Distal Humerus Fractures

Distal humerusCT distal humerus fracture




2 groups

- young patient with high velocity injury

- older patient with low velocity injuries, and comminuted, osteoporotic fractures




Humeroulnar - Hinged Joint

- trochlea axis is centre of rotation

- 40o anterior angulation in sagittal plane

- trochlea 3-8o externally rotated

- 4 - 8o valgus


Radiocapitellar - pivot joint


Medial and lateral columns


Elbow Lateral NormalElbow Lateral Normal 40 degree anterior angulation


Elbow AP NormalElbow Normal AP 4 degrees valgus


OTA / AO Classification


Type A: Extra-articular fracture


Distal Humerus Fracture


Type B: Partial articular fractures


Elbow Lateral Condyle FractureDistal humerus medial condyle

Lateral condyle                                                       Medial condyle


Type C: Complete articular fractures


Distal Humeral Fracture APDistal Humeral Fracture BicondylarDistal Humeral Fracture


CT scan


CT dis hum 1CT dis hum 2


Operative Management




1.  ORIF


2.  Distal humeral replacement


Osteoporotic and highly comminuted fractures

- difficult to ORIF


3.  "Bag of bones" treatment


Patient elderly and not operative candidate

- initial rest in plaster

- then mobilisation


Prescribed commonly, but limited high quality evidence


Aitken et al J Bone Join 2015

- 40 "elderly and low demand" patients treated non-op

- 5 year mortality 40%

- 50% non union

- DASH score 38/100

- modest function, but avoids risks


Distal Humerus Non Operative






1.  Paratricipital

- mobilise triceps either side of humerus


2.  Triceps reflecting / Bryan-Morrey

- elevate triceps aponeurosis medial to lateral off ulna


3.  Triceps splitting


4.  Olecranon osteotomy

- indicated for complex intra-articular fractures


Paratricipital Approach




AO foundation paratricipital approach


Posterior incision

- medially identify and protect ulna nerve

- laterally mobilize triceps from lateral intermuscular septum

- identify and protect radial nerve proximally


Medial triceps flipLateral triceps flip

Medial approach with ulna nerve protected           Lateral approach


Olecranon Osteotomy


Chevron OsteotomyChevron 1Chevron 2




AO foundation surgery reference Chevron osteotomy


Vumedi Chevron osteotomy



- distally based V shaped

- through bare area of olecranon

- 3 cm from tip



- TBW v plate v intramedullary screw




Jeong et al Medicine 2022

- systematic review of olecranon osteotomy and paratricipital approach

- longer operative time and higher incidence of infection with osteotomy

- no difference in outcome / ROM / hetertopic ossification / ulnar nerve injury


Coles et al J Orthop Trauma 2006

- 67 intra-articular fractures treated with olecranon osteotomy

- no nonunions


Somerson et al Should Elbow 2022

- 63 patients

- 14% wound dehiscence or infection

- 10% symptomatic hardware

- olecranon osteotomy increased re-operation rate


Fixation techniques


Vumedi surgical fixation distal humerus fracture




Precontoured anatomical plates

Parallel plates v perpendicular plates

Locking v non locking screws


Precontoured anatomical plates


Synthes distal humerus plates website


Synthes parallel platesSynthes perpendicular plates


Parallel v perpendicular plates


Elbow Parallel plates 1Elbow parallel plates 2

Parallel plates - medial plate on medial column and lateral plate on lateral column


Elbow orthogonal plates 1Elbow orthogonal plates 2

Perpendicular plates - plates at 90 degrees, with lateral plate posterior


Zalavras et al JSES 2011

- cadaveric model

- biomechanical superiority of parallel plates versus perpendicular plates


Yetter et al JSES 2021

- systematic review of 83 studies and 2362 patients

- parallel plating lower incidence of revision for fixation failure (1% v 6%)

- perpendicular plating reduced overall complication (45% v 54%)

- these complications included lower incidence neuropathy, wound dehiscence, and implant prominence


Results ORIF


Doornberg et al JBJS Am 2007

- 30 patients at a mean follow up of 19 years

- 87% good or excellent result

- mean flexion / extension arc 106 degrees

- 80% had evidence of OA on xrays

- mostly mild or moderate and not clinically significant


Complications ORIF

Han et al J Orthop Surg Res 2022

- multicentered retrospective study of 349 elbows

- postoperative ulna nerve symptoms 15%

- postoperative radial nerve symptoms 2.4%

- nonunion 4%

- deep infection 2%

- heterotrophic ossification 22%

- significant elbow stiffness 46%

- osteoarthritis 24%


Heterotopic Ossification


Distal humerus HO 1Distal humerus HO 2


Ulna nerve injury


Chen et al J Orthop Trauma 2010

- patients undergoing ORIF distal humerus

- 48 patients who underwent ulna nerve transposition versus 89 who did not

- 33% ulna neuritis with transposition

- 9% ulna neuritis without transposition


Dehghan et al J Orthop Trauma 2021

- RCT of 58 patients undergoing distal humerus ORIF

- Ulnar nerve transposition, vs not

- Overall high rates of abnormality on NCS (62%) but not different between groups

- Significant improvement in both groups over 12 months




Non union


Arthroplasty replacement





Comminuted, osteoporotic distal humerus fracture


Elderly distal humerus 1Elderly distal humerus 2




Total Elbow Arthroplasty versus ORIF


McKee et al JSES 2009

- RCT 42 patients > 65 years of age

- ORIF verus semiconstrained TEA

- 5 ORIF patients converted to TEA intraoperatively

- better elbow score at 2 years

- no difference in DASH score at 2 years

- mean ROM 107 TEA and 95 ORIF


Seok et al J Clin Med 2022

- systematic review of ORIF v TEA

- better flexion / extension arc and lower reoperation with TEA

- no difference outcome measures


Elbow Hemiarthroplasty versus ORIF


Nielsen et al JSES 2022

- systematic review of ORIF versus elbow hemiarthroplasty in patients > 50 years old

- no difference outcome measures

- high rate of complications in both


Total Elbow Arthroplasty versus Elbow Hemiarthroplasty


Indications hemiarthroplasty

- younger patient < 65 with unreconstructable fracture

- intact collaterals



- able to lift heavier weight



- instability

- late wear of olecranon cartilage


Jonsson et al JSES 2022

- RCT of 40 patients > 60 years of age

- hemiarthroplasty versus TEA

- no difference in outcome at 2 years




Distal humerus # TER 1Distal humerus # replacement 2


Vumedi Total Elbow Arthroplasty for distal humerus fracture


Vumedi Distal humerus replacement via triceps split