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Distal humerus fracture

41 citationsUpdated Sep 2026

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Overview

Internal fixation is generally accepted as the standard of care for intra-articular distal humerus fractures, with rigid anatomic fixation combined with early motion associated with favorable results [4]. While reported outcomes for acute distal humerus fractures remain inconsistent across the orthopedic literature, making retrospective comparison of surgical techniques difficult [3], treatment decisions for intra-articular fractures should be based on a combination of the best available evidence and surgeon preference [10]. A 2021 systematic review represents the largest current report of complications and reoperations following open reduction and internal fixation (ORIF) for these injuries [8].

For older patients, ORIF using a parallel construct demonstrates good functional outcomes with complication rates similar to previously reported studies [1]. In cases of unreconstructible distal humerus fractures, distal humerus hemiarthroplasty is a viable and suitable option, offering good to excellent functional outcomes with acceptable complication rates [2, 11]. Elbow hemiarthroplasty is also a viable option for complex distal humeral fractures in select patients, providing functional outcomes comparable to total elbow arthroplasty while potentially avoiding complications related to the ulnar component [16]. Total elbow arthroplasty serves as a successful treatment alternative for selected distal humerus fractures, particularly indicated for elderly patients with low anticipated physical demands, severe osteopenia, or comminution [31].

For comminuted distal humerus fractures in young patients, ORIF appears to be the preferred surgical option, offering superior functional outcomes compared to hemiarthroplasty [14]. This approach is associated with a lower incidence of complications and heterotopic ossification compared to hemiarthroplasty in this demographic [14]. When managing nonunion of distal humerus fractures, open reduction and internal fixation with bone grafting is the treatment of choice if no excessive damage of the articular surface is present [7].

Anatomy & Pathophysiology

Bony Anatomy

The elbow is a trocho-ginglymoid joint comprising medial and lateral articulations that provide bony stability [36]. Medially, the trochlea articulates with the ulna within the greater sigmoid notch to form the ulnohumeral joint, exhibiting highly congruent anatomy through almost 180° of articular contact, excluding the bare area of the greater sigmoid notch [36]. The coronoid process features medial and lateral facets that buttress the trochlea anteriorly [36]. Just distal and medial to the coronoid, the sublime tubercle serves as the attachment site for the anterior bundle of the medial ulnar collateral ligament [36]. The medial epicondyle is larger and more posteriorly oriented than the lateral epicondyle, serving as the attachment site for the flexor pronator mass [36]. Laterally, the capitellum and radial head form the radiocapitellar joint [36]. The radial head is a concave elliptical structure covered with articular cartilage along the radiocapitellar joint and approximately 270° of the articular margin [36]. The radius is held in close approximation to the ulna at the proximal radioulnar joint by the annular ligament [36].

The distal humeral articulation is angled 30° from the longitudinal axis [36]. To avoid loss of flexion or extension during reconstruction, the anterior humeral line should pass through the center of the axis of rotation [36]. The axis of rotation is angulated 5° to 7° in the coronal plane relative to the epicondylar axis, with the medial side positioned more distally than the lateral side [36]. This coronal angulation accounts for the change from a valgus carrying angle to a more varus position as the elbow flexes [36]. The olecranon provides a broad attachment site for the triceps muscle [36]. The ulna bends approximately 8° medially at 8 cm from the tip of the olecranon [36]. In the sagittal plane, the articulation to the tip of the coronoid is approximately 30° from the long axis of the ulna [36].

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 creates a weak point for complex fractures [9]. The medial column holds the medial epicondyle and medial portion of the humeral trochlea, appearing 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]. Additionally, this epiphyseal section is externally rotated by 3–8° relative to the metaphysis and flexed 40° relative to the shaft [9].

Ligaments & 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]. Secondary stabilizers include the radiocapitellar articulation, common flexor tendon, common extensor tendon, and joint capsule [25]. The MUCL is the primary valgus stabilizer of the elbow [37]. The anterior bundle of the MUCL is the most important component for stability [37]. The posterior bundle of the MUCL becomes taut at flexion beyond 120 degrees [37]. The lateral ulnar collateral ligament acts as a posterolateral stabilizer [37]. Osborne’s ligament stabilizes the ulnar nerve in the cubital tunnel [37]. The ligament of Struthers is a variant anatomy arising from the supracondylar process to attach to the medial epicondyle, serving as a potential site of median nerve compression [37]. Tensile forces are present at the medial elbow, while compressive forces are present at the lateral elbow [37].

The joint capsule allows maximum distension at approximately 70 to 80 degrees of flexion [37]. The anterior capsule attaches at a point approximately 6 mm distal to the tip of the coronoid [37]. The brachialis is the strongest elbow flexor and attaches to the coronoid 11 mm distal to the tip [37]. The biceps brachii inserts at the ulnar margin of the radial tuberosity and acts as a powerful supinator of the forearm [37]. The triceps is the primary elbow extensor and inserts on the olecranon process [37].

Pathophysiology & Injury Mechanisms

Distal humerus fractures are difficult to treat due to their epiphyseal location [9]. Approximately 3000 distal humerus fractures in adults and children are treated surgically every year in France [9]. Normal elbow function is difficult to restore if the joint is deformed by malunion or stiffened by heterotopic ossifications or capsular and ligament contractures [9]. Malunion is a common complication after distal humerus fractures influenced by biology, reduction, fixation methods, and mechanical failure [5].

Coronal shear fractures of the distal humerus can involve the capitellum, the trochlea, or both [57]. Capitellum fractures account for 1% of all elbow fractures and 6% of distal humeral fractures [57]. A mechanism for coronal shear fracture involves a direct axial load transmitted to the capitellum by the radial head following a fall onto an outstained hand [57]. A second mechanism involves lateral collateral ligament complex failure leading to posterolateral subluxation, where the radial head and coronoid shear off the capitellum and trochlea [57]. Posterior shear fractures of the distal humerus mostly involve the posterior aspect of the capitellum and are often associated with elbow dislocation [50].

Classification

AO/OTA: Distal humerus fractures are classified using the AO/OTA classification system [20]. Type A fractures are categorized as extraarticular metaphyseal, transcondylar, and apophyseal [19]. Type B fractures are defined as partial articular, while Type C fractures are defined as complete articular [19]. Within this system, capitellar fractures are denoted as 13B3, indicating distal humerus involvement, partial articular status, and frontal plane involvement [49]. The 13B3 category is subclassified into B3.1 for isolated capitellum fractures, B3.2 for trochlea fractures, and B3.3 for capitellum and trochlea fractures with a secondary fracture line in the sagittal plane [49].

Bryan and Morrey: This classification system is the most commonly used for partial articular fractures of the distal humerus [49]. Type I fractures (Hahn-Steinthal) are complete capitellar fractures with little or no extension into the lateral trochlea [49]. Type II fractures (Kocher-Lorenz) are anterior osteochondral fractures with minimal subchondral bone [49]. Type III fractures (Broberg-Morrey variant) are comminuted or compression fractures of the capitellum [49]. Type IV fractures, per the McKee et al. addendum, are coronal shear fractures of the capitellum that extend medially to include most of the trochlea [49]. The "double arc" sign on lateral radiographs is pathognomonic for Type IV coronal shear fractures, though it may not be radiographically apparent in all cases due to an internally rotated capitellum and trochlea fragment [49].

Dubberley: This classification is useful for describing coronal shear fractures of the distal humerus and selecting the surgical approach [52].

Other Considerations: Multiple classification systems exist for capitellum fractures, contributing to unclear outcomes in the literature due to a lack of comparative groups [56].

Clinical Presentation

Distal humerus fractures represent approximately 0.5% of all adult fractures [20]. In high-volume trauma centres, the incidence is approximately 5.8 per 100,000 people over one year [20]. An orthopaedic surgeon in France encounters an average of five such cases annually [9]. The age distribution is unimodal, with low risk in young adults that increases from age 50 years and rises markedly in patients over 80 years [20]. These injuries are osteoporotic fractures with a higher incidence in the female population [20]. While the age-adjusted incidence may be consistent or falling slowly, the total number of cases is thought to be increasing in developed nations due to the ageing population [20].

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

Investigations

Plain radiography: Plain radiographs remain the hallmark and best screening test for elbow evaluation [25]. Standard AP, lateral, and oblique views are obtained to assess the joint [42]. In elbow osteoarthritis, radiographs typically demonstrate osteophyte formation at the coronoid process, coronoid fossa, radial fossa, radial head, olecranon tip, and olecranon fossa [46]. However, radiographs typically underestimate the number of loose bodies present in elbow osteoarthritis [46]. Radiographic evaluations are also essential when diagnosing an osteochondritis dissecans lesion of the elbow [45].

CT: CT is beneficial if any joint incongruity or abnormal bony anatomy is present, but it is not necessary when elbow stiffness is entirely soft-tissue related [42]. It is helpful for assessing malunion architecture and the location and pattern of osteophytes or loose bodies [42]. Three-dimensional CT is used to check for heterotopic ossification [42]. For valgus extension overload syndrome, CT with two-dimensional reconstruction and three-dimensional surface rendering best visualizes the pathology [44]. In elbow osteoarthritis, CT may be useful for surgical planning by allowing a detailed assessment of osteophytes and the presence of loose bodies [46].

MRI: MRI can be used to evaluate ligaments and tendons, but it is rarely indicated for elbow stiffness [42]. MRI may be most helpful in evaluating associated injuries, including partial or complete tears of the medial collateral ligament in valgus extension overload syndrome [44]. Important aspects of osteochondritis dissecans lesions may be better seen with MRI [45].

Physical Examination: The physical exam is directed by history and the location of the patient's pain in the anterior, posterior, medial, or lateral aspect of the elbow [25]. Active and passive flexion, extension, supination, and pronation should be evaluated using a goniometer for accurate measurement, with the contralateral elbow examined for comparison [42]. Pain should be assessed during the mid-arc or at the terminal ends of motion [42]. Mid-arc range of motion pain is more common with intrinsic disease and may not improve with contracture release alone [42]. 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 [42].

The ulnar nerve is of utmost importance in the physical examination due to its anatomic proximity to the elbow [42]. An assessment for ulnar nerve subluxation should be performed, as subluxation is a relative contraindication for an arthroscopic procedure secondary to possible iatrogenic nerve injury [42]. Electromyography and nerve conduction velocity studies should be performed if any question about neurologic dysfunction exists [42].

Specific findings vary by pathology. In valgus extension overload syndrome, crepitus and tenderness over the posteromedial olecranon may be noted, pain is reproduced when the elbow is forced into extension, and elbow flexion contracture may be seen [44]. Physical examination findings in capitellum osteochondritis dissecans include lateral elbow tenderness, crepitus, and often a 15° to 20° flexion contracture [44].

Other Considerations: 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 [23].

Treatment

General Principles and Classification

The AO/OTA classification scheme categorizes distal humerus fractures into type A (extraarticular metaphyseal, transcondylar, and apophyseal), type B (partial articular), and type C (complete articular) [19]. Non-operative management is generally reserved for completely undisplaced stable fractures or for patients in whom the risks of surgery outweigh the benefits [20].

Operative

Indications: Internal fixation is the standard of care for intra-articular distal humerus fractures, where rigid anatomic fixation combined with early motion yields favorable results [4]. Arthroplasty serves as a viable alternative for unreconstructible fractures, particularly in elderly patients with severe osteopenia, comminution, or low anticipated physical demands where osteosynthesis is not feasible [2][11][13][31][32]. Specifically, semiconstrained total joint replacement is indicated for a restricted group of patients older than 60–65 years with extensively comminuted fractures not amenable to adequate and stable osteosynthesis [27].

Surgical Approach / Technique: Dual plating provides the most rigid and reliable construct for articular reduction, facilitating early range of motion and physical rehabilitation [24]. Both orthogonal and parallel plating techniques are utilized with excellent outcomes [15]. Older patients treated with a parallel construct demonstrate good functional outcomes and complication rates similar to previously reported studies [1]. Current evidence indicates that OO, TRA, TS, and TT posterior approaches provide comparable overall clinical outcomes for AO/OTA type C complete intra-articular fractures, with no statistically significant differences in most outcome measures [22].

Implant Selection: For unreconstructable fractures, distal humeral hemiarthroplasty offers good to excellent functional outcomes and range of motion with acceptable complication rates [2][11][13]. Total elbow arthroplasty provides a successful treatment alternative for selected acute fractures, particularly in physiologically older patients with lower joint demands [31][32].

Other Considerations: Management remains problematic in elderly patients with osteoporosis and comminution where ORIF may be impossible [21]. Salvage total elbow arthroplasty is a viable option for post-traumatic sequelae; however, patients undergoing salvage TEA experience a significantly increased rate of complications and significantly inferior functional outcomes compared with those who underwent TEA acutely [12].

Complications

Malunion and Nonunion

The provided evidence does not specify incidence rates, risk factors, or management strategies for malunion or nonunion in this context.

Mechanical and Fixation Complications

Bone Quality Assessment: A thorough smoking history and CT Hounsfield unit measurements in the coronal plane may identify patients with poorer bone quality who are at higher risk for postoperative mechanical complications following distal humerus fracture fixation [23].

Olecranon Osteotomy: The high risk of complications associated with olecranon osteotomy must be considered in the decision to perform this procedure in the treatment of distal humerus fractures [60].

Salvage vs. Acute Arthroplasty: Patients who underwent salvage total elbow arthroplasty for post-traumatic sequelae had a significantly increased rate of complications compared with those who underwent total elbow arthroplasty acutely [12].

Hemiarthroplasty: Elbow hemiarthroplasty potentially avoids complications related to the ulnar component [16].

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

Other Considerations: 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]. In older patients, open reduction and internal fixation using a parallel construct demonstrated good functional outcomes with complication rates similar to those in previously reported studies [1]. Malunion is a common complication after distal humerus fractures, influenced by biology, reduction, fixation methods, and mechanical failure [5].

In pediatric patients with unusual fracture patterns, management principles focus on restoring the anatomic axis, the triangle of stability, and the articular surface [6]. Restoring these structures ensures a stable elbow joint that allows for early motion and full range of motion [6].

For complex distal humerus fractures not amenable to fixation, particularly in elderly patients, distal humerus hemiarthroplasty yields satisfactory functional outcomes and range of motion [13]. Salvage total elbow arthroplasty represents a viable option for managing post-traumatic sequelae; however, patients undergoing salvage procedures experience a significantly increased rate of complications and significantly inferior functional outcomes compared with those who underwent total elbow arthroplasty acutely [12].

Intra-articular fractures are consistently and temporally associated with a more than two-fold increased risk of total elbow arthroplasty compared with extra-articular fractures in the older cohort [62]. Nearly 5.5% of patients with intra-articular distal humerus fractures progressed to total elbow arthroplasty by 10 years [62]. Ulnar nerve transposition does not have a protective effect against the development of late ulnar neuropathy after distal humerus fracture repair surgery [63].

Mortality at 1 and 2 years is substantial in older adults with isolated distal humerus fractures, strongly predicted by comorbidity burden and preinjury ambulation [17]. A thorough smoking history may identify patients with poorer bone quality at higher risk for postoperative mechanical complications following distal humerus fracture fixation [23]. CT Hounsfield Unit measurements in the coronal plane may also identify patients with poorer bone quality at higher risk for postoperative mechanical complications [23].

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] Malunion is a common complication after distal humerus fractures influenced by biology, reduction, fixation methods, and mechanical failure. [5] (10.1016/j.jisako.2024.05.009)
  • [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. [6] (10.5435/jaaos-d-17-00326)
  • [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. [7] (10.1016/j.jisako.2024.07.002)
  • [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. [31] (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. [32] (10.2106/jbjs.d.02871)
  • [L4] [49] (10.5435/00124635-200812000-00004)
  • [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. [56] (10.1177/1558944719878817)
  • [L4] [57] (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. [60] (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. [62] (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. [63] (10.1016/j.hcl.2017.09.010)

See Also

References

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[60] Complications of olecranon osteotomy in the treatment of distal humerus fracture. Clinics in Shoulder and Elbow. 2022. DOI: 10.5397/cise.2021.00591

[62] What is the incidence of total elbow arthroplasty after intra-articular versus extra-articular distal humerus open reduction and internal fixation?. Shoulder & Elbow. 2026. DOI: 10.1177/17585732261451863

[63] Ulnar Nerve Management with Distal Humerus Fracture Fixation. Hand Clinics. 2018. DOI: 10.1016/j.hcl.2017.09.010

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