt.2020.11.007)
• [L4] The incidence of distal humerus fractures in Qatar is lower than reported in developed countries, likely due to the country's demographic profile. [142] (10.1016/j.jseint.2025.01.005)
• [L4] The Wrightington classification system is a valuable tool for characterizing the majority of elbow-fracture dislocations and guiding surgical interventions. [143] (10.1016/j.jseint.2024.08.035)
• [L3] This study demonstrated similar short-term functional outcomes between EHA and ORIF for the treatment of multi-fragmentary intra-articular distal humeral fractures in patients >60 years of age. [145] (10.1177/17585732221093004)
• [L1] [146] (10.1177/17585732251328594)
• [L1] In patients aged 60 years or older with unreconstructible distal humeral fractures, elbow hemiarthroplasty and total elbow arthroplasty did not differ for function at ≥2 years. [148] (10.2106/jbjs.24.00566)
• [L4] The Wrightington classification system is a reliable and valid method of classifying fracture-dislocations of the elbow. [153] (10.1302/0301-620x.102b8.bjj-2020-0013.r1)
• [L4] [154] (10.1016/j.jhsa.2012.02.045)
• [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. [156] (10.1177/1758573216640210)
• [L4] Further studies are required to evaluate EHA as a superior treatment for patients with nonreconstructable traumatic distal humerus fractures; however, this study does support use in elderly patients with intermediate follow up. [157] (10.1177/2471549220960052)
• [L4] Despite disadvantages including excessive loss of bone stock and mechanical failure, results lead us to treat preferentially comminuted and displaced intraarticular fractures of the distal humerus in older women with associated comorbidities with a primary TEA. [158] (10.1097/00005131-200308000-00001)
• [L4] Elbow hemiarthroplasty is an alternative approach for isolated, comminuted distal humerus fractures in elderly, low-demand patients, offering encouraging intermediate outcomes with function, pain, range of motion, and satisfaction. [159] (10.1016/j.xrrt.2021.08.002)
• [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. [165] (10.1016/j.xrrt.2025.07.014)
• [L4] Good outcomes can be achieved for complex elbow fracture-dislocations through pattern recognition and management with an anatomically based reconstruction algorithm as described by the Wrightington classification system. [166] (10.1177/17585732221113534)
• [L4] Osteosynthesis by open reduction and internal fixation is a recommended option for extra-articular distal humeral fractures in elderly patients aged 70 years or older in whom conservative treatment has failed. [168] (10.1016/j.jse.2017.08.024)
• [L4] The Wrightington Classification System is a reliable and valuable tool for characterizing elbow fracture-dislocations and guiding surgical interventions, with moderate reliability overall and higher reliability when using combined 2D and 3D CT imaging. [170] (10.1302/0301-620x.107b2.bjj-2024-0294.r1)
• [L3] [171] (10.1097/bot.0b013e3181e3e273)
• [L4] The study confirms the utility of the Dubberley classification in describing the fracture and selecting the surgical approach. [172] (10.1016/j.jse.2025.05.033)
• [L4] The majority of distal humerus fractures in this series had 4 or more fragments, and fractures with more fragments had a higher percentage of small, difficult-to-repair fragments. [173] (10.1016/j.jse.2011.05.011)
• [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. [174] (10.1016/j.hcl.2015.06.008)
• [L3] Low and high body mass index and three or fewer screws in the articular segment might be risk factors for non-union of distal humerus fracture in the elderly. [176] (10.1177/17585732221131923)
• [L3] MRI is superior to radiograph in evaluating and diagnosing children's humeral lateral condyle fractures and their stability. [177] (10.1186/s13018-021-02726-6)
• [L4] Semiconstrained TEA should be considered as a salvage procedure in young post-traumatic patients with unreconstructible distal humerus fractures. [178] (10.1016/j.jsea.2026.100028)
• [L5] The management of distal humeral fractures remains problematic, particularly in elderly patients with osteoporosis and comminution where ORIF may be impossible. [179] (10.1016/j.jse.2010.11.012)
• [L4] Ultrasonography can accurately depict radial nerve lesions with coexistent plate fixation of humeral shaft fractures. [182] (10.1016/j.injury.2020.11.042)
• [L4] Radiography remains the primary imaging modality in elbow trauma, but in complex fracture patterns, where the extent of the fractures and the position or origin of dislocated fragments is not clear by radiography, the MDCT is a recommended complementary examination. [184] (10.1080/02841850410003310)
• [L2] In particular, elevated posterior fat pad and lipohemarthrosis serve as strong indirect indicators to detect occult elbow fractures and can be detected quickly and reliably by ultrasonography. [185] (10.1007/s00068-021-01648-6)
• [L4] DHH yields modest short-term clinical results for patients with unreconstructible injuries to the distal humerus, and the reoperation rate is not insignificant. [188] (10.1016/j.jse.2013.05.007)
• [L4] Long-term data demonstrate the durability of these elbows following open reduction internal fixation, with radiographic mild to moderate arthritis observed in half of patients at 17-year follow-up. [189] (10.1016/j.jhsa.2012.09.001)

See Also

• Elbow Arthroplasty
• Elbow arthroscopy
• Elbow Instability

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