Orthopaedics & Traumatology: Surgery & Research 100 (2014) S55S63

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Review article

Articular fractures of the distal humerus

T. Bgu
Service de chirurgie orthopdique et traumatologique, universit Paris-Sud, hpital Antoine-Bclre, 157, rue de la Porte-de-Trivaux, 92140 Clamart, France

a r t i c l e

i n f o

Article history:
Accepted 8 November 2013
Keywords:
Distal humerus
Fracture
Elbow
Plate
Arthroplasty
Hemiarthroplasty

a b s t r a c t
Distal humeral fractures represent 2% of all adult elbow fractures. Injury mechanisms include highenergy trauma with skin involvement, and low energy trauma in osteoporotic bone. Treatment goals are
anatomical restoration in young, high-demand patients and quick recovery of activities of daily living
in the elderly. Complete fractures are relatively easy to diagnose, but partial intra-articular fractures are
not. The clinical diagnosis must take into account potential complications such as open injuries and ulnar
nerve trauma. Standard X-rays with additional distraction series in the operating room are sufcient in
complete articular fracture cases. Partial intra-articular fractures will need CT scan and 3D reconstruction to fully evaluate the involved fragments. SOFCOT, AO/OTA and Dubberley classications are the most
useful for describing fractures and selecting treatment. Surgery is the optimal treatment and planning is
based on fracture type. Complete fractures are treated using a posterior approach. Triceps management is
a function of fracture lines and type of xation planned. Constructs using two plates at 90 or 180 are the
most stable, with additional frontal screw for intercondylar fractures. Elbow arthroplasty may be indicated in selected patients, having severely communited distal humerus fractures and osteoporotic bone.
Open fractures make xation and wound management more challenging and unfortunately have poorer
outcomes. Other complications are elbow stiffness, non-union, malunion and heterotopic ossication.
2014 Elsevier Masson SAS. All rights reserved.

1. Introduction
Articular fractures of the distal humerus in adults are difcult
to treat because of their epiphyseal location. Although not a common fracture [1], approximately 3000 distal humerus fractures in
adults and children are treated surgically every year in France [2].
An orthopaedic surgeon in France sees an average of ve distal
humerus fractures per year. Because these fractures are fairly rare,
proposing a routine but specic management scheme is challenging.
The treatment process consists of determining the injury
mechanism, dening the diagnostic modalities and developing a
treatment algorithm to allow the patient to completely regain full
mobility of this complex joint. Normal function is hard to restore if
the joint is deformed by malunion and/or stiffened by heterotopic
ossications or capsular and ligament contractures.

columns, thereby resembling a cylinder pinched between the tips

of the index nger and thumb [4]. The central area comprises
a coronoid fossa and an olecranon fossa. This area is quite thin,
which allows extensive range of exion and extension, but also
generates weak point contributing to complex fractures, especially
in the elderly.
The medial column holds the medial epicondyle and medial
portion of the humeral trochlea. When viewed from the side, this
medial column appears continuous with the humeral shaft axis.
Conversely, the lateral column is exed relative to the humeral
shaft, placing the capitellum ahead of the trochlea. The epiphyseal section of the distal humerus containing the trochlear and
capitellum articular surfaces is in 48 valgus relative to the shaft,
externally rotated by 38 relative to the metaphysis and exed
40 relative to the shaft [5], resulting in the distal humerus being
projected in front of the humeral shaft.

2. Anatomy
3. Fracture mechanism
In the frontal plane, the distal humerus has a triangular shape,
is empty in the middle and is made up of a horizontal capitellumtrochlea segment inserted between the medial and lateral columns
[3]. The interposed segment extends more distally than the

Tel.: +33 01 45 37 47 34; fax: +33 01 45 37 49 50.

E-mail addresses: thierry.begue@abc.aphp.fr, tcbegue@free.fr
1877-0568/$ see front matter 2014 Elsevier Masson SAS. All rights reserved.
http://dx.doi.org/10.1016/j.otsr.2013.11.002

Complete fractures result from impaction of the proximal ulna

onto the articular part (trochlea, capitellum) of the distal humerus.
The impact can occur with the elbow exed or extended. If the
elbow was exed at impact, the articular fragments move forward;
if the elbow was extended, they typically move backwards [3].
Some believe that contre-coup impaction towards the lower end
of the humeral shaft results in separation of the medial and lateral

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columns. Because of the complexity of the injury mechanisms,

comminuted fractures are quite common, especially in the elderly.
Partial sagittal fractures of the lateral or medial condyle are the
result of indirect trauma in valgus or varus while in full or nearly
full extension. These fractures are accompanied by capsular and
ligament injuries on the opposite side of the joint. The elbow will
be acutely unstable.
Isolated capitellum fractures are the result of compression of
the articular surface by the radial head (as if the radial head gave
the capitellum an uppercut) [6], either during the injury event with
the elbow nearly in full extension or as a result of direct trauma
to a highly exed elbow. The position of the capitellum fragment
on X-rays can help determine the position of the elbow during the
injury [3].

reconstruction shows the shape and position of the bone fragments

and is helpful in determining the appropriate surgical approach
[14] (Fig. 2). A comparison of the diagnostic ability of 2D axial
slices alone or in combination with 3D reconstruction was performed with partial distal fractures and complete fractures [14,15].
Inter-observer reproducibility was best with 3D reconstruction. In
all fracture types, more bone fragments could be identied than
when X-rays only were used. Others have found more limited
benets of 3D reconstruction, as it only improves intra-observer
reproducibility [16]. Doornberg felt that CT scanning with 3D reconstruction was only truly useful during preoperative planning for
distal humerus fracture treatment.

4. Diagnosis

All of the proposed classication systems are based on determining the status of the columns and looking for sagittal or frontal
fracture lines. The most used classication in France is the one
put forward by Lecestre et al. [17] during the 1979 SOFCOT meeting. It effectively captures the various fracture types encountered.
The AO/OTA classication system (Fig. 3) is a worldwide reference
for published studies, but does not help the surgeon determine
which treatment strategy is appropriate [18,19]. For distal humerus
articular fractures, the Dubberley classication system [20] has the
advantage of being able to differentiate between various fracture
types involving the capitellum or trochlea and then suggesting a
technique for treating each one (Fig. 4).

The clinical diagnosis is made when the patient presents a

painfully swollen and deformed elbow. Because of the articular
nature of the fracture, anatomical landmarks are disrupted. In
complete bicondylar fractures, the two condyles can be moved
independently of each other. In partial sagittal fractures, one of
the condyles will be detached from the remainder of the humerus
and moving freely. The forearm will be shorter because of proximal
ulna migration and show either valgus or varus deformity. There is
complete functional disability.
The clinical diagnosis of complete or partial sagittal fractures is
not particularly difcult. However, partial frontal fractures of the
capitellum or trochlea can go unrecognised. The functional loss is
hard to detect, but will reveal itself as either a passive or active
exion or extension decit. The elbow shape is normal. Anatomical
landmarks are in their usual location. Hemarthrosis with lling of
the posterolateral recess of the elbow is a sign of intra-articular
injury [6]. The clinical appearance can be summarized as a painful
swollen elbow after an injury event, which may explain the high
number of delayed diagnoses for these fractures.
Skin lesions may occur posteriorly, where bone is located right
under the skin. Open wounds add complexity when choosing the
surgical approach [7]. Vascular complications are most common
in supracondylar fractures. Fractures displaying signs of ischemia
must be treated urgently. Nerve injury occurs in 25% of cases and
affects either the median or ulnar nerves [811]. It is important to
determine if the ulnar nerve is injured, as it will need to be transposed during the xation process. Ruan [8] and Chen [10] believe
that transposition is only necessary if the patient displays clinical
signs before the surgery. If none are present, transposition is associated with worse results. There is no demonstrated link between
the occurrence of postoperative ulnar neuropathy and the type of
xation hardware used [11].
5. Radiological evaluation
Standard AP and lateral X-rays of the elbow are sufcient for
detecting complete fractures [12]. The AP view must allow the distal
humerus to be viewed from the front, which is difcult to achieve
in a position that is pain free for the patient. Because of the patients
pain and the displaced fragments, X-rays are often not sufcient to
identify all the bone fragments, the degree of comminution, and
allow for surgical planning. If the elbow is half-exed, a CT scan
is difcult to perform. We prefer taking X-rays with the arm in
traction with the patient under general anaesthesia in the operating
room; this allows us to align the fragments and get a good view of
the distal humerus (Fig. 1).
CT scans are useful in partial or very distal fractures because
the various fragments will be superimposed, which hinders precise
analysis of the fracture on standard views. Three-dimensional

6. Classication systems

7. Treatment
7.1. Functional and conservative treatment
The elbow joint must be mobilized early on to avoid stiffening
and heterotopic ossication. Because of axial loads, the joint cannot
be moved without inducing secondary displacement. Immobilization is only feasible in cases of non-displaced fractures, or as a
temporary treatment in the elderly before arthrolysis and arthroplasty [1,21]. Absolute non-surgical treatment can be justied in
cases of hemiplegia sequelae involving the ipsilateral upper limb,
advanced osteoporosis and fractures with extensive bone loss, but
the functional result will always be unsatisfactory [1]. Functional
treatment should only be considered in elderly patients when the
fracture is located below the insertion of the collateral ligaments
and muscles inserting on the epicondyles. The surgeon hopes for an
ideal non-union, without risk of secondary displacement because
the ligaments insert proximally to the fracture line [1,21].
7.2. Surgical treatment
Distal humerus fractures are primarily treated surgically. But
partial and complete fractures require different treatment strategies. Techniques range from conservative surgical treatment using
internal xation in young patients to elbow joint replacement in
older patients with comminuted fractures. Controversy exists as to
the best was to position the plates on each column: 90 or 180
to each other. The availability of locking compression plates has
changed how we plan internal xation and can result in lower morbidity. The main goal of surgical treatment is to obtain xation that
is stable enough to allow immediate postoperative elbow mobilization and prevent it from stiffening. If the distal humerus fracture is
immobilized in order to avoid xation failure, stiffening is almost
assured and arthrolysis will have to be performed later on.
7.2.1. Surgical approaches to the distal humerus
The choice of surgical approaches for internal xation of distal
humerus fracture is a difcult one to make, which justies the need

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Fig. 1. Type C complete articular (bicondylar) fracture of the humerus: a: AP X-rays; b: lateral X-rays; c: AP X-rays with traction; d: lateral X-rays with traction; e: TRAP
= extensor mechanism reected, = ulnar nerve; f: temporary xation before placement of locking
technique used with posterior approach [13], H = humerus, U = ulna,
compression plates with polyaxial screws; g, h: X-rays after xation.

for comprehensive presurgical planning. In elderly patients, one has

to choose between an approach best for xation and one that would
be best for arthroplasty. In the ideal scenario, the procedure could
be chosen at the time of surgery and only one surgical approach
would be needed.

7.2.1.1. Approaches for internal xation. Use of a medial approach

[2224] provides only limited exposure of the entire distal humeral
epiphysis. It exposes the anterior part of the distal quarter of the
humerus and requires neurolysis of the ulnar nerve. By longitudinally splitting the bres of muscles originating on the medial

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Fig. 2. Radiological evaluation and 3D reconstruction of type C fracture.

epicondyle, the medial epicondyle can be approached and a plate

shaped to match the contours of the distal humerus. This technique
has also been referred to as the vascular surgical approach [24].
The lateral approach is used most often with epiphysis fractures
of the elbow [22,23]. It starts centrally over the tip of the lateral
epicondyle and then extends longitudinally, providing exposure of
the lateral epicondyle, the front and back of the distal humerus
and muscles on the lateral epicondyle. With a distal humerus fracture, the approach must not damage the proximal attachment of the
muscles originating on the lateral epicondyle and the joint incision
itself is performed on either side of these structures.
The posterior approach is the only route that allows both
columns of the distal humerus to be viewed simultaneously
through one incision [23]. A vertical skin incision is made centred
over the superior mid-line of the triceps contour, with the olecranon bulge in the middle and the posterior crest of the ulna below.
The ulnar nerve must be located and released (neurolysis). Either
column can be viewed by moving the triceps muscle medially or
laterally. At this stage of the exposure, various techniques can be
used to better view the epiphysis [5]. To provide the best view of
the joint, the extensor mechanism must be cut and reected (Fig. 5).
The posterior approach is then combined with a transarticular or
extra-articular olecranon osteotomy, detachment of the terminal
tendon or cutting of the triceps at the muscle-tendon joint (TRAP
technique) [13]. We prefer using the TRAP technique, which has
similar benets as olecranon osteotomy, provides a reverse template for reconstructing the trochlea and allows rehabilitation to
start immediately (Fig. 1).

7.2.1.2. Approaches for primary total elbow arthroplasty. Various routes have been used for total elbow arthroplasty (TEA)
[1,22,2426], but a fracture-specic implant must be chosen.
Constrained, semi-constrained, unconstrained, and resurfacing
implants all have different characteristics. The former can be used
when the elbows lateral stabilizing structures are not intact, while
the latter require these structures to be preserved. The BryanMorrey and Gschwend approaches [25] disassemble the elbow,
which forces the surgeon to use a constrained (linked) implant.
The TRAP approach [5,13,22] preserves the lateral structures, which
allows faster functional recovery after the extensor mechanism is
reinserted.

7.2.2. Fixation of partial articular fractures

Displaced partial fractures must be xed with 2.7 mm or smaller
diameter screws, depending on the distance from the cartilage. The
screw heads must be buried [20,2729]. The joint must be stable enough to allow immediate rehabilitation (Fig. 6). The types
of injuries being treated determine the approach to use. Fractures of the capitellum alone, in combination with the lateral
epicondyle and capitulotrochlear groove (Hahn-Steinthal fracture)
and of the entire articular surface (Kocher diacondylar fracture)
are best treated through a lateral or anterolateral route. Medial
epicondyle fractures and trochlear fractures are treated through
the medial approach. If the main fracture line has a sagittal
path and extends to one of the columns, plate xation will be
required.

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Fig. 3. SOFCOT (a) and AO/OTA classication systems (b).

7.2.3. Fixation of complete articular (bicondylar) fractures

This is the gold standard of distal humerus fracture xation.
Because the elbow has two columns (medial and lateral), each can
be used for xation in the frontal plane, even if the columns are
not completely solid. The aim is to achieve simultaneous bicortical
purchase of the screws through both columns. Since the introduction of early-precontoured anatomical plates [17], various plates
are now commercially available: pure lateral, posterolateral, pure
medial and posteromedial. These can be used with conventional
or locking screws. The main benet of precontoured plates is that
they provide an acceptable anatomical compromise, with the plate
serving as a reference or support when reconstructing the anatomy
of the distal humerus.
In bicondylar fractures, the most mechanically stable construct
is the combination of a lateral plate with at least four bicortical
screws above the fracture site and a medial plate with at least two
bicortical screws on either side of the site. A construct with two
parallel plates (180 placement) is the best in terms of biomechanics [30]. An additional posterior plate, placed on the lateral column
to prevent rotation (three plates in all) is the most stable construct
for comminuted fractures [3]. But construct stability is negatively
affected by the rotation and moment arm induced by the upper
arm and forearm segments. Published studies have compared 90
or 180 dual-plate constructs [31]. Randomized studies have shown
180 constructs to be superior [3134].
In osteoporotic patients, screw hold in the diaphysis and epiphysis is precarious. In this group of patients, the primary treatment
goal is bone union [22], even if some stiffness occurs. This can justify using a protective splint to immobilize the joint. A tricortical
autologous bone graft can be added to the xation hardware to help
reconstruct the medial or lateral columns as needed [35].

The basic principles of internal xation for reconstruction of the

distal humerus anatomical triangle are the following:
temporary xation of bone fragments with K-wires;
restoring the normal width along with aligning the trochlear
groove with the anterior humeral cortex;
xation of articular fragments to the medial and lateral bone
columns using shaped plates;
intra-operative verication that the hardware does not encroach
upon the articular surfaces and fossa, and allows for full range of
motion;
making sure the xation construct is stable enough to allow early
mobilization of the joint.
7.2.4. Advantages of LCP for xation of distal humerus fractures
Locking compression plates (LCP) are particularly benecial for
partial distal humerus fractures. Monocortical xation is sufcient
since the diverging nature of the screws in the locked holes ensures
good construct stability. These plates can rarely be used alone, but
are often used with direct screw xation. LCPs can also be used as
a neutralization plate, resorting to shorter plate and one less screw
per fragment.
The benet of using LCP in complex distal humerus fractures was
shown in an experimental model where two plate xation positions
were evaluated: two posterior plates or medial and lateral plates
at 90 to each other [36]. In both types of constructs, conventional
(non-locking) reconstruction plates were compared with locking
compression plates. The differences between the different plate
types were insignicant in torsional loading and anterior-posterior
bending when applied in the same conguration. However, when
a 90 construct was used, locking compression plates had 2550%

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Fig. 4. Dubberley classication system [20].

better stiffness and strength relative to other constructs for the various movements tested (exion, extension, rotation). Superiority
of locking compression plates was evident when the plates were
applied at 90 in supracondylar fractures, which would be most
relevant in patients with reduced bone mass.
There is also clinical evidence of no secondary displacement or
xation failure occurring with LCP, especially in elderly patients
with low-quality trabecular bone [32]. Complete xation with two
precontoured anatomical plates at 90 or 180 , allowing placement
of totally angular stable locking screws and non-locking screws
was felt to be the most suitable technique for these fractures. This
type of construct is best suited for very distal fractures because
the screws are locked into the plate. It was also pointed out that
smaller diameter screws could be used because of the high angular
stability of these constructs. Other groups [33,34] use 180 constructs with locking screws, in part because of the high xation
quality (more stable construct resembling a monoblock implant)
and in part because smaller diameter screws can be used in the
distal fragment, which is the keystone for construct stability (Fig. 1).

Fig. 5. Management of extensor mechanism after posterior approach: a: triceps

splitting; b: TRAP (triceps reecting anconeus pedicle), = drawing of periosteum
and aponeurosis reection; c: Bryan-Morrey approach; d: olecranon osteotomy; e:
triceps sparing.

7.2.5. Total elbow arthroplasty and hemiarthroplasty

Total elbow arthroplasty has been proposed as an alternative
treatment for distal humerus fractures in osteoporotic bone, especially in elderly patients, and for comminuted type C fractures.
In cases where the surgeon does not want to disrupt the extensor mechanism, a posterior triceps sparing approach can be used
[25,37]. After resecting the distal part of the fractured humerus
and making a single cut perpendicular to the humerus, enough
space is created to insert the two components of a constrained total
elbow arthroplasty with its transverse axis. The implant itself provides stability, but there is no possibility of going back because
the epiphysis bone, capsular and ligament structures have been
removed. We prefer using the Triceps reecting anconeus pedicle (TRAP) method described by ODriscoll [13,22]. This method
preserves the ligaments and olecranon and offers an axial view
of the humerus, which guarantees proper rotational positioning of

Fig. 6. Fracture of capitellum with countersunk screw head.

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Fig. 7. Complex distal humerus fracture in osteoporotic bone: a, b: initial X-rays; c: posterior approach using TRAP technique; d: placement of distal humerus hemiarthroplasty
template; e, f: postoperative X-rays.

the humeral implant and ensures good postoperative functional

results. The lateral columns are stabilized as needed (Fig. 7).
Total elbow arthroplasty provides good early outcomes when
treating complex distal humerus fractures in elderly patients, with
immediate postoperative mobilization and quick return to activities of daily living [26,3740]. Implantation of a semi-constrained
total elbow arthroplasty in patients having an average age of 81
years led to good results in 83% of patients [34]. Hemiarthroplasty (resurfacing) implants have been used more recently [26]
but their true place in fracture treatment has not yet been established. In a randomized, multicentre study comparing total elbow
arthroplasty with internal xation (90 or 180 plates), the results
were better with elbow replacement in osteoporotic subjects
after at least two years of follow-up [41]. But the medium and
long-term outcome of elbow replacement performed on an emergency basis for distal humerus fracture remains to be evaluated
[42].
8. Complications
8.1. Open fractures
Open distal humerus fractures are difcult to treat because
of the need to simultaneously manage soft tissue injuries, often
posterior and directly over the distal humerus, and also stabilize the fracture [7]. Use of two external xators (one medial,
one lateral) has been recommended to achieve epiphysis union
and preserve humeral alignment [43]. A monolateral xator
can be used instead, as long as the distraction occurs in the
humeral axis. The construct must span the humerus and ulna,

with the distal anchorage point being in the proximal part of

the ulna (i.e. olecranon area). Ligamentotaxis aligns the distal
humeral epiphysis through traction forces. Long-term results of
open fracture treatment are consistently worse than treatment
of equivalent closed fractures, independent of the stabilization
method chosen [3,4,7]. A hinged xator can be used. The xator would be locked initially and then released to provide
secondary mobilization after the soft tissues have healed. But
the drawback of using a xator with xed centre of rotation is
that it will be impossible to regain the entire range of motion
because of a cam effect during the last 30 degrees of extension.
8.2. Elbow stiffness
This is the most common complication of distal humerus fractures. If the stiffness is disabling, a full evaluation with thin CT
slices and CT arthrography will help to identify osteophytes, radiolucent intra-articular foreign bodies and the volume of the joint
cavity. The stiffness can be classied as either extrinsic or intrinsic,
depending on if the joint is incongruent and the potential exists for
loss of gliding between articular facets. Extrinsic causes of stiffness are anterior and/or posterior capsule adhesions, adhesions
to the triceps or brachialis muscles, capsule contraction, intra- or
extra-articular osteophytes, jutting out of xation hardware. Mild
stiffness (less than 30 ) can be treated by arthroscopic arthrolysis [44] or limited open arthrolysis without hardware removal.
Complex injuries must be treated by open arthrolysis [12] with
hardware removal or total elbow arthroplasty in combination with
arthrolysis in the older subjects [45].

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8.3. Non-union and malunion

Disclosure of interest

Distal humerus non-union is quite common in osteoporotic

patients after partial articular fractures. In complex fractures, this
can result in unattached or free oating fragments in the joint. CT
scan and CT arthrography evaluations must be performed to identify intra-articular injuries that could be excised by arthroscopy or
in an open procedure. Fragments of the entire trochlea or capitellum may also be present. In younger patients, the bone can be
freshened and the fragment reattached with fully buried hardware
[12]. In older patients, the involved fragments can be excised and a
total joint replacement performed. In a small patient series [46], the
outcome of total elbow replacement after failure of internal xation
was good in 11 of 14 cases, with no differences found relative to primary total elbow replacement performed on an emergency basis.
However, the number of infection-type complications, ulnar nerve
injuries or loosening seemed higher in secondary arthroplasty cases
[46].
Two main types of malunion can be encountered:

The author declares that he has no conicts of interest concerning this article.

extra-articular ones that are easily treated with osteotomy and

direct xation after reduction;
intra-articular ones due to lack of anatomical restoration of joint
surfaced [12] that are harder to treat. These now have to be taken
into consideration when managing joint stiffness.
8.4. Peri-articular osteomas
Osteomas or peri-articular ectopic ossications contribute to
posttraumatic elbow stiffening. The average published rate of
heterotopic ossications is 8.6% (range 021%) if preventative
treatments are not used [5]. Although not statistically signicant, there was a trend towards less heterotopic ossications
after indomethacin preventative treatment in high-energy distal
humerus articular fractures. Known risk factors are an associated
brain injury, delayed surgical management, and sequential surgery
with secondary nal treatment. Only a level C recommendation
can be issued for adding peri-articular ossication preventative
treatment in at-risk patients.

9. Conclusion
Distal humerus articular fractures are uncommon injuries
requiring precise radiographic analysis for planning optimal treatment. In high-energy fractures in younger patients, the anatomy
of the joint surfaces must be restored. CT scanning with 3D reconstruction helps the surgeon view all the fragments and choose the
most suitable surgical approach for the injury in question. Fixation for complex fractures will consist of reconstruction plates or
locking compression plates, with one plate being placed on each
column to neutralize disassembly forces, especially rotational ones.
We recommend using templates to put together the construct being
implanted. The advent of monoaxial and polyaxial locking screws
has changed the indications and extended xation options to fractures in osteoporotic or diseased bone. The primary objective of
distal humerus xation is a perfectly stable fracture; this will enable
the early rehabilitation needed to regain normal mobility. With
low-energy distal humerus fractures in older, osteoporotic patients,
the degree of fracture comminution and the absolute need for fast
return to activities of daily living may lead the surgeon to choose
total elbow arthroplasty or hemiarthroplasty. Fracture complications such as stiffness, peri-articular ossication, non-union and
malunion are quite common. Since fracture sequelae are challenging to treat, the optimal treatment must be performed right away.

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