Distal Humerus Fractures

Definition

Adult fracture of the humerus at or distal to the supracondylar flare. Children are covered in Fracture of the Distal Humeral Physis.

Epidemiology

  • About 2% of adult fractures and one third of humeral fractures
  • Bimodal distribution
  • Young men after high energy trauma
  • Older women after low energy falls on osteoporotic bone

Anatomy

  • Medial and lateral columns form a triangle with the trochlea as the tie arch
  • Lateral column ends in the capitellum, medial column in the nonarticular medial epicondyle
  • Articular segment projects anteriorly at about 40 degrees to the shaft
  • Ulnar nerve lies behind the medial epicondyle in the cubital tunnel

Classification

AO/OTA Classification

TypeDescription
13-AExtra-articular
13-BPartial articular, one column or coronal shear
13-CComplete articular, articular block separated from the shaft
  • Jupiter and Mehne column concept divides fractures into single column, bicolumn and articular surface patterns
  • Bicolumn patterns include T, Y, H and lambda types

Clinical Features

  • Fall onto the flexed elbow or direct high energy blow
  • Inspect posterior skin for an open wound
  • Document ulnar, median and radial nerve function before any intervention
  • Ulnar nerve deficit is the commonest nerve finding before and after surgery
  • Check the radial pulse and forearm compartments

Investigations

  • AP and lateral elbow radiographs
  • Traction views under anaesthesia clarify articular fragments
  • CT with 3D reconstruction for articular comminution and coronal shear fragments

Management

  • Nonoperative. Brief splint then early motion, the bag of bones method, for low demand patients
  • ORIF. Displaced fractures in fit patients, see Distal Humerus Fracture Fixation
  • Dual plating. Parallel or orthogonal column plates give similar results
  • Posterior exposure. Olecranon osteotomy for 13-C fractures
  • Lateral exposure. Lateral or anterolateral approach for capitellar and lateral column fractures
  • Total elbow arthroplasty. Linked semiconstrained implant for comminuted 13-C fractures in older osteoporotic patients
  • McKee 2009 RCT. In patients over 65, TEA gave better Mayo Elbow Performance Scores than ORIF at 2 years
  • Ulnar nerve. Identify and protect in every case, with anterior transposition at surgeon discretion

Complications

  • Stiffness, with loss of terminal extension
  • Ulnar neuropathy
  • Nonunion, usually supracondylar
  • Heterotopic ossification
  • Olecranon osteotomy nonunion
  • Aseptic loosening after TEA

References

  1. McKee MD, Veillette CJ, Hall JA, Schemitsch EH, Wild LM, McCormack R, Perey B, Goetz T, Zomar M, Moon K, Mandel S, Petit S, Guy P, Leung I. A multicenter, prospective, randomized, controlled trial of open reduction-internal fixation versus total elbow arthroplasty for displaced intra-articular distal humeral fractures in elderly patients. J Shoulder Elbow Surg. 2009, 18(1), 3-12. PubMed
  2. Nauth A, McKee MD, Ristevski B, Hall J, Schemitsch EH. Distal humeral fractures in adults. J Bone Joint Surg Am. 2011, 93(7), 686-700. PubMed
  3. Jupiter JB, Mehne DK. Fractures of the distal humerus. Orthopedics. 1992, 15(7), 825-33. PubMed

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 19 October 2026.