Send Orders for Reprints to reprints@benthamscience.

ae
The Open Orthopaedics Journal, 2017, 11, (Suppl-8, M3) 1353-1363 1353

The Open Orthopaedics Journal

Content list available at: www.benthamopen.com/TOORTHJ/

DOI: 10.2174/1874325001711011353

REVIEW ARTICLE
Distal Humeral Fractures-Current Concepts
James C. Beazley, Njalalle Baraza*, Robert Jordan and Chetan S. Modi
University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, CV2 2DX, Coventry, UK

Received: March 25, 2017 Revised: July 17, 2017 Accepted: July 18, 2017
Abstract:
Background:
Distal humerus fractures constitute 2% of all fractures in the adult population. Although historically, these injuries have been treated
non-operatively, advances in implant design and surgical technique have led to improved outcomes following operative fixation.

Methods:
A literature search was performed and the authors’ personal experiences are reported.

Results:
This review has discussed the anatomy, classifications, treatment options and surgical techniques in relation to the management of
distal humeral fractures. In addition, we have discussed controversial areas including the choice of surgical approach, plate
orientation, transposition of the ulnar nerve and the role of elbow arthroplasty.

Conclusion:
Distal humeral fractures are complex injuries that require a careful planned approach, when considering surgical fixation, to restore
anatomy and achieve good functional outcomes.

Keywords: Distal humerus fracture, Fracture fixation, Open reduction internal fixation, Total elbow arthroplasty, Anatomy, Elbow.

1. INTRODUCTION
Distal humerus fractures constitute 2% of all fractures in the adult population [1]. The injuries are distributed in a
bi-modal fashion with the first peak being seen in the young resulting from high-energy trauma and the second peak
being seen in the elderly osteoporotic population [2]. Although relatively rare, the incidence of these fractures is rising
as Pavlanen et al. reported a 5 fold increase in distal humerus fractures between 1970 and 1998 [3]. Treatment is aimed
at restoring a functional elbow, which Morrey described as requiring 30 to 130 degree range of motion [4]. Loss of this
movement can severely affect activities of daily living and lead to a loss of independence in the elderly population [5].
Treatment of these injuries is challenging due to fracture comminution, poor bone quality and difficulty in restoring the
complex anatomy of the distal humerus.
Historically, these injuries have been treated non-operatively although most studies report this management to be
associated with significant functional impairment [2]. Evolution in implant design and surgical technique has led to
improved outcomes in operatively treated patients and has resulted in fixation being the current standard of care.
Operative fixation has been shown to give satisfactory results with long term follow up demonstrating good or excellent
outcome in 86% [6, 7]. In an elderly population, internal fixation has been reported to result in better function than
those managed non-operatively [8]. The goals of surgical treatment are to restore articular congruity and bone alignment
*
Address correspondence to this author at the Department of Trauma and Orthopaedics, University Hospitals Coventry and Warwickshire NHS Trust,
Clifford Bridge Road, CV2 2DX, Coventry, UK, Tel: 02476965094; E-mail [email protected]

1874-3250/17 2017 Bentham Open

1354 The Open Orthopaedics Journal, 2017, Volume 11 Beazley et al.

whilst providing rigid, stable fixation that enables early active motion [9, 10]. Currently controversy exists over several
issues of operative management including the optimal surgical approach, plate orientation, management of the ulnar
nerve and the role of elbow arthroplasty. This review will cover the anatomy and classification of distal humerus
fractures, investigations and the treatment options for distal humerus fractures including discussion surrounding these
controversial areas.

2. ANATOMY AND CLASSIFICATION OF DISTAL HUMERAL FRACTURES

In the coronal plane, the distal humerus is of triangular shape, formed by the medial and lateral columns linked by
the articular segment as illustrated in Fig. (1). This simple concept is useful when trying to reconstruct complex
fractures as described by O’Driscoll [11]. The central area is thinner and compromises the coronoid fossa and olecranon
fossa. The articular surface is in 4-8 degrees of valgus relative to the shaft and flexed 40 degrees relative to the shaft.
The AO classification is the most commonly used classification system. Fractures are divided into A-extra-articular, B-
partial articular and C-complete articular, with further subdivision of these groups into 1,2, and 3 depending on the
location of the fracture and the degree of comminution.

Fig. (1). Distal humerus triangle. Triangle formed by medial column (red), lateral column (blue) and articular surface (green).

3. IMAGING DISTAL HUMERAL FRACTURES

Good quality radiographs should be obtained although this may be difficult due to patient discomfort. For the distal
humerus, the AP is taken with the elbow flexed to 40 degrees to facilitate olecranon disengagement from the fossa
allowing for better visualisation of the distal humerus. Standard lateral images, with the shoulder abducted to 90 degrees
and the elbow flexed to 90 degrees with the plate underneath the medial aspect give good views of the humeral condyle
and olecranon. A CT scan can give further clarity regarding comminution, articular involvement and aid surgical
planning. At our institution, we obtained 3D reconstructions of all intra-articular distal humerus fractures to aid our pre-
operative planning. This practice is supported by evidence to suggest that the use of 3D reconstructions over 2D images
improves the accuracy of classification [12].

4. NON-OPERATIVE TREATMENT
Non-operative treatment involves temporary splintage for pain relief followed by gentle mobilisation. This approach
has been associated with poor outcomes. Nauth et al. demonstrated that in elderly patients, those treated non-operatively
were almost three times more likely to have an unacceptable result than those treated operatively (RR=2.8 95% CI
1.78-4.4) [13]. Non-operative management is consequently reserved for undisplaced fractures and for patients with
dementia or those unable to tolerate anaesthesia. Recently Aitken et al. reported that non-operative treatment could give
a modest functional result in low demand patients whilst avoiding the substantial surgical risks [14].
Distal Humeral Fractures The Open Orthopaedics Journal, 2017, Volume 11 1355

5. OPERATIVE INTERVENTION FOR DISTAL HUMERUS FRACTURES

5.1. Surgical Approach

Numerous surgical approaches to the distal humerus have been described, each conferring differing advantages in
terms of exposure and soft tissue disruption. Stanley demonstrated that the trans-olecranon approach gave the best
articular exposure; the median percentages of visible distal humeral articular surface for the triceps splitting, triceps
reflection, and olecranon osteotomy approaches were 35%, 46% and 57%, respectively [15]. Despite the olecranon
osteotomy providing the greatest exposure of the distal articular surface, 40% of the anterior surface remained
unvisualised [15]. In addition, an olecranon osteotomy carries the risk of non-union, future need for the removal of
metalwork and potentially limiting any future arthroplasty.
The triceps splitting approach was first described by Campbell [16] but has the potential to result in triceps
weakness. Bryan and Morrey described a triceps reflecting technique [17] that spares the triceps mechanism by
reflecting from medial to the lateral direction and has the advantage of avoiding damage to the extensor mechanism. At
our institution, for management of an extra-articular fracture (AO type A) or limited articular involvement (type
B1/B2), we utilise the triceps sparing approach. This approach is chosen as it gives adequate exposure for these
fractures, avoids disruption to the extensor mechanism and can still be converted to an olecranon osteotomy if greater
exposure of the articular surface becomes required. For complex intra-articular fractures (type C), an olecranon
osteotomy is preferred.

5.2. Olecranon Osteotomy Technique

The patient is positioned in the lateral position with the arm hanging over an “L” holder. The image intensifier is
positioned such that it can be easily moved in and out of the operative field with adequacy of imaging being checked
prior to prepping and draping of the patient. The arm is exsanguinated and a sterile tourniquet inflated. A midline
posterior incision is made being proximal to the level of the fracture and curving down lateral to the olecranon avoiding
the weight-bearing zone. Full-thickness medial and lateral flaps are created. The ulnar nerve is identified proximally
and released from the cubital tunnel and through the flexor pronator aponeurosis to the level of its first anterior motor
branch.
The interval between the medial intermuscular septum and triceps is developed. The triceps is elevated off the
posterior aspect of the humerus following which, the lateral window is created. If the dissection is extended proximally,
the radial nerve is encountered approximately 10cm proximal to the lateral epicondyle and should be sought and
protected. A capsulotomy is performed on either side of the olecranon and the “bare area,” of the ulna is identified. The
apex distal chevron osteotomy is performed with an oscillating saw and completed with an osteotome to facilitate
interdigitation. A swab can be used to protect the articular surface when completing the osteotomy. The olecranon
fragment is then wrapped in a saline soaked swap and sutured proximally thus completing the approach.

5.3. Fracture Fixation

The goal of fixation is to provide anatomic reduction and rigid internal fixation of the articular surface to the shaft to
allow early mobilisation. The use of fixation solely with Kirschner wires or screws has been shown to be inferior to
rigid plate fixation in terms of functional outcome [18]. Although plate fixation in now the standard treatment, there
remains a debate on the optimum configuration of plates. Perpendicular plating was originally advocated by the AO
group, but parallel plating has grown in popularity. Biomechanical studies have demonstrated that parallel plating
provides improved stability compared with the perpendicular locking system [3, 19 - 21]. However, clinical studies that
have compared perpendicular to parallel plating reported no difference between the groups in terms of functional
outcome or complication rate [22, 23]. The use of locking compression plates has been advocated for osteoporotic
fractures as they provide angular stability and the head-locking mechanism potentially results in a stiffer construct [24].
However, biomechanical studies have shown no significant difference in stiffness between locking and traditional
compression plates [25]. Therefore although fixed angle plates have gone some way to improving fixation in the
presence of poor bone stock, loss of fixation in the osteoporotic patient remains a concern [26].
Surgical technique is dependent on the fracture pattern but O’Driscoll described eight key surgical principles to base
operative fixation upon (Table 1). Following the approach the fracture surfaces are gently debrided. The least
comminuted column is reduced and held with bone clamps and temporary Kirschner wires. This allows accurate
reconstruction of the more comminuted parts including the articular surface. Subchondral screws may sometimes be
1356 The Open Orthopaedics Journal, 2017, Volume 11 Beazley et al.

required to reconstruct articular fragments. Two plates are utilised with the less comminuted column selected first and
secured with a pre-contoured locking plate before the second column is then fixed with a further pre-contoured plate.
Different length plates are chosen to avoid a stress riser at the end of the plates and risk of a peri-prosthetic fracture. An
example case of operative fixation is demonstrated in Figs. (2 and 3). At our centre typical post-operative management
protocol includes; a back slab for one to two weeks to protect the wound, passive mobilisation from two weeks then
active after six weeks.
Table 1. Technical objectives described O’Driscoll [11].

Sr.No Objective
1 Every screw should pass through a plate
2 Each screw should engage a fragment on the opposite side that is also fixed to a plate.
3 As many screws as possible should be placed in the distal fragments.
4 Each screw should be as long as possible.
5 Each screw should engage as many articular fragments as possible.
The screws should lock together by interdigitation within the distal fragment, thereby creating a fixed-angle architecture that provides
6
stability to the entire distal humerus.
7 Plates should be applied such that compression is achieved at the supracondylar level for both columns.
8 Plates used must be strong enough and stiff enough to resist breaking or bending before union occurs at the supracondylar level.

Fig. (2). Pre-operative CT and parallel plating of AO type C1 fracture.

Fig. (3). Pre-operative CT and parallel plating of AO type C1 fracture.

Distal Humeral Fractures The Open Orthopaedics Journal, 2017, Volume 11 1357

Despite the evolution of surgical techniques, operative fixation has been associated with dissatisfaction in 15% of
patients and complication rates of up to 35% [27, 28]. Known factors that affect outcome include fracture comminution,
reduction accuracy, fixation stability and quality of postoperative rehabilitation [29]. Complications can include
hardware failure, fracture, non-union, malunion, heterotopic ossification, elbow stiffness and ulnar neuropathy [30 -
33]. An example of a peri-prosthetic fracture is illustrated in Fig. (4).

Fig. (4). Example of peri-prosthetic fracture following a mechanical fall one year after fixation of distal humerus.

The incidence of heterotopic ossification (HO) following fixation of distal humerus fractures varies widely and is
reported to be between 0 and 21% [34]. Risk factors for HO include head injury, delay in operative intervention, and
surgery prior to definitive fixation. To date there is no level 1 evidence examining the role of HO prophylaxis in the
management of distal humerus fractures treated with ORIF. Nauth et al. pooled the results of 6 studies examining the
incidence of HO in 259 patients undergoing fixation of distal humeral fractures utilising modern fixation techniques and
not treated with HO prophylaxis [13]. They found an 8.6% rate of symptomatic HO. Two recent case series have both
reported HO rates of 3% in 67 patients with distal humerus fractures treated with HO prophylaxis, but did report a non-
union rate of 6% [22, 35]. At our institution we do not routinely give HO prophylaxis unless risk factors are present.
Three-quarters of malunion or non-union cases are caused by inadequate initial fracture fixation suggesting that
optimal stable fixation is difficult to achieve [36]. Elderly patients are particular at risk of fixation failure [37, 38] and
John et al. reported 26% of over 80 year old’s were dissatisfied with the outcome following surgery [39]. This has led to
the introduction of total elbow arthroplasty in certain patients but this remains a controversial area.

6. ELBOW ARTHROPLASTY
Total elbow arthroplasty (TEA) is becoming recognised as a safe and effective alternative to operative fixation in
the treatment of comminuted intra-articular distal humerus fractures in the elderly patient [22]. This is reflected in the
number of TEAs performed annually for distal humeral fractures, which has increased 2.6 fold between 2002 to 2012
[34]. An example of a case managed with TEA is illustrated in Figs. (5 and 6). TEA has limited longevity due to aseptic
loosening, an example of which is illustrated in Fig. (7), therefore TEA is only recommended in patients with sedentary
lifestyles [40] who can comply with the post-operative rehabilitation regime [22]. TEA patients will have lifelong
restrictions placed upon them with limited weight bearing to decrease risk of premature wear or subsequent revision
[41]. Prasad et al. [42] analysed the survival of TEA in fracture patients and showed that only 53% had implant survival
of more than 10 years and 89.5% of patients demonstrated loosening of their prostheses at this stage.
1358 The Open Orthopaedics Journal, 2017, Volume 11 Beazley et al.

Fig. (5). Comminuted distal humerus fracture (AO type C3) in an elderly patient undergoing TEA.

Fig. (6). Comminuted distal humerus fracture (AO type C3) in an elderly patient undergoing TEA.

Fig. (7). Example of loosening of elbow arthroplasty.

Distal Humeral Fractures The Open Orthopaedics Journal, 2017, Volume 11 1359

McKee et al. compared operative fixation with TEA in a prospective, randomized, multicenter study for 40 patients
presenting with comminuted, displaced, intra-articular fractures of the distal humerus (OTA/AO type C) in patients over
the age of 65 years [33]. The study reported better Mayo Elbow Performance Score in the total elbow arthroplasty
group at 6 months (86 vs 68, P = .003), 12 months (88 vs 72, P = .007), and 2 years (86 vs 73, P = .015). A significant
difference favoring DASH score was reported at 6 months but at no further time point. Additionally there was a 25%
rate of intra-operative conversion to TEA in the ORIF group because of extensive comminution and an inability to
achieve stable fixation. Reoperation rates for TEA (3/25 [12%]) and ORIF (4/15 [27%]) were not statistically different
(P = 0.2). The authors concluded that TEA is a preferred alternative to fixation in elderly patients with complex distal
humeral fractures that are not amenable to stable fixation [33]. In a recent systematic review comparing TEA to ORIF
for the treatment of distal humeral fractures in the elderly, Githens et. al. pooled the results of 27 papers including 563
patients and found no significant difference between groups with respect to functional outcome or complications rates
[41]. Currently this area and the treatment of choice for these patients remain unclear.
Hemiarthroplasty is an alternative option and has the theoretical advantage of reducing the polyethylene wear and
being a more durable implant [43, 44]. However for implantation the patient must have an intact or reconstructable
radial head, coronoid, medial and lateral columns and functional collateral ligaments [45]. The implant requires fewer
restrictions on the patients’ activities and so may be a feasible option for slightly younger patients. Good outcomes have
been demonstrated in small case series with medium term follow up [45, 46], although reported complication rates are
comparable to that of TEA [42].

7. ULNAR NERVE
The ulnar nerve should be identified and protected throughout the surgical procedure. Controversy surrounds the
benefit of routine ulna nerve transposition following fixation; transposition theoretically lets the ulnar nerve lie in a
fresh bed but given the need to dissect further the nerve may become devascularised [47]. Chen et al. performed a
retrospective review analysing the results of 89 patients undergoing ORIF for distal humerus fractures who underwent
either a decompression alone or combined with transposition. The authors reported a significantly increased rate of ulna
neuritis post-operatively in the transposition group vs. the non-transposition group (33% vs 9% p = 0.0003) and
concluded there was no clear benefit to ulna nerve transposition [48]. For patient with pre-operative ulnar nerve
symptoms then transposition has been reported to improve recovery of symptoms (p <0.05) [49]. At our institution we
do not routinely transpose the nerve unless significant subluxation of the nerve exists on flexion following
reconstruction.

8. CORONAL SHEAR FRACTURES

Capitellar fractures are rare accounting for only 1% of total elbow injuries and 6% of distal humeral fractures [50].
The mechanism of injury is usually resulting from a fall on an outstretched hand or flexed elbow where radial head
imparts a shear force on the capitellum, lateral trochlear ridge and trochlea [51]. Isolated coronal shear fractures of the
capitellum or trochlea (AO type B3) are relatively rare injuries and account for a small percentage of distal humerus
fractures [52]. Coexisting soft tissue or bony injuries are common with 60% of patients with coronal shear fractures also
having lateral collateral ligament (LCL) injuries or radial head fractures [53]. The most commonly used classification
for these fractures is the Bryan and Morrey classification system [54]. It is based on 3 types of capitellum fractures.
Type 1 (Hahn-Steinthal) lesions involve a fracture isolated to the capitellum with attached subchondral bone. Type 2
fractures (Kocher-Lorenz) predominantly involve the articular cartilage overlying the capitellum. Type 3 (Broberg-
Morrey) lesions are comminuted capitellum fractures. A fourth type was later added by McKee that is defined as a
capitellum fracture that extends medially into the trochlea [51].
Inadequately treated capitellum fractures may lead to poor function and reduced range of motion [55, 56]. Poor
results have been reported with conservative management of these fractures but are also associated with posterior
comminution of the lateral condyle or multiple articular fragments [57]. Excision of the capitellar fragment has been
suggested [58, 59]; however, in the long run, this will lead to radiohumeral osteoarthritis and instability of the elbow
[60, 61].
Typically the lateral approach is used to gain access to the fracture. In the presence of an incompetent LCL, the
elbow can be hinged open, gaining good exposure to the joint surface. If the LCL is intact, either the plane between the
extensor digitorum communis and extensor carpi radialis brevis (Kaplan interval – the author’s preference) or the more
posterior plane between the anconeus and extensor carpi ulnaris (Kocher interval) can be used to access the fracture [51,
1360 The Open Orthopaedics Journal, 2017, Volume 11 Beazley et al.

54]. The fracture is fixed with anterior to posterior headless variable pitch screws; these implants have been shown to be
superior to either Kirschner wires or cancellous screws [62]. In the presence of metaphyseal comminution, a lateral
plate may be applied. The LCL is then repaired if incompetent. Patients are placed in a back slab for two weeks to
protect the wound and are then fully mobilised.

CONCLUSION
Distal humerus fractures are a challenging but rewarding group of injuries to manage. Advances in plate design and
surgical technique have improved the outcome for patients undergoing internal fixation, which is the current standard
treatment. However the procedure can be challenging and has a high rate of complications. Total elbow arthroplasty has
been advocated as a treatment option especially for elderly patients or those with unreconstructable distal humerus
fractures.

CONSENT FOR PUBLICATION

Not applicable.

CONFLICT OF INTEREST
The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS
Declared none.
REFERENCES

[1] Frankle MA, Herscovici D Jr, DiPasquale TG, Vasey MB, Sanders RW. A comparison of open reduction and internal fixation and primary
total elbow arthroplasty in the treatment of intraarticular distal humerus fractures in women older than age 65. J Orthop Trauma 2003; 17(7):
473-80.
[http://dx.doi.org/10.1097/00005131-200308000-00001] [PMID: 12902784]
[2] Robinson CM, Hill RM, Jacobs N, Dall G, Court-Brown CM. Adult distal humeral metaphyseal fractures: Epidemiology and results of
treatment. J Orthop Trauma 2003; 17(1): 38-47.
[http://dx.doi.org/10.1097/00005131-200301000-00006] [PMID: 12499966]
[3] Palvanen M, Kannus P, Niemi S, Parkkari J. Secular trends in the osteoporotic fractures of the distal humerus in elderly women. Eur J
Epidemiol 1998; 14(2): 159-64.
[http://dx.doi.org/10.1023/A:1007496318884] [PMID: 9556175]
[4] Morrey BF, Askew LJ, Chao EY. A biomechanical study of normal functional elbow motion. J Bone Joint Surg Am 1981; 63(6): 872-7.
[http://dx.doi.org/10.2106/00004623-198163060-00002] [PMID: 7240327]
[5] McKee MD, Jupiter JB. Fractures of the distal humerus. 3rd ed. Philadelphia: Lippincott: Skeletal trauma. 2002; pp. 765-82.
[6] McKee MD, Wilson TL, Winston L, Schemitsch EH, Richards RR. Functional outcome following surgical treatment of intra-articular distal
humeral fractures through a posterior approach. J Bone Joint Surg Am 2000; 82-A(12): 1701-7.
[http://dx.doi.org/10.2106/00004623-200012000-00003] [PMID: 11130643]
[7] Doornberg JN, van Duijn PJ, Linzel D, et al. Surgical treatment of intra-articular fractures of the distal part of the humerus. Functional
outcome after twelve to thirty years. J Bone Joint Surg Am 2007; 89(7): 1524-32.
[PMID: 17606792]
[8] Srinivasan K, Agarwal M, Matthews SJ, Giannoudis PV. Fractures of the distal humerus in the elderly: Is internal fixation the treatment of
choice? Clin Orthop Relat Res 2005; (434): 222-30.
[http://dx.doi.org/10.1097/01.blo.0000154010.43568.5b] [PMID: 15864057]
[9] Gabel GT, Hanson G, Bennett JB, Noble PC, Tullos HS. Intraarticular fractures of the distal humerus in the adult. Clin Orthop Relat Res
1987; (216): 99-108.
[PMID: 3815977]
[10] Fornasiéri C, Staub C, Tourné Y, Rumelhart C, Saragaglia D. Biomechanical comparative study of three types of osteosynthesis in the
treatment of supra and intercondylar fractures of the humerus in adults. Rev Chir Orthop Repar Appar Mot 1997; 83(3): 237-42.
[PMID: 9255359]
[11] O’Driscoll SW. Optimizing stability in distal humeral fracture fixation. J Shoulder Elbow Surg 2005; 14(1)(Suppl. S): 186S-94S.
[http://dx.doi.org/10.1016/j.jse.2004.09.033] [PMID: 15726080]
[12] Doornberg J, Lindenhovius A, Kloen P, van Dijk CN, Zurakowski D, Ring D. Two and three-dimensional computed tomography for the
classification and management of distal humeral fractures. Evaluation of reliability and diagnostic accuracy. J Bone Joint Surg Am 2006;
88(8): 1795-801.
Distal Humeral Fractures The Open Orthopaedics Journal, 2017, Volume 11 1361

[PMID: 16882904]
[13] Nauth A, McKee MD, Ristevski B, Hall J, Schemitsch EH. Distal humeral fractures in adults. J Bone Joint Surg Am 2011; 6(93)(7): 686-700.
[14] Aitken SA, Jenkins PJ, Rymaszewski L. Revisiting the ‘bag of bones’: Functional outcome after the conservative management of a fracture of
the distal humerus. Bone Joint J 2015; 97-B(8): 1132-8.
[http://dx.doi.org/10.1302/0301-620X.97B8.35410] [PMID: 26224833]
[15] Wilkinson JM, Stanley D. Posterior surgical approaches to the elbow: A comparative anatomic study. J Shoulder Elbow Surg 2001; 10(4):
380-2.
[http://dx.doi.org/10.1067/mse.2001.116517] [PMID: 11517370]
[16] Campbell WC. Incision for exposure of the elbow joint. Am J Surg 1932; 15: 65-7.
[http://dx.doi.org/10.1016/S0002-9610(32)90997-0]
[17] Bryan RS, Morrey BF. Extensive posterior exposure of the elbow. A triceps-sparing approach. Clin Orthop Relat Res 1982; (166): 188-92.
[PMID: 7083671]
[18] Papaioannou N, Babis GC, Kalavritinos J, Pantazopoulos T. Operative treatment of type C intra-articular fractures of the distal humerus: The
role of stability achieved at surgery on final outcome. Injury 1995; 26(3): 169-73.
[http://dx.doi.org/10.1016/0020-1383(95)93495-4] [PMID: 7744471]
[19] Stoffel K, Cunneen S, Morgan R, Nicholls R, Stachowiak G. Comparative stability of perpendicular versus parallel double-locking plating
systems in osteoporotic comminuted distal humerus fractures. J Orthop Res 2008; 26(6): 778-84.
[http://dx.doi.org/10.1002/jor.20528] [PMID: 18203185]
[20] Arnander MW, Reeves A, MacLeod IA, Pinto TM, Khaleel A. A biomechanical comparison of plate configuration in distal humerus fractures.
J Orthop Trauma 2008; 22(5): 332-6.
[http://dx.doi.org/10.1097/BOT.0b013e31816edbce] [PMID: 18448987]
[21] Schemitsch EH, Tencer AF, Henley MB. Biomechanical evaluation of methods of internal fixation of the distal humerus. J Orthop Trauma
1994; 8(6): 468-75.
[http://dx.doi.org/10.1097/00005131-199412000-00003] [PMID: 7869160]
[22] Shin SJ, Sohn HS, Do NH. A clinical comparison of two different double plating methods for intraarticular distal humerus fractures. J
Shoulder Elbow Surg 2010; 19(1): 2-9.
[http://dx.doi.org/10.1016/j.jse.2009.05.003] [PMID: 19574065]
[23] Lee SK, Kim KJ, Park KH, Choy WS. A comparison between orthogonal and parallel plating methods for distal humerus fractures: A
prospective randomized trial. Eur J Orthop Surg Traumatol 2014; 24(7): 1123-31.
[http://dx.doi.org/10.1007/s00590-013-1286-y] [PMID: 23921559]
[24] Frigg R. Locking compression plate (LCP). An osteosynthesis plate based on the dynamic compression plate and the point contact fixator
(PC-fix). Injury 2001; 32(Suppl. 2): 63-6.
[http://dx.doi.org/10.1016/S0020-1383(01)00127-9] [PMID: 11718740]
[25] Korner J, Diederichs G, Arzdorf M, et al. A biomechanical evaluation of methods of distal humerus fracture fixation using locking
compression plates versus conventional reconstruction plates. J Orthop Trauma 2004; 18(5): 286-93.
[http://dx.doi.org/10.1097/00005131-200405000-00004] [PMID: 15105750]
[26] Inglis AE, Ranawat CS, Straub LR. Synovectomy and débridement of the elbow in rheumatoid arthritis. J Bone Joint Surg Am 1971; 53(4):
652-62.
[http://dx.doi.org/10.2106/00004623-197153040-00004] [PMID: 5580024]
[27] Holdsworth BJ, Mossad MM. Fractures of the adult distal humerus. Elbow function after internal fixation. J Bone Joint Surg Br 1990; 72(3):
362-5.
[PMID: 2341427]
[28] John H, Rosso R, Neff U, Bodoky A, Regazzoni P, Harder F. Operative treatment of distal humeral fractures in the elderly. J Bone Joint Surg
Br 1994; 76(5): 793-6.
[PMID: 8083271]
[29] Zhang C, Zhong B, Luo CF. Comparing approaches to expose type C fractures of the distal humerus for ORIF in elderly patients: Six years
clinical experience with both the triceps-sparing approach and olecranon osteotomy. Arch Orthop Trauma Surg 2014; 134(6): 803-11.
[http://dx.doi.org/10.1007/s00402-014-1983-y] [PMID: 24777538]
[30] Korner J, Lill H, Muller LP, et al. Distal humerus fractures in elderly patients: Results after open reduction and internal fixation. Osteoporos
Int 200(16)(Supple 2): S73-9.
[http://dx.doi.org/10.1007/s00198-004-1764-5]
[31] Södergård J, Sandelin J, Böstman O. Postoperative complications of distal humeral fractures. 27/96 adults followed up for 6 (2-10) years.
Acta Orthop Scand 1992; 63(1): 85-9.
[http://dx.doi.org/10.3109/17453679209154857] [PMID: 1738980]
[32] McKee MD, Jupiter JB. A contemporary approach to the management of complex fractures of the distal humerus and their sequelae. Hand
Clin 1994; 10(3): 479-94.
[PMID: 7962152]
1362 The Open Orthopaedics Journal, 2017, Volume 11 Beazley et al.

[33] McKee MD, Veillette CJ, Hall JA, et al. 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.
[http://dx.doi.org/10.1016/j.jse.2008.06.005] [PMID: 18823799]
[34] Rajaee SS, Lin CA, Moon CN. Primary total elbow arthroplasty for distal humeral fractures in elderly patients: A nationwide analysis. J
Shoulder Elbow Surg 2016; 25(11): 1854-60.
[http://dx.doi.org/10.1016/j.jse.2016.05.030] [PMID: 27528540]
[35] Liu JJ, Ruan HJ, Wang JG, Fan CY, Zeng BF. Double-column fixation for type C fractures of the distal humerus in the elderly. J Shoulder
Elbow Surg 2009; 18(4): 646-51.
[http://dx.doi.org/10.1016/j.jse.2008.12.012] [PMID: 19362859]
[36] Haas N, Hauke C, Schütz M, Kääb M, Perren SM. Treatment of diaphyseal fractures of the forearm using the Point Contact Fixator (PC-Fix):
Results of 387 fractures of a prospective multicentric study (PC-Fix II). Injury 2001; 32(Suppl. 2): B51-62.
[http://dx.doi.org/10.1016/S0020-1383(01)00126-7] [PMID: 11718739]
[37] Korner J, Lill H, Müller LP, Rommens PM, Schneider E, Linke B. The LCP-concept in the operative treatment of distal humerus fractures--
biological, biomechanical and surgical aspects. Injury 2003; 34(Suppl. 2): B20-30.
[http://dx.doi.org/10.1016/j.injury.2003.09.022] [PMID: 14580983]
[38] Waddell JP, Hatch J, Richards R. Supracondylar fractures of the humerus results of surgical treatment. J Trauma 1988; 28(12): 1615-21.
[http://dx.doi.org/10.1097/00005373-198812000-00001] [PMID: 3199462]
[39] John H, Rosso R, Neff U, Bodoky A, Regazzoni P, Harder F. Distal humerus fractures in patients over 75 years of age. Long-term results of
osteosynthesis. Helv Chir Acta 1993; 60(1-2): 219-24.
[PMID: 8226060]
[40] Goldberg SH, Urban RM, Jacobs JJ, King GJ, O’Driscoll SW, Cohen MS. Modes of wear after semiconstrained total elbow arthroplasty. J
Bone Joint Surg Am 2008; 90(3): 609-19.
[http://dx.doi.org/10.2106/JBJS.F.01286] [PMID: 18310712]
[41] Githens M, Yao J, Sox AH, Bishop J. Open reduction and internal fixation versus total elbow arthroplasty for the treatment of geriatric distal
humerus fractures: A systematic review and meta-analysis. J Orthop Trauma 2014; 28(8): 481-8.
[http://dx.doi.org/10.1097/BOT.0000000000000050] [PMID: 24375273]
[42] Prasad N, Ali A, Stanley D. Total elbow arthroplasty for non-rheumatoid patients with a fracture of the distal humerus: A minimum ten-year
follow-up. Bone Joint J 2016; 98-B(3): 381-6.
[http://dx.doi.org/10.1302/0301-620X.98B3.35508] [PMID: 26920964]
[43] Argintar E, Berry M, Narvy SJ, Kramer J, Omid R, Itamura JM. Hemiarthroplasty for the treatment of distal humerus fractures: Short-term
clinical results. Orthopedics 2012; 35(12): 1042-5.
[http://dx.doi.org/10.3928/01477447-20121120-06] [PMID: 23218618]
[44] Hausman M, Panozzo A. Treatment of distal humerus fractures in the elderly. Clin Orthop Relat Res 2004; (425): 55-63.
[http://dx.doi.org/10.1097/01.blo.0000131485.47685.8c] [PMID: 15292788]
[45] Schultzel M, Scheidt K, Klein CC, Narvy SJ, Lee BK, Itamura JM. Hemiarthroplasty for the treatment of distal humeral fractures: Midterm
clinical results. J Shoulder Elbow Surg 2017; 26(3): 389-93.
[http://dx.doi.org/10.1016/j.jse.2016.09.057] [PMID: 27914843]
[46] Nestorson J, Ekholm C, Etzner M, Adolfsson L. Hemiarthroplasty for irreparable distal humeral fractures: Medium-term follow-up of 42
patients. Bone Joint J 2015; 97-B(10): 1377-84.
[http://dx.doi.org/10.1302/0301-620X.97B10.35421] [PMID: 26430013]
[47] Yamaguchi K, Sweet FA, Bindra R, Gelberman RH. The extraneural and intraneural arterial anatomy of the ulnar nerve at the elbow. J
Shoulder Elbow Surg 1999; 8(1): 17-21.
[http://dx.doi.org/10.1016/S1058-2746(99)90048-4] [PMID: 10077790]
[48] Chen RC, Harris DJ, Leduc S, Borrelli JJ Jr, Tornetta P III, Ricci WM. Is ulnar nerve transposition beneficial during open reduction internal
fixation of distal humerus fractures? J Orthop Trauma 2010; 24(7): 391-4.
[http://dx.doi.org/10.1097/BOT.0b013e3181c99246] [PMID: 20577067]
[49] Ruan HJ, Liu JJ, Fan CY, Jiang J, Zeng BF. Incidence, management, and prognosis of early ulnar nerve dysfunction in type C fractures of
distal humerus. J Trauma 2009; 67(6): 1397-401.
[http://dx.doi.org/10.1097/TA.0b013e3181968176] [PMID: 19797987]
[50] Ruchelsman DE, Tejwani NC, Kwon YW, Egol KA. Open reduction and internal fixation of capitellar fractures with headless screws. J Bone
Joint Surg Am 2008; 90(6): 1321-9.
[http://dx.doi.org/10.2106/JBJS.G.00940] [PMID: 18519327]
[51] McKee MD, Jupiter JB, Bamberger HB. Coronal shear fractures of the distal end of the humerus. J Bone Joint Surg Am 1996; 78(1): 49-54.
[http://dx.doi.org/10.2106/00004623-199601000-00007] [PMID: 8550679]
[52] Carroll MJ, Athwal GS, King GJ, Faber KJ. Capitellar and Trochlear. Fractures Hand Clin 2015; 31(4): 615-30.
[PMID: 26498550]
Distal Humeral Fractures The Open Orthopaedics Journal, 2017, Volume 11 1363

[53] Heck S, Zilleken C, Pennig D, Koslowsky TC. Reconstruction of radial capitellar fractures using fine-threaded implants (FFS). Injury 2012;
43(2): 164-8.
[http://dx.doi.org/10.1016/j.injury.2011.04.009] [PMID: 21616488]
[54] Bryan RS, Morrey BF. Fractures of the distal humerus.The elbow and its disorders. Philadelphia: WB Saunders 1985; pp. 302-99.
[55] Grantham SA, Norris TR, Bush DC. Isolated fracture of the humeral capitellum. Clin Orthop Relat Res 1981; 161: 262-9.
[PMID: 7307389]
[56] Ong KL, Mahadev A. Cannulated cancellous screw fixation for capitellum fractures in adolescents. J Orthop Surg (Hong Kong) 2011; 19(3):
346-9.
[http://dx.doi.org/10.1177/230949901101900317] [PMID: 22184168]
[57] Ashwood N, Verma M, Hamlet M, Garlapati A, Fogg Q. Transarticular shear fractures of the distal humerus. J Shoulder Elbow Surg 2010;
19(1): 46-52.
[http://dx.doi.org/10.1016/j.jse.2009.07.061] [PMID: 19884023]
[58] Alvarez E, Patel MR, Nimberg G, Pearlman HS. Fracture of the capitulum humeri. J Bone Joint Surg Am 1975; 57(8): 1093-6.
[http://dx.doi.org/10.2106/00004623-197557080-00010] [PMID: 1201993]
[59] Yamaguchi K, Sweet FA, Bindra R, Gelberman RH. The extraneural and intraneural arterial anatomy of the ulnar nerve at the elbow. J
Shoulder Elbow Surg 1999; 8(1): 17-21.
[http://dx.doi.org/10.1016/S1058-2746(99)90048-4] [PMID: 10077790]
[60] Singh AP, Singh AP, Vaishya R, Jain A, Gulati D. Fractures of capitellum: A review of 14 cases treated by open reduction and internal
fixation with Herbert screws. Int Orthop 2010; 34(6): 897-901.
[http://dx.doi.org/10.1007/s00264-009-0896-9] [PMID: 19894049]
[61] Mahirogullari M, Kiral A, Solakoglu C, Pehlivan O, Akmaz I, Rodop O. Treatment of fractures of the humeral capitellum using herbert
screws. J Hand Surg [Br] 2006; 31(3): 320-5.
[http://dx.doi.org/10.1016/J.JHSB.2006.02.002] [PMID: 16616979]
[62] Elkowitz SJ, Polatsch DB, Egol KA, Kummer FJ, Koval KJ. Capitellum fractures: A biomechanical evaluation of three fixation methods. J
Orthop Trauma 2002; 16(7): 503-6.
[http://dx.doi.org/10.1097/00005131-200208000-00009] [PMID: 12172281]

© 2017 Beazley et al.

This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a
copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and
reproduction in any medium, provided the original author and source are credited.