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Distal humerus fracture

40 citationsUpdated Aug 2026

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Overview

Reported outcomes for acute distal humerus fractures remain inconsistent across the orthopedic literature, making it difficult for surgeons to retrospectively compare surgical techniques and clinical outcomes across studies [3]. This systematic review represents the largest report of complications and reoperations of intra-articular distal humeral fractures after open reduction and internal fixation (ORIF) in the current literature [9]. 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 [7].

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 [12]. ORIF is also a viable treatment option for distal humeral fractures in the elderly, provided careful patient selection is required [10]. 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].

When reconstruction is not feasible, alternative arthroplasty strategies are indicated. Distal humerus hemiarthroplasty is a viable option in the treatment of unreconstructible distal humerus fractures, with good to excellent outcomes expected [2]. It is a suitable option for unreconstructable distal humeral fractures and offers good functional outcomes with acceptable complication rates [8]. 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 [17]. 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 [24]. For nonunion of distal humerus fractures, ORIF with bone grafting is the treatment of choice if no excessive damage of the articular surface is present [4].

Anatomy & Pathophysiology

Osseous Morphology and Fracture Patterns

Posterior shear fractures of the distal humerus predominantly involve the posterior aspect of the capitellum and are frequently associated with elbow dislocation [33]. Fracture mapping of coronal shear fractures reveals morphological variations that may limit the efficacy of precontoured locking plates, thereby supporting individualized hybrid fixation strategies [31].

Pediatric Considerations

Management principles for unusual pediatric distal humerus fracture patterns focus on restoring the anatomic axis, the triangle of stability, and the articular surface to ensure a stable elbow joint [5]. Restoration of these structures ensures a stable elbow joint that allows for early motion and full range of motion [5].

Complications and Defects

Malunion of distal humerus fractures is a common complication influenced by biology, reduction quality, fixation methods, and mechanical failure [6]. Nonunion of distal humerus fractures is treated with open reduction and internal fixation with bone grafting if the articular surface is not excessively damaged [4]. Bone transport combined with internal fixation can achieve bone healing without docking site nonunion in post-traumatic distal humerus defects and nonunions [30].

Fixation Biomechanics and Surgical Approaches

Dual plating provides the most rigid and reliable construct for reduction of the articular surface in intra-articular distal humerus fractures, allowing for early range of motion and physical rehabilitation [25]. The 90°-configuration of LCPs considerably decreases fragment movement compared to conventional reconstruction plates in the operative treatment of distal humerus fractures [37]. Anterior minimally invasive inverted PHILOS plate fixation for distal humeral shaft fractures minimizes soft tissue damage and reduces the risk of iatrogenic radial nerve injury [41].

Neural Considerations

There is a lack of consensus on defining and diagnosing different types of ulnar nerve dysfunction in distal humerus fractures [36].

Classification

AO/OTA: Distal humerus fractures are classified using the AO/OTA system [29]. Capitellar fractures are denoted as 13B3, representing distal humerus partial articular frontal plane fractures [32]. These are subclassified as B3.1 for isolated capitellum fractures, B3.2 for trochlea fractures, and B3.3 for capitellum and trochlea fractures with a secondary fracture line in the sagittal plane [32]. Capitellum and trochlea fractures may also be components of more complex, multifragmentary intercondylar fractures, such as 13C3.3 [32].

Bryan and Morrey: This system categorizes partial articular fractures into type I to type III, with an addendum of type IV by McKee et al [32]. Type I fractures (Hahn-Steinthal) are complete capitellar fractures with little or no extension into the lateral trochlea [32]. Type II fractures (Kocher-Lorenz) are anterior osteochondral fractures with minimal subchondral bone [32]. Type III fractures (Broberg-Morrey variant) are comminuted or compression fractures of the capitellum [32].

McKee et al: Type IV fractures are described as coronal shear fractures of the capitellum that extend medially to include most of the trochlea [32]. These are often identified by the presence of the pathognomonic “double arc” sign on lateral radiographs of the elbow [32]. However, this sign may not be radiographically apparent in all type IV fractures due to the presence of an internally rotated capitellum and trochlea fragment [32].

Dubberley: This classification is used to describe coronal shear fractures of the distal humerus and select the surgical approach [35].

Other Considerations: Several classifications for partial articular fractures of the distal humerus have been described, with the utility of newly proposed schemes lying in their ability to dictate surgical treatment and predict functional and patient-based outcomes [32]. Outcomes for capitellum fractures are unclear due to the existence of multiple classification systems [39].

Clinical Presentation

Malunion is a common complication following distal humerus fractures, influenced by biology, reduction quality, fixation methods, and mechanical failure [6].

In older adults with isolated distal humerus fractures, mortality at 1 and 2 years is substantial. This outcome is strongly predicted by comorbidity burden and preinjury ambulation status [18].

Investigations

Plain radiography: Standard imaging is essential for initial assessment and surgical planning, which must be based on the specific fracture type [13]. In pediatric cases, prompt recognition of transphyseal fractures is critical; these are typically managed with closed reduction and percutaneous pinning, often aided by an arthrogram, to restore the anatomic axis, the triangle of stability, and the articular surface [43]. This approach ensures a stable elbow joint that allows for early motion and full range of motion, usually resulting in excellent outcomes [43]. Management principles for unusual pediatric distal humerus fracture patterns similarly focus on restoring these anatomical landmarks to ensure stability [5].

CT: Computed tomography with Hounsfield Unit (HU) measurements in the coronal plane may identify patients with poorer bone quality [21]. This assessment helps identify individuals at higher risk for postoperative mechanical complications following distal humerus fracture fixation [21].

Other Considerations: Internal fixation is generally accepted as the standard of care for intra-articular distal humerus fractures, with rigid anatomic fixation combined with early motion associated with favorable results [14]. Dual plating provides the most rigid and reliable construct for reduction of the articular surface to allow for early range of motion and physical rehabilitation [25]. Both orthogonal and parallel plating techniques can be used to treat distal humerus fractures with excellent outcomes [15]. Open reduction and internal fixation with an AO reconstruction plate is very useful and effective in the treatment of displaced fractures of the adult distal humerus [26]. For complex distal humerus fractures not amenable to fixation, particularly in elderly patients, distal humerus replacement (DHH) yields satisfactory functional outcomes and range of motion [11]. Salvage total elbow arthroplasty (TEA) represents a viable option for the management of post-traumatic sequelae following the treatment of a distal humeral fracture; however, patients who underwent salvage TEA had a significantly increased rate of complications and significantly inferior functional outcomes compared with those who underwent TEA acutely [16].

Treatment

Non-Operative

The management of distal humeral fractures remains problematic, particularly in elderly patients with osteoporosis and comminution where open reduction and internal fixation (ORIF) may be impossible [19].

Operative

Indications: ORIF is a viable treatment option for distal humeral fractures in the elderly, provided careful patient selection is applied [10]. Distal humerus hemiarthroplasty is a viable option for unreconstructible distal humerus fractures, with good to excellent outcomes expected [2].

Surgical Approach / Technique: Orthogonal (OO), triceps-reflecting anconeus approach (TRA), triceps-splitting (TS), and triceps-turning (TT) posterior approaches provide comparable overall clinical outcomes in the management of AO/OTA type C complete intra-articular distal humerus fractures [20]. Most outcome measures for OO, TRA, TS, and TT posterior approaches show no statistically significant differences [20].

Implant Selection: ORIF using parallel precontoured plates demonstrates good functional outcomes and complication rates similar to previously reported studies in elderly patients [1]. Distal humeral hemiarthroplasty is a suitable option for unreconstructable distal humeral fractures, offering good functional outcomes with acceptable complication rates [8]. Distal humerus hemiarthroplasty yields satisfactory functional outcomes and range of motion in complex distal humerus fractures not amenable to fixation, particularly in elderly patients [11].

Revision: Salvage total elbow arthroplasty (TEA) is a viable option for the management of post-traumatic sequelae following the treatment of a distal humeral fracture [16]. Patients who underwent salvage TEA had a significantly increased rate of complications and significantly inferior functional outcomes compared with those who underwent TEA acutely [16].

Other Considerations: A systematic review represents the largest report of complications and reoperations of intra-articular distal humeral fractures after ORIF in the current literature [9].

Complications

Malunion: Malunion is a common complication after distal humerus fractures, influenced by biology, reduction quality, fixation methods, and mechanical failure [6]. Smoking history and computed tomography (CT) 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 [21].

Nonunion: Open reduction and internal fixation with bone grafting is the treatment of choice for nonunion of distal humerus fractures if there is no excessive damage to the articular surface [4].

Post-Traumatic Sequelae (Salvage): Salvage total elbow arthroplasty (TEA) is a viable option for post-traumatic sequelae following distal humerus fracture treatment, but patients have significantly increased complication rates and inferior functional outcomes compared to those undergoing acute TEA [16]. Elbow hemiarthroplasty offers functional outcomes comparable to total elbow arthroplasty while potentially avoiding complications related to the ulnar component [17].

Olecranon Osteotomy: There is a high risk of complications associated with olecranon osteotomy in the treatment of distal humerus fractures [42].

Other Considerations: Reported outcomes for acute distal humerus fractures remain inconsistent across the orthopedic literature, complicating retrospective comparisons of surgical techniques and clinical outcomes [3]. Older patients undergoing open reduction and internal fixation (ORIF) of the distal humerus using a parallel construct demonstrate good functional outcomes and similar complication rates to previously reported studies [1]. Management of distal humerus fractures remains problematic in elderly patients with osteoporosis and comminution where ORIF may be impossible [19]. Mortality at 1 and 2 years is substantial in older adults with isolated distal humerus fractures and is strongly predicted by comorbidity burden and preinjury ambulation [18].

Recovery

Light activity (weeks): Evidence does not specify a week range for light activity or desk work in the provided data.

Full activity (months): Evidence does not specify a month range for full activity or manual work in the provided data.

Complete recovery / outcome plateau (months): Evidence does not specify a month range for complete recovery or outcome plateau in the provided data.

Rehabilitation protocol: Management of unusual pediatric distal humerus fracture patterns focuses on restoring the anatomic axis, the triangle of stability, and the articular surface [5]. Restoration of these structures ensures a stable elbow joint, which allows for early motion and full range of motion [5].

Functional milestones: Older patients undergoing open reduction and internal fixation (ORIF) of the distal humerus using a parallel precontoured plate construct demonstrate good functional outcomes [1]. Long-term results of well-performed ORIF demonstrate satisfactory outcomes in most patients with bicolumnar distal humerus fractures [45]. Distal humerus hemiarthroplasty yields good to excellent outcomes [2] and offers good functional outcomes with acceptable complication rates [8]. In complex distal humerus fractures not amenable to fixation, distal humeral hemiarthroplasty yields satisfactory functional outcomes and range of motion [11], and is particularly effective in elderly patients [11]. Elbow hemiarthroplasty offers functional outcomes comparable to total elbow arthroplasty [17]. Total elbow arthroplasty (TEA) as a primary treatment mode yields encouraging results for carefully selected comminuted distal humerus fractures in elderly patients [46].

Other Considerations: Reported outcomes for acute distal humerus fractures remain inconsistent across the orthopedic literature, making it difficult for surgeons to retrospectively compare surgical techniques and clinical outcomes across studies [3]. Malunion is a common complication after distal humerus fractures, influenced by biology, reduction quality, fixation methods, and mechanical failure [6]. A thorough smoking history may identify patients with poorer bone quality at higher risk for postoperative mechanical complications following distal humerus fracture fixation [21]. CT Hounsfield Unit (HU) measurements in the coronal plane may also identify patients with poorer bone quality at higher risk for postoperative mechanical complications following distal humerus fracture fixation [21]. Transposition does not have a protective effect against the development of late ulnar neuropathy after distal humerus fracture repair surgery [47].

In older adults with isolated distal humerus fractures, mortality at 1 and 2 years is substantial [18]. Mortality at 1 and 2 years in older adults with isolated distal humerus fractures is strongly predicted by comorbidity burden [18] and preinjury ambulation status [18]. Intra-articular distal humerus fractures are associated with a more than two-fold increased risk of progressing to TEA compared with extra-articular fractures in older cohorts [44]. The increased risk of TEA following intra-articular versus extra-articular fractures in older cohorts is consistent across all studied time points [44]. Nearly 5.5% of older patients with intra-articular distal humerus fractures progress to TEA by 10 years [44].

For unreconstructible distal humerus fractures, distal humerus hemiarthroplasty is a viable treatment option [2] and a suitable option for unreconstructable distal humeral fractures [8]. Elbow hemiarthroplasty is a viable option for complex distal humeral fractures in select patients [17]. Total elbow arthroplasty (TEA) is particularly indicated for elderly patients with comminuted distal humerus fractures who also have significant rheumatoid arthritic changes [46]. Salvage total elbow arthroplasty is a viable option for managing post-traumatic sequelae following distal humeral fracture treatment [16]. However, patients undergoing salvage TEA have a significantly increased rate of complications compared to those undergoing acute TEA [16] and significantly inferior functional outcomes compared to those undergoing acute TEA [16].

Key Evidence

  • [L4] Older patients who underwent ORIF of the distal humerus using a parallel construct demonstrated good functional outcomes and similar complications to those in previously reported studies. [1] (10.1016/j.jhsa.2022.01.030)
  • [L4] Distal humerus hemiarthroplasty is a viable option in the treatment of unreconstructible distal humerus fractures, with good to excellent outcomes expected. [2] (10.1016/j.jse.2022.02.015)
  • [L1] Reported outcomes for acute distal humerus fractures remain inconsistent across the orthopedic literature, making it difficult for surgeons to retrospectively compare surgical techniques and clinical outcomes across studies. [3] (10.1016/j.otsr.2018.08.017)
  • [L5] Open reduction and internal fixation with bone grafting is the treatment of choice for nonunion of distal humerus fractures if no excessive damage of the articular surface is present. [4] (10.1016/j.jisako.2024.07.002)
  • [L5] Management principles focus on restoring the anatomic axis, the triangle of stability, and the articular surface to ensure a stable elbow joint that allows for early motion and full range of motion. [5] (10.5435/jaaos-d-17-00326)
  • [L5] Malunion is a common complication after distal humerus fractures influenced by biology, reduction, fixation methods, and mechanical failure. [6] (10.1016/j.jisako.2024.05.009)
  • [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. [7] (10.5397/cise.2019.22.2.113)
  • [L4] Distal humeral hemiarthroplasty is a suitable option for unreconstructable distal humeral fractures and offers good functional outcomes with acceptable complication rates. [8] (10.1177/17585732211023100)
  • [L1] This systematic review is the largest report of complications and reoperations of intra-articular distal humeral fractures after ORIF in the current literature. [9] (10.1016/j.jse.2021.02.017)
  • [Paper] Open reduction and internal fixation is a viable treatment option for distal humeral fractures in the elderly, but careful patient selection is required. [10] (10.1016/j.injury.2007.08.006)
  • [L1] DHH yields satisfactory functional outcomes and range of motion in complex distal humerus fractures not amenable to fixation, particularly in elderly patients. [11] (10.1016/j.jseint.2026.101695)
  • [L4] For comminuted distal humerus fractures in young patients, ORIF appears to be the preferred surgical option, offering superior functional outcomes and a lower incidence of complications and heterotopic ossification. [12] (10.1016/j.xrrt.2025.07.014)
  • [L4] Surgery is the optimal treatment for articular fractures of the distal humerus, with planning based on fracture type. [13] (10.1016/j.otsr.2013.11.002)
  • [L5] Internal fixation is generally accepted as the standard of care for the treatment of intra-articular distal humerus fractures, with rigid anatomic fixation combined with early motion associated with favorable results. [14] (10.1016/j.hcl.2007.09.001)
  • [L5] Distal humerus fractures are complex, and both orthogonal and parallel plating techniques can be used to treat these difficult fractures with excellent outcomes. [15] (10.1016/j.hcl.2010.05.008)
  • [L1] Salvage TEA represents a viable option for the management of post-traumatic sequelae following the treatment of a distal humeral fracture, although patients who underwent salvage TEA had a significantly increased rate of complications and significantly inferior functional outcomes compared with those who underwent TEA acutely. [16] (10.1302/0301-620x.108b1.bjj-2025-0475.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. [17] (10.1177/1758573216640210)
  • [L3] In older adults with isolated distal humerus fractures, mortality at 1 and 2 years is substantial and strongly predicted by comorbidity burden and preinjury ambulation. [18] (10.1016/j.jse.2026.02.013)
  • [L5] The management of distal humeral fractures remains problematic, particularly in elderly patients with osteoporosis and comminution where ORIF may be impossible. [19] (10.1016/j.jse.2010.11.012)
  • [L1] Current evidence indicates that OO, TRA, TS, and TT posterior approaches provide comparable overall clinical outcomes in the management of AO/OTA type C complete intra-articular distal humerus fractures, with most outcome measures showing no statistically significant differences. [20] (10.1186/s13018-026-06739-x)
  • [L3] A thorough smoking history and CT HU measurements in the coronal plane may identify patients with poorer bone quality at higher risk for postoperative mechanical complications following distal humerus fracture fixation. [21] (10.5435/jaaos-d-26-00191)
  • [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. [24] (10.1016/j.hcl.2015.06.008)
  • [L4] Although the inherent complexity of the distal humerus makes a single treatment method unrealistic, dual plating provides the most rigid and reliable construct for reduction of the articular surface to allow for early range of motion and physical rehabilitation. [25] (10.1016/j.jse.2025.12.020)
  • [L4] Open reduction and internal fixation with AO reconstruction plate is very useful and effective in the treatment of displaced fractures of the adult distal humerus. [26] (10.1016/j.injury.2003.11.018)
  • [L1] [29] (10.1177/17585732251328594)
  • [L4] All cases achieved bone healing without docking site nonunion, and patients demonstrated good recovery of elbow joint function postoperatively with no significant limitations in flexion and extension. [30] (10.1186/s13018-025-06058-7)
  • [L4] Precontoured locking plates may have geometric limitations in specific complex morphologies, supporting individualized hybrid fixation strategies. [31] (10.1186/s12891-026-09582-7)
  • [L4] [32] (10.5435/00124635-200812000-00004)
  • [L4] Posterior shear fractures of the distal humerus mostly involve the posterior of the capitellum and are often associated with elbow dislocation. [33] (10.1016/j.jse.2026.05.003)
  • [L4] The study confirms the utility of the Dubberley classification in describing the fracture and selecting the surgical approach. [35] (10.1016/j.jse.2025.05.033)
  • [L5] There is a lack of consensus on defining and diagnosing different types of ulnar nerve dysfunction, necessitating prospective studies with standardized definitions. [36] (10.1016/j.jhsa.2011.11.023)
  • [L5] The 90°-configuration of LCPs was found to considerably decrease fragment movement compared to conventional reconstruction plates. [37] (10.1016/j.injury.2003.09.022)
  • [L4] The article summarizes the existing body of evidence on capitellum fractures, noting that outcomes are unclear due to multiple classification systems and a literature consisting of small case series without comparative groups, and proposes areas for future study. [39] (10.1177/1558944719878817)
  • [L4] This technique minimizes soft tissue damage, reduces the risk of iatrogenic radial nerve injury, and ensures reliable fracture stabilization. [41] (10.1186/s13018-025-05560-2)
  • [L2] The high risk of complications in olecranon osteotomy must be considered in the decision to perform this procedure in the treatment of distal humerus fractures. [42] (10.5397/cise.2021.00591)
  • [L5] Prompt recognition and appropriate treatment, typically with closed reduction and percutaneous pinning with the aid of an arthrogram, usually result in excellent outcomes. [43] (10.5435/jaaos-d-15-00297)
  • [L4] In the older cohort, intra-articular fractures were consistently and temporally associated with a more than two-fold increased risk of TEA compared with extra-articular fractures at every time point studied, with nearly 5.5% of patients progressing to TEA by 10 years. [44] (10.1177/17585732261451863)
  • [L5] Long-term results of well-performed open reduction and internal fixation demonstrate satisfactory outcomes in most patients. [45] (10.5435/00124635-201001000-00004)
  • [L4] Encouraging results have been reported using TEA as a primary mode of treatment for carefully selected comminuted distal humerus fractures in elderly patients, particularly if the patient also has significant rheumatoid arthritic changes. [46] (10.1016/j.hcl.2004.06.006)
  • [L1] The authors conclude that transposition does not have a protective effect against the development of late ulnar neuropathy after distal humerus fracture repair surgery. [47] (10.1016/j.hcl.2017.09.010)

See Also

References

[1] The Outcomes of Intra-Articular Distal Humerus Open Reduction and Internal Fixation Using Parallel Precontoured Plates in the Elderly. The Journal of Hand Surgery. 2023. DOI: 10.1016/j.jhsa.2022.01.030

[2] Distal humerus hemiarthroplasty for trauma: a systematic review of the outcomes and complications. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2022.02.015

[3] Outcomes of distal humerus fractures: What are we measuring?. Orthopaedics & Traumatology: Surgery & Research. 2018. DOI: 10.1016/j.otsr.2018.08.017

[4] Nonunion of distal humeral fractures: Current concepts. Journal of ISAKOS. 2024. DOI: 10.1016/j.jisako.2024.07.002

[5] Approaching Unusual Pediatric Distal Humerus Fracture Patterns. Journal of the American Academy of Orthopaedic Surgeons. 2019. DOI: 10.5435/jaaos-d-17-00326

[6] Malunion of distal humeral fractures: Current concepts. Journal of ISAKOS. 2024. DOI: 10.1016/j.jisako.2024.05.009

[7] Surgical Treatment Strategy for Distal Humerus Intra-articular Fractures. Clinics in Shoulder and Elbow. 2019. DOI: 10.5397/cise.2019.22.2.113

[8] Outcomes and complications of distal humeral hemiarthroplasty for distal humeral fractures – A systematic review. Shoulder & Elbow. 2021. DOI: 10.1177/17585732211023100

[9] Complications of articular distal humeral fracture fixation: a systematic review and meta-analysis. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2021.02.017

[10] Management of distal humeral fractures in the elderly. Injury. 2007. DOI: 10.1016/j.injury.2007.08.006

[11] Distal humerus hemiarthroplasty for complex intra-articular fractures in elderly or nonfixable patients: a meta-analysis of clinical and functional outcomes. JSES International. 2026. DOI: 10.1016/j.jseint.2026.101695

[12] Hemiarthroplasty vs. open reduction and internal fixation for comminuted distal humerus fractures in patients under 65 years: a systematic review. JSES Reviews, Reports, and Techniques. 2025. DOI: 10.1016/j.xrrt.2025.07.014

[13] Articular fractures of the distal humerus. Orthopaedics & Traumatology: Surgery & Research. 2014. DOI: 10.1016/j.otsr.2013.11.002

[14] Distal Humerus Fractures. Hand Clinics. 2007. DOI: 10.1016/j.hcl.2007.09.001

[15] Use of Orthogonal or Parallel Plating Techniques to Treat Distal Humerus Fractures. Hand Clinics. 2010. DOI: 10.1016/j.hcl.2010.05.008

[16] Total elbow arthroplasty for the management of post-traumatic sequelae of distal humeral fractures. The Bone & Joint Journal. 2026. DOI: 10.1302/0301-620x.108b1.bjj-2025-0475.r1

[17] Elbow hemiarthroplasty for the management of distal humeral fractures: current technique, indications and results. Shoulder & Elbow. 2016. DOI: 10.1177/1758573216640210

[18] Predictors of mortality after isolated distal humerus fractures in older adults. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2026.02.013

[19] Distal humeral fractures: fixation versus arthroplasty. Journal of Shoulder and Elbow Surgery. 2011. DOI: 10.1016/j.jse.2010.11.012

[20] Comparative efficacy and safety of different posterior surgical approaches for Intra-articular distal humerus fractures. Journal of Orthopaedic Surgery and Research. 2026. DOI: 10.1186/s13018-026-06739-x

[21] Can Computed Tomography Hounsfield Units Predict Distal Humerus Fracture Mechanical Complications?. Journal of the American Academy of Orthopaedic Surgeons. 2026. DOI: 10.5435/jaaos-d-26-00191

[24] Total Elbow Arthroplasty for Distal Humerus Fractures. Hand Clinics. 2015. DOI: 10.1016/j.hcl.2015.06.008

[25] Outcomes of intra-articular distal humerus open reduction and internal fixation based on severity of articular comminution. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2025.12.020

[26] Surgical treatment of acute displaced fractures of adult distal humerus with reconstruction plate. Injury. 2004. DOI: 10.1016/j.injury.2003.11.018

[29] A systematic review, and meta-analysis of pain outcomes following total elbow replacement and hemi-replacement for unreconstructible acute distal humerus fractures in adults. Shoulder & Elbow. 2025. DOI: 10.1177/17585732251328594

[30] Bone transport combined with internal fixation in post-traumatic distal humerus defects and nonunions: retrospective analysis of 16 patients. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06058-7

[31] Fracture mapping of coronal shear fractures of the distal humerus: morphological analysis and fixation efficacy. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-09582-7

[32] Coronal Plane Partial Articular Fractures of the Distal Humerus: Current Concepts in Management. Journal of the American Academy of Orthopaedic Surgeons. 2008. DOI: 10.5435/00124635-200812000-00004

[33] Surgical treatment for posterior distal humeral shear fractures. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2026.05.003

[35] Unsatisfactory radiographic findings do not correlate with functional impairment in patients with coronal shear fractures of the distal humerus treated with internal fixation: a long-term retrospective study according to Dubberley's classification. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2025.05.033

[36] Distal Humerus Fractures: Handling of the Ulnar Nerve. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2011.11.023

[37] The LCP-concept in the operative treatment of distal humerus fractures – biological, biomechanical and surgical aspects. Injury. 2003. DOI: 10.1016/j.injury.2003.09.022

[39] Coronal Shear Fractures of the Distal Humerus: A Review of Diagnosis, Treatment, and Outcomes. HAND. 2019. DOI: 10.1177/1558944719878817

[41] The clinical outcomes of anterior minimally invasive inverted PHILOS plate fixation for distal humeral shaft fractures. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05560-2

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

[43] Transphyseal Fracture of the Distal Humerus. Journal of the American Academy of Orthopaedic Surgeons. 2016. DOI: 10.5435/jaaos-d-15-00297

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

[45] Current Treatment Strategies for Bicolumnar Distal Humerus Fractures. American Academy of Orthopaedic Surgeon. 2010. DOI: 10.5435/00124635-201001000-00004

[46] Total elbow anthroplasty and distal humerus elbow fractures. Hand Clinics. 2004. DOI: 10.1016/j.hcl.2004.06.006

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

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Using Creative Commons Public Licenses

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Considerations for licensors: Our public licenses are intended for use by those authorized to give the public permission to use material in ways otherwise restricted by copyright and certain other rights. Our licenses are irrevocable. Licensors should read and understand the terms and conditions of the license they choose before applying it. Licensors should also secure all rights necessary before applying our licenses so that the public can reuse the material as expected. Licensors should clearly mark any material not subject to the license. This includes other CC- licensed material, or material used under an exception or limitation to copyright. More considerations for licensors: wiki.creativecommons.org/Considerations_for_licensors

Considerations for the public: By using one of our public licenses, a licensor grants the public permission to use the licensed material under specified terms and conditions. If the licensor's permission is not necessary for any reason--for example, because of any applicable exception or limitation to copyright--then that use is not regulated by the license. Our licenses grant only permissions under copyright and certain other rights that a licensor has authority to grant. Use of the licensed material may still be restricted for other reasons, including because others have copyright or other rights in the material. A licensor may make special requests, such as asking that all changes be marked or described. Although not required by our licenses, you are encouraged to respect those requests where reasonable. More considerations for the public: wiki.creativecommons.org/Considerations_for_licensees

Creative Commons Attribution-NonCommercial 4.0 International Public License

By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.