CURRENT CONCEPTS

Elbow Fractures: Distal Humerus

Andrew S. Wong, MD, Mark E. Baratz, MD

A distal humerus fracture can be a debilitating and difficult injury to treat. The anatomy of
the distal humerus is highly complex, as it articulates with both the radius and ulna and
allows for motion in multiple planes. Furthermore, comminution and osteopenia may render
the metaphyseal-diaphyseal junction weak, making adequate stabilization difficult. Various
methods of surgical fixation have been described, with bicolumnar plating being the most
popular. Controversy over fixation techniques and the introduction of recently developed
implants, including precontoured plates and locking plates, have led to renewed focus on
biomechanical testing of various fixation constructs. Failure of adequate reconstruction or
fixation can be addressed with adjunctive measures such as incorporation of structural bone
grafts, external fixation, or, in certain instances, salvage with total elbow arthroplasty. The
articular surface can also be injured from a shear force, resulting in fractures of the
capitellum and trochlea in the coronal plane. This article presents a review of current
literature concerning the diagnosis, classification, treatment, and outcome of distal humerus
fractures. (J Hand Surg 2009;34A:176–190. © 2009 Published by Elsevier Inc. on behalf of
the American Society for Surgery of the Hand.)
Key words Distal humerus, fractures, elbow.

RACTURES OF THE distal humerus are an increas- erative treatment unsuccessful and often makes fracture

F ingly common1 and often difficult injury to treat.

Although the overall incidence of distal humerus
fractures in adults has been reported to be only 5.7 cases
per 100,000,2 these fractures can lead to considerable
long-term impairment. Patients who sustain distal hu-
merus fractures fall into a bimodal distribution of young
patients, involved in high-energy trauma, and elderly,
osteoporotic patients, typically injured from a low-en-
ergy fall.2 In both instances, fractures may range from a
simple extra-articular fracture pattern to a complex pat-
tern, involving extensive destruction of the articular
surface with comminution and bone loss in the metaph-
yseal-diaphyseal junction of the bone. Difficulty is fur-
ther compounded by the difficult fracture anatomy. The
distal location and articular involvement makes nonop-
From Allegheny General Hospital, Pittsburgh, PA.
Current Concepts
fixation difficult.
Given the challenges in treating these fractures, there
has been controversy regarding treatment. This article
presents a review of current literature concerning the
diagnosis, classification, treatment, and outcome of
treatment of distal humerus fractures.
DIAGNOSIS
The mainstay in diagnosing distal humerus fractures is
conventional radiography, including views of the wrist
and shoulder to rule out concomitant injury. Standard
views, including anteroposterior, lateral, and oblique
views, can generally confirm the presence of and help
to characterize distal humerus fractures.3 However, in
fractures with severe comminution and shortening, frac-
ture fragments may overlap, obscuring the area in ques-
tion. In the absence of articular comminution, intraop-

Received for publication October 16, 2008; accepted in revised form October 26, 2008.
No benefits in any form have been received or will be received related directly or indirectly to the
subject of this article.
Corresponding author: Mark E. Baratz, MD, Allegheny General Hospital, Orthopaedics, 1307
Federal Street, 2nd Floor, Pittsburgh, PA 15212; e-mail: mbaratz@wpahs.org.
0363-5023/09/34A01-0029$36.00/0
doi:10.1016/j.jhsa.2008.10.023
erative traction views may be helpful in delineating the
major fracture fragments.
In shear fractures of the distal humeral surface, a
radial head– capitellum view may be helpful. A modi-
fication of a lateral view, the radial head– capitellum
view is shot by angling the beam of the radiograph 45°
anteriorly to diminish overlap of the humeroradial and

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 ELBOW FRACTURES: DISTAL HUMERUS 177

FIGURE 1: Radial head– capitellum view. A The radiographic beam is angled 45° anteriorly from a standard lateral elbow
radiograph. B Radiographic view of the radial head– capitellum.

FIGURE 2: Evaluation of a distal humerus articular and concomitant olecranon fracture with multiple different modalities. A, B
Anteroposterior and lateral radiographic views. C, D Representative 2-D CT reconstructions. E–G Three-dimensional CT
reconstruction views.

humeroulnar articulations (Fig. 1).4 This allows for anatomy of the distal humerus, confounded by the dis-
better visualization of small fragments of the capitellum tortion caused by comminution and displacement, can
that may be largely composed of articular cartilage. The make accurate assessment difficult. Three-dimensional
Current Concepts

double-arc sign is indicative of a fracture of the capi-
tellum and lateral trochlear ridge.5 The “double-arc”
represents the increased radiographic density of the
subchondral bone of the capitellum and trochlear ridge.
Computed tomography (CT) is a powerful tool for
characterizing fractures of the distal humerus.3 Two-
dimensional (2-D) CT allows for accurate assessment
of the fracture in multiple planes and is often useful in
surgical planning.6 However, the complexity of the
(3-D) reconstructions provide a surface view of the
anatomy and the ability to subtract the ulna and hu-
merus from the image (Fig. 2). This technique is be-
lieved by some authors to improve the accuracy of
fracture characterization. In a study by Dornberg et al.,
the addition of 3-D reconstructions to plain radiographs
and 2-D CT scans of distal humerus fracture improved
intraobserver reliability but not the interobserver agree-
ment.7 These findings support the findings of Vannier et

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 178 ELBOW FRACTURES: DISTAL HUMERUS

FIGURE 3: Schematic of the AO classification system of distal humerus fractures. Group A includes extra-articular fractures.
Group B includes intra-articular fractures involving 1 column. Group C fractures are intra-articular and involve both columns.

al., who found 3-D CT to be equivalent to conventional an extra-articular fracture; type B fractures extend into
modalities in the evaluation of complex articular frac- the articular surface; and type C fractures describe com-
tures.8 plete separation of the articular surface from the shaft.
Current Concepts

Numerical attachments, from 1 to 3, are used to further

CLASSIFICATION
Fractures of the distal humerus can be broadly classified
into supracondylar, transcondylar, and intercondylar
fractures based on the location of the fracture above the
olecranon fossa, through the olecranon fossa, or be-
tween the condyles of the distal humerus, respectively.3
A more comprehensive and commonly used system is
the AO classification system (Fig. 3). Type A describes
classify degree of comminution, with 3 being more
highly comminuted.3 Intercondylar fractures can be
characterized by the Riseborough and Radin classifica-
tion scheme, with all types including a supracondylar
component9 (Fig. 4). Type I are nondisplaced fractures
between the capitellum and trochlea. Type II fractures
have a displaced, nonrotated fracture between the con-
dyles, whereas type III fractures have a displaced and

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 ELBOW FRACTURES: DISTAL HUMERUS 179

FIGURE 4: Schematic of the Riseborough and Radin classification of intercondylar fractures (all types including a supracondylar
component). A Type 1, B type II, C type III, D type IV.

rotated fracture. Type IV describes severe comminution
of the articular surface of one or both condyles.
NONSURGICAL TREATMENT
In nondisplaced fractures of the distal humerus, the
literature supports nonoperative treatment. This consists
of a period of immobilization, followed by bracing.3
However, given the proximity of the many fractures to
the joint, it may be difficult or impossible to control
distal fractures with functional braces. Further, immo-
bilization of patients in a long-arm cast counters the
goal of early movement of the elbow to prevent stiff-
ness. Our experience suggests that rigid surgical fixa-
tion is preferable. There is less morbidity of operative
intervention in patients with nondisplaced fractures than
in those with more extensive fractures, and a stable
fracture allows for immediate motion and reliable heal-
ing3 (Fig. 5).
The role for nonoperative treatment in displaced
distal humerus fractures is limited, especially with intra-
articular extension.3 However, in the setting of patients
who are unable to have operative intervention due to
medical comorbidities, treatment with the “bag of
bones” method may be the best alternative. This tech-
nique consists of immobilizing the elbow in 60° of
flexion for 2 to 3 weeks, followed by gentle motion.3
SURGICAL APPROACH
Surgical intervention is considered the standard treat-
painting the exposed articular surfaces with methylene
blue, the authors determined that the olecranon osteot-
omy provided better exposure of the articular surface
than did the triceps-splitting and the triceps-reflecting
techniques, but this difference did not reach statistical
significance in the case of triceps-reflecting exposure.11
It is our experience that the triceps-splitting and triceps-
reflecting exposures allow visualization of the posterior
portion of the trochlea, and only the olecranon osteot-
omy provides access to the anterior aspect of the troch-
lea and capitellum.
The triceps-splitting posterior approach exploits the
proximal innervation of the muscle, which allows for
splitting of the tendon and distal muscle fibers without
denervating the muscle (Fig. 6A–C). Most surgeons
will limit the exposure to a split that stops at the tip of
the olecranon. This technique is most commonly used
for fractures without articular comminution, as expo-
sure of the articular surface is limited.3,12 Ziran et al.
reviewed their experience with a true triceps-splitting
approach in 34 fractures.13 They performed a more
extensive variation of this approach in which they peeled
the triceps off the olecranon and both collateral liga-
ments off the distal humerus. This allowed them to see
and fix fractures with extension to the anterior aspect of
the distal humerus. They did have 1 case of heterotopic
ossification (HO), 1 transient ulnar nerve palsy, 5 non-
unions, and 4 cases of varus or valgus instability.
We usually stop short of peeling off the triceps
Current Concepts

ment for displaced distal humeral fractures.10 There are
several options for the surgical approach. In general
terms, complex, comminuted fracture patterns that in-
volve the articular surface require more extensive ex-
posure than do extra-articular, simple fracture patterns.
In an attempt to elucidate the most advantageous ap-
proach for such complex fractures, Wilkinson and Stan-
ley performed a triceps-splitting, triceps-reflecting, and
olecranon osteotomy on cadaveric human elbows. By
tendon when using this approach and have been reluc-
tant to release the collateral ligaments. By mobilizing
the triceps tendon-muscle unit both medially and later-
ally, 2 additional “windows” are created that allow for
additional visualization, greater ease in reduction, and
accuracy of implant placement (Fig. 6D, E). Further,
resection of approximately 1 cm of the tip of the olec-
ranon can aid in the view of the trochlea.3 We have used
this approach for fractures with proximal extension,

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 180 ELBOW FRACTURES: DISTAL HUMERUS

FIGURE 5: A 67-year-old woman sustains a low-energy elbow injury. A, B Anteroposterior and lateral radiographic views of the
elbow reveal a nondisplaced supracondylar humerus fracture. The patient elected nonoperative treatment despite counseling for
operative intervention. C, D Anteroposterior and lateral views showing progression of fracture to nonunion after 2 months of
nonoperative treatment. E, F Anteroposterior and lateral views showing resultant open reduction and internal fixation of fracture
nonunion.

extra-articular fractures, and simple “T”-type fractures
in which the articular surface can be reduced by seeing
only the posterior aspect of the trochlea.
Bryan and Morrey described the posterior “triceps-
sparing” approach, initially designed for reconstructive
surgery of the elbow, particularly total elbow arthro-
plasty (Fig. 6F, G). This involves elevating the triceps
tendon from medial to lateral off of the olecranon with
care to maintain continuity of the triceps tendon with
Current Concepts
fractures through this approach. Another recent study
evaluated triceps tendon strength after triceps-sparing
versus triceps-splitting or V-Y approach. The authors
found all approaches to result in marked weakening of
the triceps, but with statistically better strength after the
triceps reflecting approach than after approaches that
divided the tendon.16 We have found this approach
adequate for exposing extra-articular fractures without
proximal extension and simple articular fractures that

the proximal ulnar periosteum. At the completion of the
procedure, the tendon is repaired to the proximal ulna
using sutures placed through drill holes.14 In a recent
single-surgeon review of functional outcome of AO
type C fractures through a triceps-sparing approach, 7
patients were found to have good clinical scores, me-
dian arc of motion of 90°, and no radiographic evidence
of HO.15 However, the authors noted in their discussion
that they had some difficulty fixing lateral condylar
can be aligned with indirect reduction. Care must be
taken when retracting the muscle on the lateral side. We
have seen 2 cases in which retraction with a Homan
retractor placed on the lateral cortex resulted in transient
radial nerve palsies.
The olecranon osteotomy has been described for all
fractures of the distal humerus, but particularly for
fractures with comminution of the articular surface.
Previous authors have described a relatively high inci-

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 ELBOW FRACTURES: DISTAL HUMERUS 181

FIGURE 6: Surgical approaches to the distal humerus. A The ulnar nerve is identified, mobilized, and carefully protected. B
Triceps-splitting approach: superficial division of triceps. C Triceps-splitting approach: deep dissection exposing the distal
Current Concepts

humerus. One centimeter of the olecranon tip can be resected to increase visualization. D The medial border of triceps is elevated
to expose medial humerus. E The lateral border of the triceps can also be elevated to exposure of the lateral humerus. Care must
be taken to avoid excessive traction on the radial nerve. F Triceps-reflecting approach: The triceps is elevated from the distal
humerus, and triceps tendon is dissected subperiosteally from the olecranon insertion. G Triceps-reflecting approach: The triceps
tendon is completely reflected laterally taking care to preserve continuity with the ulnar periosteum. The tendon is subsequently
repaired through bone tunnels back to the olecranon. H Olecranon osteotomy: A chevron-shaped osteotomy provides increased
bony healing surface. Completion of the osteotomy through the far-cortex is completed with an osteotome to avoid damage to
articular surface. I Olecranon osteotomy: Extensive exposure of distal humerus, including the articular surface, after elevation of
the triceps off the posterior humerus.

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 182 ELBOW FRACTURES: DISTAL HUMERUS

FIGURE 7: A The anatomy of the distal humerus is likened to a hand holding a spool of thread with strong support of the spool
from each finger and a central void. B Likewise, the distal humerus has strong medial and lateral columns, which support the
distal articular segment. The thin central area of the bone, made up of the olecranon and coronoid fossae, provide little bony
support.

dence of nonunion. The risk of nonunion potential
complication is lessened with use of a chevron-shaped
osteotomy of the olecranon and proper fixation of the
osteotomy.3 After the osteotomy is performed, the dis-
tal humerus is exposed by elevating the entire triceps
unit off the posterior distal humerus. Care should be
taken not to dissect proximal to the distal one-fourth of
the humerus to avoid injury to the crossing radial
nerve.17 The osteotomy is repaired using screws, plates,
or wires.
Coles et al. conducted a retrospective review of
patients having olecranon osteotomy for complex distal
humerus fractures.18 Sixty-seven patients had adequate
follow-up to determine healing status of the osteotomy.
All osteotomies healed; however, 2 osteotomies re-
quired early revision osteosynthesis to address loss of
reduction. In most cases, the osteotomy was stabilized
with a single intramedullary screw, washer, and dorsal-
ulnar figure-of-8 wire construct. Plate fixation was used
if the initial fixation was deemed inadequate. Implant
irritation appeared to be a major factor for revision
surgery. Eight percent of patients had elective implant
removal for hardware irritation alone. An additional
Current Concepts
reflecting procedure to the transolecranon approach as
well.20,21
ULNAR NERVE
Regardless of the approach, exposure of distal humerus
fractures involves identifying and protecting the ulnar
nerve.12 The nerve is at risk during fracture reduction
and while placing hardware. At the start of the proce-
dure, the ulnar nerve is mobilized, tagged with a vessel
loop and, in most cases, transposed anteriorly.12,22
Doornberg et al. reported a 12- to 30-year follow-up of
intra-articular distal humerus fractures treated without
transposition of the ulnar nerve.23 They reported only 1
ulnar nerve complication: a case of painful ulnar neu-
ropathy necessitating subsequent anterior ulnar nerve
transposition. Although ulnar nerve transposition may
not be required for a safe exposure and acceptable
outcome, it makes revision surgery much safer and
easier.
STABILIZATION OF BONE
The distal humerus is made up of a medial and a lateral
column (Fig. 7). The articular surface is linked to the

21% of patients had implants removed with coincident
revision procedures.
Recent studies have also described variations on
these established techniques. Olecranon osteotomy has
been combined with the triceps-splitting approach for
distal articular fractures with extension to the midshaft
of the humerus.19 Concern over denervation of the
anconeus with olecranon osteotomy led to a description
of the adaptation of the anconeus flap from the triceps
shaft of the humerus via medial and lateral metaphyseal
flares. The central area of the supracondylar region is
weak because of the thin bone that lies between the
coronoid and olecranon fossae.3 This area is particu-
larly thin in patients with osteopenia.24 Diaphyseal-
metaphyseal contact is essential in creating a stable
construct that has a good chance to heal.3
Many techniques have been described in the fixation
of distal humerus fractures, such as use of specialized

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 ELBOW FRACTURES: DISTAL HUMERUS 183

FIGURE 8: A 33-year old man involved in a high-speed motor vehicle accident sustains an open distal humerus fracture. A, B
Anteroposterior and lateral injury films show a high degree of fracture comminution and bone loss, extensive intra-articular
involvement, and displacement of the fractures. C Anteroposterior view after the initial surgical management, which consisted of
thorough debridement of the fracture, provisional fixation, and placement of antibiotic beads. D, E Anteroposterior and lateral
views after definitive treatment. Definitive treatment: the articular surface was reconstructed with multiple, fully threaded screws.
Tricortical iliac crest was harvested and applied to the lateral column to reconstruct the areas of extensive bone loss. Stable
fixation was achieved with bicolumnar plating. The patient went on to unite the fracture.

Y-shaped plates or minifragment fixation.24,25 How-
ever, the most popular approach involves placing 1
plate on the medial column and a second on the lateral
column (Fig. 8). Authors have recommended orthogo-
nal plating of the medial and posterolateral columns
(90-90 technique or perpendicular plating) of the distal
Plates placed in a parallel orientation were found to
have statistically significantly greater strength and stiff-
ness than did those in a perpendicular orientation (p ⬍
.05).
Placing a plate on the lateral aspect of the distal
humerus can be technically difficult and requires strip-
Current Concepts

humerus as well as parallel placement of plates on the
medial and lateral aspects of the distal humerus.26 –30
Proponents of parallel plating submit that a laterally
based plate allows for a long screw to be placed from
the lateral to medial cortex, whereas a screw placed in
a plate positioned on the posterolateral cortex must be
substantially shorter.24 Arnander et al. studied the stiff-
ness of the perpendicular and parallel constructs using
3.5-mm reconstruction plates on epoxy resin humeri.31
ping soft tissues off of the lateral supracondylar ridge.31
A recent anatomic study evaluating the intraosseous
blood supply of the distal humerus showed that the
distal humerus diaphysis is consistently supplied by a
single nutrient artery. Distal to this point, blood flow
consists of watershed supply via multiple perforating
vessels. The lateral column is perfused by segmental
posterior condylar perforating vessels, which may be
stripped away with extensive subperiosteal elevation,

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 184 ELBOW FRACTURES: DISTAL HUMERUS

FIGURE 9: Elderly, low-demand woman with a supracondylar humerus fracture nonunion. A Anteroposterior and lateral
radiographs reveal an established nonunion. B Lateral and radiographic view of elbow after treatment with total elbow
arthroplasty.

increasing the risk of delayed union or nonunion.32
Furthermore, the degree of fixation of both methods
may be above the threshold necessary for early motion
and predictable fracture healing, rendering the marginal
strength of parallel plating clinically unimportant. It has
been our experience that simple “T-type” distal hu-
merus fractures can be adequately treated with nearly
any form of bicolumnar fixation, including “Y” plates,
dual reconstruction plates, 3.5-mm dynamic compres-
sion plates, and precontoured plates placed in either a
parallel or orthogonal orientation. We have seen a num-
ber of nonunions in “T-condylar” fractures treated with
one third tubular plates. The most challenging fracture
is low distal humerus fracture with articular comminu-
tion. In this injury, we have had our best results using
parallel, precontoured plates.
Adequate fixation in osteopenic bone is a major issue
in treating distal humerus fractures in the elderly.27
Schuster et al. compared the stiffness of conventional
reconstruction plates, surgeon-contoured 3.5-mm lock-
ing compression plates, and precontoured distal hu-
merus locking plates in cadaver specimens of varying
bone mineral densities.27 Although stiffness in the 3
groups was not significantly different (extension, p ⫽
.881; flexion, p ⫽ .547), under cyclic loading the failure
rate was lower in the distal humerus plate group than in
the conventional reconstruction plate group (p ⫽ .026).
There was no statistical difference seen between the
locking compression plate group and the conventional
Current Concepts
tating with screws from the other plate.27 Thus, the
surgeon must assess the most judicious use of locked
plating to maximize benefit of the fixed-angle construct
while limiting unnecessary technical challenges.
Regardless of fixation technique, comminution, bone
loss, or poor bone quality may render internal fixation
inadequate, placing the fracture at risk for nonunion.10
Some reports have identified the primary mode of fail-
ure as loss of fixation of the distal fragment.34,35 Hinged
external fixation has been reported to aid in stability of
fixation while allowing motion of the elbow. Deuel et
al. biomechanically tested the additional stability af-
forded by external fixation to various levels of internal
fixation in a cadaver model.10 They found that addition
of external fixation to compromised reconstruction
plate constructs rendered stability that was similar to or
significantly greater than that with optimal internal fix-
ation alone (p ⬍ .05).
Reconstruction of the articular surface of the distal
humerus is important in avoiding joint arthrosis. The
articulating segment is commonly reconstructed prior to
attempts to reattach it to the shaft of the humerus. With
comminution of the joint surface, care must be taken to
avoid compression of the joint surface, which would
alter the width and contour. To achieve this goal, the
articular segment is fixed with a fully threaded cortical
screw.3 In the face of severe destruction of the distal
humerus, the articular segment may not be reconstruct-
ible with standard internal fixation. Tricortical segments

reconstruction plate group (p ⫽ .619). However, the
authors of this study concluded that in the case of poor
bone mineral density, both the distal humerus plate and
locking compression plates were superior to conven-
tional reconstruction plating. Despite a possible biome-
chanical advantage in osteoporotic bone, in the clinical
setting locked plating can be challenging due to the
fixed angle of the screw.33 This can lead to suboptimal
placement of screws as well as difficulty in interdigi-
of iliac crest can be used to rebuild comminuted seg-
ments.36 Several authors have used portions of the
radial head to reconstruct lateral trochlear defects.37 In
rare instances, use of osteochondral allografts may be
indicated.3
ELBOW ARTHROPLASTY
Primary total elbow arthroplasty has emerged as a
viable option for managing distal humerus fractures

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 ELBOW FRACTURES: DISTAL HUMERUS
in the appropriate patient.3 Common indications in-
clude severely comminuted intra-articular fractures
in which adequate fixation is not possible, particu-
larly in low-demand patients under the age of 65.
Elbow arthroplasty is also an option in older patients
with pre-existing, symptomatic elbow arthritis. Contra-
indications include pre-existing infection, high demand
and noncompliant patients, nonfunctioning biceps
muscle, and, in the opinion of some authors, open
fractures.38,39 It is our practice to approach each case
with the plan to fix the distal humerus. However, in
older patients with a severe fracture and poor bone, a
total elbow implant is available in the operating room
(Fig. 9).
Muller et al. reported a series of 43 fractures treated
with primary total elbow arthroplasty with a mean fol-
low-up of 7 years.38 These patients achieved an average
range of motion from 24° to 131°. Thirty-two of 49
patients received no further surgery and did not expe-
rience any complications. Five revision arthroplasties
were required.
In an extensive review of 92 elbows that received
total elbow arthroplasty as salvage for distal humeral
nonunion, Cil et al. reported improvements in the ma-
jority of patients. The authors found 74% of patients
with no pain or mild pain and 85% with a satisfactory
subjective result.40 In terms of function, 83% reported
that they could use their extremity in 4 or more activ-
ities of daily living. Patients in the series had an average
flexion-extension arc of 113°. However, Cil et al. also
documented a notable complication rate, with 32 reop-
erations. Complications included aseptic loosening of
the implant in 12 patients, with increased risk for loos-
ening observed in younger patients (under age 65) and
with the cement technique of precoating the ulnar com-
ponent. Five fractures of the implant occurred. Review
of the implant failure revealed that the fractures were
likely associated with the substantial bone loss from the
fracture, as failure occurred at the junction of the fixed
component with the unsupported segment. Further-
more, fractures of the implant all occurred in extrasmall
or small titanium implants, leading the authors to rec-
ommend use of the largest implants possible and strict
adherence to activity restrictions. Additional complica-
tions included 4 periprosthetic fractures, 12 soft-tissue
and wound complications, 2 transient nerve palsies, 1
C-ring failure, 1 bushing failure, and 1 painful proximal
radioulnar joint necessitating radial head excision. Im-
plant survival was 96% at 2 years, 82% at 5 years, and
65% at 10 and 15 years.
Prasad and Dent retrospectively compared patients
who had primary versus delayed total elbow arthro-
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185
plasty for distal humeral fractures with a mean fol-
low-up of 56 months.41 Patients were found to have no
statistically significant difference (p ⬍ .05) in Mayo
Elbow Performance Score (MEPS). Implant survival
was also similar in the 2 groups, with survivorship of
93% at 88 months in the early group and 76% in the
delayed group. Of note, among the 32 patients in this
series, 10 were reported to have complications includ-
ing aseptic loosening (5 cases), infection (2 cases), HO
(1 case), and ulnar nerve palsy (2 cases). Reported risk
factors for implant failure include age of 65 years or
less, 2 or more prior surgeries, or prior infection.40
Although several reports have set forth promising re-
sults for this difficult problem, caution should be exer-
cised in elbow replacements in the setting of fracture.
Patients must be appropriately counseled as to the po-
tential for complications and the importance of adher-
ence to restrictions.
Several newly described modalities have also been
recently reported in the treatment of selected distal
humerus fractures. Kalogrianitis et al. examined their
experience with the primary treatment of distal humerus
fractures with an unlinked total elbow prosthesis.42
Nine elbows in 9 patients were followed for a mean of
4 years. At final evaluation, all 9 elbows were stable and
pain relief was satisfactory. Additionally, Adolffson
and Hammer reported on their experience with 4 pa-
tients treated with humeral hemiarthroplasty, all of
whom were found to have good or excellent results with
short-term follow-up.43 Additional studies and longer
follow-up are needed to more fully judge the merits of
these techniques.
OUTCOMES
Reported outcomes are difficult to interpret given the
wide range of injury and treatment. Furthermore, much
of the existing literature consists of relatively small
series.41 However, in recent reports, with appropriate
rigid fixation, union rates are excellent, reported in the
range 91% to 100%.2,22 Several reports have rated
outcomes based on patient-reported outcome scales as
well as objective measure of outcome. In a report of
outcome after treatment of complex distal humerus
Current Concepts
fractures with parallel plating at a mean of 2 years, good
to excellent outcomes based on the MEPS were found
in 27 of 34 (79%) patients.24 This is comparable with
other reports, which range from 84% to 100% good to
excellent outcomes.15,22,44 In terms ofobjectively mea-
surable outcomes, mean flexion arc of the elbow after
surgical stabilization is reported in the range 90° mean
arc to 106° mean arc,15,22–24 with mean pronation-
supination arc of 150° mean arc to 165° mean arc.15,23
 186 ELBOW FRACTURES: DISTAL HUMERUS
In a report of 12- to 30-year outcomes after surgical
treatment of intra-articular fractures, Doornberg et al.
found the short-term reports of success to be durable
based on Disabilities of the Arm, Shoulder, and Hand
score, MEPS, American Shoulder and Elbow Surgeons
score, and visual analog satisfaction scale, with 26 of 30
(87%) good to excellent results. However, their findings
also revealed radiographic evidence of posttraumatic
arthritis in 80% of patients despite optimal surgical
treatment.23
COMPLICATIONS
Various complications are encountered in the treatment
of distal humerus fractures, with rates reported as high
as 48%.45 Apparent risk factors include high-energy
injuries, open fractures, and, in some accounts, nonop-
erative treatment.2,24,45,46 Although the vast majority of
patients heal, 1 author has reported delayed union in 9%
of patients at 12 weeks, with approximately half of
these patients healing without further surgery within 24
weeks.2 Another consistently reported complication is
HO. Gofton et al. noted important HO in 13% of
patients, with a trend toward decreased incidence in
patients who received postoperative prophylaxis with
indomethacin 100 mg twice per day for 24 hours, fol-
lowed by 6 weeks of indomethacin 25 mg 3 times
daily.45 Other reports have noted development of HO as
the most important complication that limited range of
motion.24 Other less common reported complications
include infection and ulnar nerve neuropathy.
ARTICULAR SHEAR FRACTURES
Articular shear fractures merit a separate discus-
sion given the challenges unique to this injury.
These fractures are rare, making up only 1% of all
elbow fractures.47 They usually result from low-
energy trauma, such as a fall from standing height,
but may also result from high-energy trauma. Lee
et al. described a direct mechanism of injury to the
capitellum as loading of the joint with the elbow
partially flexed and the forearm partially pronated,
driving the radial head axially across the base of
the capitellum.48 Additionally, the capitellum may
Current Concepts
be injured indirectly. In this instance, a subluxed
or dislocated radial head forcefully reduces, apply-
ing a shear force to the capitellum.
Articular shear fractures are separately classified
from other distal humeral fractures. Type I fractures,
so-called “Hahn-Steinthal fractures,” involve the entire
capitellum and lateral trochlear ridge. Type II (Kocher-
Lorenz) fractures involve only the articular surface of
the capitellum with subchondral bone. Type III frac-
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tures are comminuted fractures of the capitellum.3
McKee et al. described a type IV fracture consisting of
a coronal shear fracture of the capitellum with extension
across much of the trochlea49 (Fig. 10). Ring et al.
presented a more descriptive method of classification
based on division of the articular surface into 5 regions:
capitellum and lateral trochlea, lateral epicondyle, pos-
terior aspect of the lateral column, posterior aspect of
the trochlea, and medial epicondyle. Taking into ac-
count these anatomic regions, they identified 5 patterns
of injury involving various combinations of these 5
regions.50
Many methods of treatment have been reported since
Hahn first described a fracture of the capitellum in 1853
based on his findings at autopsy of a palpable promi-
nence at the elbow. These include closed reduction and
immobilization, excision, open reduction and internal
fixation, and replacement. Current literature supports
closed treatment of nondisplaced fractures with a brief
period of immobilization.3 With nonoperative manage-
ment, close clinical and radiographic monitoring is nec-
essary to ensure maintenance of reduction. Older re-
ports have shown success with immediate excision of
capitellar fractures, and, in selected patients, this may
still be an acceptable approach.51,52 However, current
literature favors open reduction and internal fixation
whenever possible as this restores the lateral buttress of
the elbow.
Regarding surgical approach, some authors favor a
posterior skin incision over the more common lateral
incision.53–55 A posterior incision allows for use of
multiple different deeper surgical planes through a sin-
gle incision. We have used a lateral approach for type I
and II fractures: those that involve the capitellum alone
or the capitellum plus a small portion of the trochlea.
Described deeper intervals include the Kocher (between
the extensor carpi ulnaris and anconeus), Boyd (eleva-
tion of the anconeus and supinator off the ulna), and/or
Kaplan (between the extensor digitorum communis and
extensor carpi radialis brevis) intervals. In many in-
stances, these intervals are used in combination, with
the Kaplan approach used for visualization, reduction,
and provisional K-wire fixation and the more posterior
Kocher interval used for definitive fixation. Additional
exposure can be achieved with release of the lateral
collateral ligament, necessitating subsequent repair.53,54
In the event of a fracture extensively involving the
trochlea, the medial extent of the fracture is often dif-
ficult to access. In such instances, it may be necessary to
perform a medial approach via a flexor-pronator split
or, in some cases, an olecranon osteotomy.50,53,56 It has
been our practice to start the exposure on the lateral
 ELBOW FRACTURES: DISTAL HUMERUS 187

FIGURE 10: Classification of capitellar fractures. A Type I Hahn–Steinthal, B Type II Kocher–Lorenz.

condylar ridge and split the common extensor in line
with the axis of the radius. If the lateral ulnar collateral
ligament is intact, in most cases, it can be left alone. An
excellent view of the capitellum and lateral half of the
trochlea is facilitated by elevating the capsule and the
origins of the radial wrist extensors off of the antero-
lateral aspect of the humerus. We do not hesitate to
reflect the lateral ulnar collateral ligament off of the
lateral epicondyle with or without a fleck of bone if this
is necessary to help reduce or fix the fracture. The
lateral ulnar collateral ligament is repaired through drill
reflecting the extensive variability in fracture patterns.
Fracture fixation can be accomplished with lag screws,
headless compression screws, bioabsorbable screws,
plates, and pins, alone or in various combinations (Fig.
11). Elkowitz et al. studied the relative biomechanical
strength of anteroposterior (AP) and posteroanterior
(PA) cancellous lag screws and AP headless compres-
sion screws (Acutrak; Acumed, Beaverton, OR) after
stabilizing a type I capitellar fracture.57 Posteroanterior
cancellous lag screws were found to have less displace-
ment upon cyclic loading than AP cancellous screws,
Current Concepts

holes in the lateral epicondylar region at the end of the
case. If the fracture involves the entire trochlea, we will
perform an olecranon osteotomy. Reducing the fracture
may be complicated by anterior impaction of the pos-
terolateral margin of the lateral epicondyle. Ring et al.
has demonstrated the technique of disimpacting this
bone, allowing it to hinge on its posterior cortex and
bone-grafting into the defect to facilitate reduction.50
Various methods of fixation have been described,
with no statistically significant difference in load to
failure. In comparison with the AP headless compres-
sion screw, the PA cancellous lag screw was found to
be less stable in cyclic loading and weaker in load to
failure, although the difference was not statistically
significant. The authors concluded that this study dem-
onstrated superiority of certain constructs, but recog-
nized that surgeon comfort and fracture variation
should dictate choice of fixation.

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 188 ELBOW FRACTURES: DISTAL HUMERUS

FIGURE 11: A, B Capitellar shear fracture: A defect from coronal shear fracture and B corresponding articular fragment. C, D
Reduction and compression of capitellar fragment with reduction forceps. Provisional fixation with guide wires for cannulated lag
screws. E, F Intraoperative fluoroscopic verification of anatomic reduction and fixation of fracture.

In recent studies, authors appear to favor use of PA
screws, directed from the posterolateral column anteri-
orly into the fragment to avoid articular damage.53,54,56
However, Sen et al. favor placing screws from lateral to
anterior to avoid posterior stripping of the lateral con-
dyle in the hopes of diminishing the risk of avascular
necrosis of the capitellum.54 Fortunately, the risk of
avascular necrosis seems to be exceptionally low.49,55
Sen et al. also described an antiglide plate that is used in
conjunction with screw fixation to resist shearing forces
at the capitellum.54 In this technique, a minifragment
Current Concepts
fragment is often composed primarily of articular car-
tilage and contains only a thin shell of subchondral
bone, making fixation difficult with lag techniques. In
these cases, it may be necessary to use AP directed
screws, bioabsorbable screws, or, as a last resort, frag-
ment excision.
Assessing outcome from current literature is
difficult as fixation techniques and fracture types
vary among studies; furthermore, most studies are
retrospective in design and include relatively few
patients in each series. Dubberley et al. have re-

plate is bent distally to fit the curvature of the superior
extra-articular portion of the capitellum. The plate is
then placed over the anterior surface of the lateral
column and fixed proximally only. More complex frac-
tures involving the trochlea may require additional
screws placed from the posteromedial column. In the
case of posterior comminution, it may be necessary to
supplement fixation with additional plates, pins, cannu-
lated screws, or bone graft.53 In type II fractures, the
cently reported their experience in a relatively
large series of 28 patients after open reduction and
internal fixation of capitellar and trochlear frac-
tures.53 Patients had an average flexion-extension
arc of 119° and supination-pronation arc of 156°.
This is equivalent to that of other studies,
which report flexion-extension arcs from 96° to
131° and pronation-supination arcs from 167° to
180°.49,50,55,56

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 ELBOW FRACTURES: DISTAL HUMERUS
Reviews of patient-reported outcomes have shown
similarly promising results. Ring et al. reported 16 of 21
(76%) good to excellent results based on the MEPS
score.50 Dubberley et al. reported their average MEPS
score to correspond with an excellent outcome.53 Many
other reports have shown that all patients in their series
achieved good to excellent outcomes using a variety of
outcomes scores.49,55,56 Dubberley et al. also reported a
correlation between severity of injury and patient out-
come, based on the MEPS. Type I fractures had a
significantly better outcome than did types II and III (p
⫽ .01).53
Although reported outcomes after surgical treatment
of articular shear fractures are generally favorable, it is
important to note the notable rate of complications and
need for additional surgery associated with treating
these fractures. In the 2 largest series to our knowledge,
Dubberley et al. and Ring et al. report that 12 of 28
(43%) and 10 of 21 (48%) patients, respectively, re-
quired at least 1 additional procedure.50,53 Common
reasons for reoperation included removal of symptom-
atic hardware after olecranon osteotomy, capsulectomy,
hardware removal for inadequate motion, and non-
union.50,53 More infrequently, authors have reported
radiocapitellar arthrosis, HO, and ulnar nerve neuropa-
thy.50,55 Dubberley et al. described 2 patients with
severe type III fractures that required conversion to total
elbow arthroplasty.49 Interestingly, in our review of
recent studies, no authors reported avascular necrosis of
the capitellum.49,50,53,55,56
Following the common goal of elbow surgery, early
postoperative motion is initiated as allowed by the con-
straints of bony and ligamentous stability. Authors re-
ported initiation of active-assisted flexion and extension
within 1 to 2 days of surgery and began passive motion
and strengthening at 6 weeks, with use of a daytime
resting splint between therapy sessions.53 Adequate re-
pair of the lateral ligamentous complex ideally leaves
the elbow stable; however, with concern over lateral
ligamentous instability, splinting is used to maintain the
forearm in pronation and to limit extension within the
arc of stability.53
Distal humerus fractures remain a challenge in diag-
nosis, surgical intervention, and rehabilitation. Ad-
vances in the understanding of fracture patterns through
improved diagnostic imaging, new techniques of expo-
sure, improved fixation, and recognition of proper re-
habilitation techniques have improved patient out-
comes. Ongoing research is necessary to promote future
improvements in treatment and rehabilitation, espe-
cially in light of the aging population and increased
patient expectations.
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189
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