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Distal humerus fracture

102 citationsUpdated Sep 2026

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Overview

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

Open reduction and internal fixation (ORIF) remains the predominant treatment choice for most distal humerus injuries [69]. Different surgical approaches involve trade-offs between exposure and complication rates [69]. In older patients, ORIF using a parallel construct has demonstrated good functional outcomes and similar complications to previously reported studies [1], with functional recovery generally being satisfactory despite the difficulty of treatment in this population [3]. For comminuted fractures in young patients, ORIF is the preferred surgical option, offering superior functional outcomes and a lower incidence of complications and heterotopic ossification compared to hemiarthroplasty [167].

Arthroplasty serves as a critical alternative, particularly for unreconstructable fractures or in the elderly. Total elbow joint replacement should be available at the time of surgery for all distal humeral fractures in the elderly patient population [4]. Primary arthroplasty produces reliable results regarding revisions and adverse events [33], providing similar clinical and functional outcomes whether performed as a primary procedure or after failed internal fixation [39]. Distal humerus hemiarthroplasty is a viable option for unreconstructible fractures, associated with good to excellent long-term outcomes and acceptable complication rates [6, 13, 25, 67, 73]. It offers functional outcomes comparable to total elbow arthroplasty while potentially avoiding complications related to the ulnar component [158]. In elderly, low-demand patients, elbow hemiarthroplasty provides encouraging intermediate outcomes for isolated, comminuted fractures [161]. Although rarely indicated 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 [66]. Nonoperative management is associated with acceptable functional outcomes and low rates of delayed surgery in the elderly [2]. Satisfactory outcomes have been observed in selected lower-demand, medically unwell, or older patients [12]. Nonoperative treatment should be considered for comminuted intraarticular fractures in elderly patients 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 functions as a trocho-ginglymoid joint, combining trochoid motion through the radiocapitellar and proximal radioulnar joints with ginglymoid motion through the ulnohumeral joint [88]. The distal humeral shaft is triangular in cross-section with its apex directed anteriorly, flaring and flattening at the distal end to form an arch of two condyles [88, 85]. This distal segment bifurcates into medial and lateral cortical columns [83, 88]. The medial column diverges approximately 45 degrees from the humeral shaft in the coronal plane, terminating as the medial epicondyle [85, 88]. The lateral column diverges at approximately 20 degrees in the coronal plane and curves anteriorly as it extends distally, creating a 35 to 40 degrees angle with the shaft in the sagittal plane [85, 88]. In the coronal plane, the trochlea is more distal than the capitellum, resulting in a valgus alignment of 4 to 8 degrees [88]. Including the ulna, the elbow exhibits a valgus angle in extension of 10 to 17 degrees, termed the carrying angle [88]. Axially, the distal humerus articular surface is internally rotated 3 to 8 degrees [88]. The articular surface of the distal humerus is angled 30 degrees anterior to the humeral shaft axis [83, 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 trochlea and capitellum comprise the articular component of the distal humerus [86]. The articular surface of the capitellum starts at the most distal aspect of the lateral column and 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, 85]. Shaped like a spool with a central sulcus, the trochlea articulates with the central ridge of the greater sigmoid notch of the proximal ulna [88]. A portion of the lateral trochlear ridge is covered with articular cartilage but remains non-articulating throughout normal elbow range of motion [113]. The olecranon fossa lies posteriorly and the coronoid fossa anteriorly, separated by a thin bony septum [86, 88]. Just proximal to the trochlea, the floors of these fossae are composed of thin cortical bone, while their walls contain thick cortical bone that can be an asset in plate fixation with screws [86]. The tolerances of the olecranon and coronoid fossae to accommodate their respective bony processes are narrow; screw placement through these fossae may lead to impingement and decreased elbow range of motion [88]. The posterior aspect of the lateral column is relatively flat and wide, well suited for application of a posterolateral plate [88].

The medial epicondyle is larger and more posteriorly oriented than the lateral epicondyle [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]. It lines up in its lesser sigmoid, or radial notch, with the annular ligament surrounding it [85]. The greater sigmoid notch of the ulna has a bare area devoid of cartilage along its transverse axis [77, 108]. The coronoid has a medial and lateral facet which buttresses the trochlea anteriorly [77]. The sublime tubercle 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, and the articulation to the tip of the coronoid is approximately 30° from the long axis of the ulna in the sagittal plane [77]. With the elbow in 90 degrees of flexion, the medial condyle, lateral condyle, and olecranon form a palpable triangle [85].

Ligamentous Anatomy

The medial collateral ligament (MCL) consists of anterior, posterior, and transverse bundles [83]. It originates on the posterior medial epicondyle and inserts on the sublime tubercle of the medial coronoid process [83]. The anterior bundle is the primary restraint to valgus stress within functional elbow range of motion [83, 78]. The posterior bundle has the greatest change and length, becoming taut at flexion beyond 120 degrees, and serves as the primary restraint to valgus stress with the elbow in maximal flexion [78, 83]. Stability in full extension is provided by the MCL, joint capsule, and ulnohumeral articulation [83]. The secondary restraint to valgus stress within functional elbow ROM is the radial head [83].

The lateral collateral ligament complex consists of the radial collateral ligament, the lateral ulnar collateral ligament, and the annular ligament [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 [77, 88]. The annular ligament attaches to the anterior and posterior margins of the lesser sigmoid notch [88]. This complex functions as an important restraint to varus and posterolateral rotatory instability [88]. It is vulnerable to injury during application of a direct lateral plate; therefore, exposure of the lateral aspect of the distal lateral column should not extend past the equator of the capitellum to protect the complex [88].

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]. The anterior capsule attaches at a point approximately 6 mm distal to the tip of the coronoid and allows maximum distension at approximately 70 to 80 degrees of flexion [78]. Tensile forces are present at the medial elbow, while compressive forces are present at the lateral elbow [78]. The radial head should line up with the capitellum at all arm positions on all radiographic views [78].

Muscular Anatomy

The triceps is the primary elbow extensor and inserts on the olecranon process with a broad tendinous insertion posteriorly [78, 85]. The brachialis is the strongest elbow flexor and attaches to the coronoid 11 mm distal to the tip, as well as the tuberosity of the ulna anteriorly [78, 85]. The biceps brachii inserts at the ulnar margin of the radial tuberosity, with the long head proximal and short head distal, and acts as a powerful supinator of the forearm [78]. 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 medial epicondyle is the attachment site for the origins of the flexor pronator mass [77]. The common origin of the extensor muscles is attached to the lateral condylar fragment in lateral condyle fractures [80].

Neurovascular Anatomy

The ulnar nerve passes through the cubital tunnel at the medial column of the elbow and enters the anterior forearm by traveling between the two heads of the flexor carpi ulnaris [85]. It is located just superficial to the posteromedial joint capsule [89]. The radial nerve is separated from the humerus by fibers of the medial head of the triceps proximally and the brachialis laterally, except in the distal third of the humeral shaft [56]. Along the distal third of the humerus, the radial nerve is not protected by interposed muscle, placing it at greater risk for injury during fracture [56]. The musculospiral groove and the lateral intermuscular septum are important landmarks of the humerus that contain the radial nerve and profunda brachial artery [56].

The median nerve and brachial artery are located just superficial to the anteromedial joint capsule and brachialis muscle [89]. On the anterolateral side of the elbow, the radial nerve splits into the superficial sensory branch and the posterior interosseous nerve [89]. The posterior interosseous nerve is just superficial to the anterior joint capsule and at the level of the radiocapitellar joint, coursing longitudinally along the medial side of the capitellum [89]. At the level of the joint, a thin layer of brachialis lies between the posterior interosseous nerve and the capsule, but distally at the level of the radial neck, the nerve may come in direct contact with the capsule [89]. During lateral approach exposure, the radial nerve enters the interval between the brachialis and brachioradialis muscles in the proximal angle of the wound, and its deep branch enters the supinator muscle [80].

Biomechanics and Range of Motion

The normal range of elbow flexion/extension is 0 to 150 degrees, with a functional range of 30 to 130 degrees [83]. Alternatively, the normal elbow has a range of motion from 0° to 140° from extension to flexion, with a functional arc of 100° [42]. The normal forearm pronosupination is 80 to 85 degrees in each direction, with a functional range of 50 degrees [83]. Specifically, the normal elbow has a range of motion of 75° and 85° in pronation and supination respectively, with a functional arc of 100° for forearm rotation [42]. The normal valgus carrying angle of the elbow is 5 to 10 degrees for men and 10 to 15 degrees for women [83]. In full extension, 60% of axial load is transmitted through the radiocapitellar joint [83].

Elbow stability is determined by primary and secondary stabilizers [42]. The three primary stabilizers are the ulnohumeral articulation, the medial ulnar collateral ligament, and the lateral ulnar collateral ligament complex [42]. Secondary stabilizers include the radiocapitellar articulation, the common flexor tendon, the common extensor tendon, and the joint capsule [42]. The ulnohumeral joint allows for flexion and extension, while the radiocapitellar joint allows for forearm rotation [85]. The complex anatomy of the distal humerus reflects its articulation with both the radius and ulna and allows a wide range of motion in multiple planes [86].

Pathophysiology and Injury Mechanisms

Successful outcomes for distal humerus fractures are difficult to achieve because of the complex anatomy of the elbow, associated osteopenia, and articular and metaphyseal comminution [18]. A flexion-extension 'arc of injury' relates fracture types to elbow position at the moment of impact [109]. Distal humeral fractures mostly occur above 110° flexion during impact [109]. Radial head and coronoid fractures follow impact along the forearm up to 80° flexion [109]. Olecranon fractures occur by direct impact around 90° flexion [109].

Heterotopic ossification is a relatively common complication of elbow trauma [22]. Restoration of a functional arc of movement after internal fixation is not always achieved due to heterotopic ossification in some patients [22]. The specific functional implications of heterotopic ossification may be difficult to isolate because movement may also be impaired by associated posttraumatic deformity, arthritis, or capsular fibrosis [22]. The underlying mechanisms of ectopic bone formation are poorly understood [22]. Orthogonal plate configuration, olecranon osteotomy, and longer operative time were associated with increased odds of dysfunctional elbow stiffness following operative fixation of distal humerus fractures [53].

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 also described as unimodal, with low risk in young adults that increases from age 50 and rises markedly in those over 80 years [148]. These fractures account for approximately 0.5% of all adult fractures [148], with an incidence of approximately 5.8/100,000 people reported over one year in a high-volume trauma centre [148]. Incidence is higher in the female population [148]. While the number of cases is thought to be increasing in developed nations due to the ageing population, the age-adjusted incidence may be consistent or falling slowly [148].

Classification Systems

AO/OTA: This system classifies distal humerus fractures into type A (extra-articular), type B (partial articular), and type C (complete articular) [149]. Each type is subdivided into three groups (1, 2, and 3) based on fracture pattern, and each group is further divided into three subgroups (1, 2, and 3) according to the degree of fragmentation [149]. This structure results in twenty-seven different potential injury patterns [149].

Mehne and Matta: This system divides distal humeral fractures into Grade I (intra-articular), Grade II (extra-articular intracapsular), and Grade III (extracapsular) [149]. Intracapsular fractures are subdivided into four groups: A (single column), B (bicolumnar), C (capitellar), and D (trochlear) [149]. 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 [149].

Copenhagen Classification for Distal Humeral Fractures (CCDHF): This classification demonstrated validity and clinical applicability, showing a moderate level of agreement among observers [62]. It is useful for identifying patients who may require hemi- or total elbow arthroplasty [62].

Wrightington: This system is a reliable and valid method for classifying fracture-dislocations of the elbow [155]. It serves as a valuable tool for characterizing the majority of elbow-fracture dislocations and guiding surgical interventions [145]. The system has moderate reliability overall, with higher reliability when using combined 2D and 3D CT imaging [172].

Capitellum Angle: 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 [104].

Dubberley: This classification is useful in describing the fracture and selecting the surgical approach for coronal shear fractures of the distal humerus [174].

Imaging and Diagnostic Accuracy

Two- and three-dimensional computed tomography has been evaluated for the reliability and diagnostic accuracy of classifying distal humeral fractures [149]. Distal humerus fracture lines are characteristic and highly related to the micro-architecture difference of the distal humerus [34]. Three-dimensional mapping of these fractures may provide guidance for treatment plan selection and surgical fixation design [34]. In a specific series, the majority of distal humerus fractures had 4 or more fragments [175]. Fractures with more fragments had a higher percentage of small, difficult-to-repair fragments [175].

Clinical Application and Decision Making

A clinically applicable fracture classification aids the surgical decision-making process when used in conjunction with a management algorithm [38]. 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 [168]. The use of a classification system based on the humeral capitellum angle is associated with a low incidence of complications for subtypes managed with simple fixation [104].

Other Considerations

Current elbow fracture dislocation classification systems only describe one element of the injury or only include one pattern [50].

Clinical Presentation

Distal humerus fractures are complex injuries that require a careful planned approach to restore anatomy and achieve good functional outcomes [24]. Successful outcomes are difficult to achieve due to the complex anatomy of the elbow, associated osteopenia, and articular and metaphyseal comminution [18]. 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].

Complications develop in one out of three patients over 65 years of age with distal humerus fractures [10]. Heterotopic ossification is a relatively common complication of elbow trauma that may prevent the restoration of a functional arc of movement after internal fixation [22]. Malunion is a common complication after distal humerus fractures influenced by biology, reduction, fixation methods, and mechanical failure [61]. Nonunion of the distal humerus is a challenging issue where surgical treatment is usually required [141]. Pathologic fractures in the distal humerus are uncommon and associated with a very high reoperation rate [11].

Investigations

Plain radiography: Plain radiographs remain the hallmark and best screening test for elbow evaluation [42]. The physical examination is directed by history and the location of the patient's pain in the anterior, posterior, medial, or lateral aspect of the elbow [42]. Elbow stability is determined by primary and secondary stabilizers, including the ulnohumeral articulation, medial ulnar collateral ligament (MUCL), and lateral ulnar collateral ligament (LUCL) complex [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]. When experienced and skilled surgeons perform fixation of type C distal humerus fracture, the immediate postoperative radiograph is not predictive of fixation failure [41].

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 [186]. Two- and three-dimensional imaging and modeling of distal humerus fractures have been evaluated for diagnostic accuracy [72]. 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]. Computed tomography 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 [74]. A thorough smoking history combined with CT HU measurements in the coronal plane may identify patients with poorer bone quality at higher risk for postoperative mechanical complications [74].

MRI: Magnetic resonance imaging (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 [179].

Ultrasonography: Ultrasonography can accurately depict radial nerve lesions with coexistent plate fixation of humeral shaft fractures [184]. 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 [187]. Point-of-care ultrasonography has been evaluated for the diagnosis of elbow fractures in children [49].

Other Considerations: The evaluation of the elbow requires an intimate understanding of the anatomy, biomechanics, and diagnostic tests for this complex joint [42]. 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].

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 of fractures of the distal extremity of the humerus 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].

Operative

Indications: Most intra-articular distal humerus fractures require operative fixation for an anatomic reduction and to allow for early motion to optimize outcome [52]. Open reduction and internal fixation (ORIF) of Type C intraarticular distal humerus fractures is safe and effective [60], and 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]. ORIF remains the predominant treatment choice for most distal humerus injuries [69]. For extra-articular distal humerus fractures, judicious management with extraarticular plates has yielded encouraging results [31]. Osteosynthesis by ORIF is a recommended option for extra-articular distal humeral fractures in elderly patients aged 70 years or older in whom conservative treatment has failed [170].

Surgical Approach / Technique: Distal humerus fractures present a significant technical challenge and need meticulous technique and experience to achieve optimal results [15]. The triceps fascial tongue exposure is a useful approach for surgeons treating distal humerus fractures [23], and the triceps tongue approach is a safe and effective approach for the treatment of distal humeral fractures [133]. A posterior midline incision with a triceps-sparing approach, accomplished by reflecting the triceps attachment and periosteum in continuity, is a recommended operative technique for total elbow arthroplasty in distal humerus fractures [120]. The trans-olecranon approach offers excellent exposure for reconstruction of the articular surface especially in type C3 fractures [129]. An intact olecranon can act as a mould over which reconstruction of distal humerus is easy with the additional advantage of avoiding the creation of an additional intra-articular fracture [129].

Implant Selection: Open reduction and plate fixation for distal humeral fractures is a reasonable treatment option with acceptable complication rates and favorable clinical outcomes [122]. Short-term results demonstrate satisfactory clinical outcomes with low rates of revision for distal humerus fracture fixed with a linking beam [36]. 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, low pain levels, excellent range of motion, and high patient reported outcome scores [142].

Other Considerations: 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 [178]. The management of distal humeral fractures remains problematic, particularly in elderly patients with osteoporosis and comminution where ORIF may be impossible [181]. 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].

Arthroplasty: Distal humerus hemiarthroplasty may be an effective treatment for certain distal humeral fractures based on long-term review data [9]. Distal humerus hemiarthroplasty 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 are maintained in patients treated with hemiarthroplasty compared to 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]. Further studies are required to evaluate elbow hemiarthroplasty as a superior treatment for patients with nonreconstructable traumatic distal humerus fractures, though current data support use in elderly patients with intermediate follow-up [159]. Primary total elbow replacement for treatment of complex distal humerus fractures in elderly patients yielded satisfactory short-term outcomes [28]. 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 [176]. 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]. In patients older than 65 years with intra-articular distal humerus fracture, ORIF had better outcomes than TEA [58]. Conversely, 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 [138]. Results lead to treating preferentially comminuted and displaced intraarticular fractures of the distal humerus in older women with associated comorbidities with a primary TEA [160]. Semiconstrained TEA should be considered as a salvage procedure in young post-traumatic patients with unreconstructible distal humerus fractures [180]. 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 [55]. Patients treated with total joint replacement for acute distal humerus fractures must have low physical demands and subsequent athletics are precluded [55].

Complications

General Outcomes: Complex distal humeral fractures carry a high incidence of complications [8]. In elderly patients, these injuries are difficult to treat and present an appreciable number of complications, although functional recovery is generally satisfactory [3]. Reported outcomes for acute distal humerus fractures remain inconsistent across the orthopedic literature, which complicates retrospective comparison of surgical techniques and clinical results [16].

Nerve Palsy: Ulnar nerve dysfunction is a recognized complication of open reduction and internal fixation. The incidence of immediately postoperative ulnar nerve dysfunction is 10.1% [173]. At final follow-up, the incidence of ulnar nerve dysfunction rises to 16% [173].

Heterotopic Ossification: Heterotopic ossification is a relatively common complication of elbow trauma that can prevent the restoration of a functional arc of movement [22].

Fixation Failure and Mechanical Complications: When experienced and skilled surgeons perform fixation of type C distal humerus fractures, the immediate postoperative radiograph is not predictive of fixation failure [41]. 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 [74].

Arthroplasty-Related Complications: Distal humeral hemiarthroplasty offers good functional outcomes with acceptable complication rates for unreconstructable distal humeral fractures [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]. Pathologic fractures in the distal humerus are associated with a very high reoperation rate [11].

Recovery

Other Considerations: The provided evidence base does not contain specific data regarding recovery timelines, such as weeks for light activity, months for full activity, or the duration of complete recovery and outcome plateau. Consequently, these phases are omitted. Available data focuses on long-term durability, functional outcomes, and complication rates rather than short-term rehabilitation milestones.

Nonoperative Management: Conservative treatment of distal humerus fractures 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].

Operative Management: Internal Fixation: Long-term data demonstrate the durability of elbows following open reduction internal fixation for coronal shear fractures, with radiographic mild to moderate arthritis observed in half of patients at 17-year follow-up [191].

Operative Management: Arthroplasty: Distal humerus hemiarthroplasty (DHH) offers a treatment option for unreconstructable distal humeral fractures and is associated with a good long-term outcome [13]. Elbow range of motion and functional use are maintained in patients treated with hemiarthroplasty for distal humerus fractures, as compared with short-term studies [7, 27]. However, DHH yields modest short-term clinical results for patients with unreconstructible injuries to the distal humerus, and the reoperation rate is not insignificant [190]. Total elbow arthroplasty (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]. TEA is a viable treatment modality for complex open fractures of the distal humerus, indicated by the absence of infectious complications and satisfactory functional outcomes [59]. 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 [150]. 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 [147].

Complications and Prognosis: Complications develop in one out of three patients over 65 with distal humerus fractures [10].

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] 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)
• [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)
• [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)
• [L2] [49] (10.1016/j.annemergmed.2012.07.112)
• [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)
• [L3] Orthogonal plate configuration, olecranon osteotomy, and longer operative time were associated with increased odds of dysfunctional elbow stiffness. [53] (10.1016/j.jse.2024.06.010)
• [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)
• [L4] [56] (10.1016/j.jhsa.2006.02.013)
• [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)
• [L1] [72] (10.1016/j.jse.2012.01.009)
• [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] 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. [104] (10.1016/j.injury.2020.02.111)
• [L5] [108] (10.1016/s0749-0712(21)00128-1)
• [Paper] [109] (10.1016/0020-1383(95)93494-3)
• [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. [113] (10.2106/jbjs.18.01270)
• [L4] [120] (10.2106/00004623-199706000-00004)
• [L3] Open reduction and plate fixation for distal humeral fractures is a reasonable treatment option with acceptable complication rates and favorable clinical outcomes. [122] (10.1186/s13018-022-03292-1)
• [L4] [129] (10.1016/s0020-1383(02)00009-8)
• [L3] The TT approach is a safe and effective approach for the treatment of distal humeral fractures. [133] (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. [138] (10.1016/j.jse.2008.06.005)
• [L5] Nonunion of the distal humerus is a challenging issue where surgical treatment is usually required. [141] (10.1016/j.jisako.2024.07.002)
• [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. [142] (10.1016/j.xrrt.2020.11.007)
• [L4] The Wrightington classification system is a valuable tool for characterizing the majority of elbow-fracture dislocations and guiding surgical interventions. [145] (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. [147] (10.1177/17585732221093004)
• [L1] [148] (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. [150] (10.2106/jbjs.24.00566)
• [L4] The Wrightington classification system is a reliable and valid method of classifying fracture-dislocations of the elbow. [155] (10.1302/0301-620x.102b8.bjj-2020-0013.r1)
• [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. [158] (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. [159] (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. [160] (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. [161] (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. [167] (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. [168] (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. [170] (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. [172] (10.1302/0301-620x.107b2.bjj-2024-0294.r1)
• [L3] [173] (10.1097/bot.0b013e3181e3e273)
• [L4] The study confirms the utility of the Dubberley classification in describing the fracture and selecting the surgical approach. [174] (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. [175] (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. [176] (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. [178] (10.1177/17585732221131923)
• [L3] MRI is superior to radiograph in evaluating and diagnosing children's humeral lateral condyle fractures and their stability. [179] (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. [180] (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. [181] (10.1016/j.jse.2010.11.012)
• [L4] Ultrasonography can accurately depict radial nerve lesions with coexistent plate fixation of humeral shaft fractures. [184] (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. [186] (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. [187] (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. [190] (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. [191] (10.1016/j.jhsa.2012.09.001)

See Also

• Elbow Arthroplasty
• Elbow Instability

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