Trauma Meeting
Published: 2020-03-22

Sequelae of distal humeral fractures

Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, Sapienza University, Rome, Italy
Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, Sapienza University, Rome, Italy
Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, Sapienza University, Rome, Italy
Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, Sapienza University, Rome, Italy
distal humerus fractures complications ulnar nerve neuropathies stiffness heterotopic ossifications nonunion pseudoarthrosis malunion post-traumatic osteoarthritis


Distal humerus fractures (DHF) are rare and complex injuries. Although knowledge of these lesions among surgeons has increased in recent decades, a high rate of complications and unsatisfactory results are still reported. The main complications are ulnar nerve neuropathies, stiffness, heterotopic ossifications, nonunions, malunions, painful hardware and post-traumatic osteoarthritis. Careful pre-operative planning, choosing the correct surgical approach, mini-invasive and tissue-sparing surgery, stable osteosynthesis, correct management of the ulnar nerve and early rehabilitation can improve clinical outcomes by reducing the number of complications. The type of trauma, bone exposure, timing of surgery in polytraumas and varying levels of compliance among patients represent inevitable risk factors for unsatisfactory outcomes. Early and appropriate treatment of complications is associated with better results as it reduces the development of osteoarthritis and avoids a long period of functional disability. The aim of this study is to describe the main complications of DHF and ways of preventing and treating them


Distal humerus fractures (DHF) are considered rare lesions whose prevalence is 0.2-2% of all adult fractures and approximately 30% of elbow fractures. The incidence rate is 5.7/100,000 per year, though this value is likely to increase in next 10 years owing to population aging. These fractures occur in a bimodal distribution, with the first peak in young males, usually following high-energy traumas, and a second peak in elderly women, as a consequence of pathological fractures related to osteoporosis 1.

DHF used to be associated with poor prognosis, poor clinical outcomes and high complication rates, due above all to secondary displacement and joint stiffness. The recent introduction of better surgical techniques, hardware and materials has significantly improved outcomes and reduced failure rates. In the 1980s, A.O. principles introduced the concepts of anatomic reduction, double plate rigid fixation and early mobilization; consequently, minimal osteosynthesis and conservative treatment were progressively abandoned. The further reduction in surgical failure rates in the elderly in recent decades may in part be ascribed to the introduction of prosthetic replacements, which are now considered the treatment of choice in comminuted fractures of the distal humerus in low-demand aged patients.

Nevertheless, the complication rates associated with this type of fracture remain significant, particularly when such lesions are managed by non-expert elbow surgeons. According to the recent literature, the rate of major complications ranges between 19 and 53%,: unsatisfactory outcomes are mainly correlated with severe comminution of fractures, bone defects, open high-energy traumas, poor bone-stock, older age and the timing of surgery 2. The most common complications in DHF include ulnar neuropathy, joint stiffness, nonunion, olecranon osteotomy-related complications, malunions, osteoarthritis and infections.

Accurate pre-operative planning is mandatory as each kind of complication requires a different management and different surgical procedures. The initial fracture pattern, previous surgical approaches, ulnar nerve position (transposed or not transposed) and function, implant features and articular surface status, as well as the patients’ comorbidities and compliance, should always be assessed carefully when planning the timing and type of surgery and post-operative treatment.

Pre-operative planning includes standard radiographs and CT with tridimensional reconstructions and radio-ulnar subtraction; CT is mandatory to evaluate the sequelae of comminuted fractures and to better understand the articular surface involvement, the deformity pattern and the extension and features of any bony defects. MRI is rarely indicated in the acute and chronic settings, though it is recommended to detect or evaluate bone infections, cartilage damage and osteonecrosis. Radiolabeled autologous WBC scintigraphy is frequently used to detect sites of abnormal bone remodeling, e.g. in silent/asymptomatic infections, and to evaluate the effectiveness of antibiotic therapy. Ultrasound, MRI and EMNG may be indicated in post-traumatic neuropathies to better assess the type of injury (neurapraxia, neurotmesis, axonotmesis).

The choice of surgical procedures for DHF sequelae should take into account the possible need to use devices for hardware removal, new internal fixation and/or prosthetic replacement. Patient positioning should be carefully assessed when auxiliary surgical fields are required for bone/tendon graft harvesting. The availability of equipment such as image intensifier, surgical microscope and electro-neuro-stimulator should be considered in selected cases. Lastly, alternative surgical strategies aimed at avoiding or overcoming intraoperative complications should be discussed.

The aim of this study is to describe the main complications of DHF as well as their prevention and treatment.


Neurological lesions are a common complication in DHF. The ulnar nerve is most commonly involved, though the radial and median nerves might also be affected. Nerves lesions directly due to trauma are reported in between 0% and 26% of cases, while late-onset chronic post-traumatic neuropathies are reported in between 0% and 17% of cases; the latter affect the ulnar nerve in the majority of cases.

Ulnar nerve damage is frequently observed in the first days after surgery and is mainly caused by intraoperative compression, stretch, contusion or transection, devascularization, bony or hardware impingement or inadequate anterior transposition at the end of surgery; this clinical finding may also be due to misdiagnosed preexisting damage caused directly by the trauma 3.

Late-onset neuropathies are often related to adhesions or compression by a medial plate, excessive callus or scar formation, nerve instability, nonunion and malunions with significant deformities, medial heterotopic ossifications (HO) and hardware malpositioning or failure).

The severity of nerve injuries ranges between low-grade parasthesiae, which frequently resolve spontaneously within 2-4 weeks of the injury, to complete sensitive/motor palsy, although isolated sensitive deficits are more common. Pre-operative traumatic lesions are treated with decompression and transposition while neurotmesis, a rare injury, is repaired by suture or graft. In mild late-onset neuropathies, conservative treatment is the first effective option, especially if anterior transposition was performed at the time of DHF primary surgery and yields good outcomes in the majority of cases within 2-4 months. Nerve function in patients treated conservatively should be periodically assessed by means of a clinical examination and EMNG. If conservative treatment with anti-inflammatory/neurotrophic drugs and physical therapy fails and nerve deterioration occurs, ulnar neurolysis and anterior transposition need to be performed quickly to avoid permanent damage.

Heterotopic ossifications

Heterotopic ossifications (HO), whose estimated incidence is 0-21% 4,5, are more common in polytrauma patients 6 with extended soft-tissue and neurovascular damage 7, concomitant central nervous system injury, delayed surgical treatment and prolonged immobilization after surgery 8. Furthermore, HO seem to be more common when a transolecranon approach is used: Chen et al. observed a 12% HO rate with the transolecranon approach and a 0% HO rate with the Brian-Morrey approach 9.

The clinical severity of HO varies depending on their location and size. In 1994, Hastings introduced a classification designed for clinical practice: it divides HO in Type I (asymptomatic), Type IIA (symptomatic HO with stiffness in E/F), Type IIB (symptomatic HO with stiffness in P/S) and Type IIC (symptomatic HO with combined stiffness in E/F and P/S). Type IIIA, IIIB e IIIC are used for ankylosis of the elbow joint in E/F, P/S and combined, respectively. Surgical treatment is recommended in Types II and III, or whenever neurological compression symptoms occur.

The optimal timing for excision surgery of HO has not been established: some authors have suggested that the biological activity of HO should be monitored by CT, X-rays, serum alkaline phosphatase or bone scintigraphy and that surgery should only be performed after the full maturation of HO (approx. 6-12 months) in order to avoid recurrences 10; however, none of the aforementioned examinations has displayed a high sensitivity or specificity 11. The evaluation of radiographic features (well-defined rounded margins with clear trabeculae and cortical bone) of HO remain the most widely used method to evaluate the maturation of HO 12, a process that usually ends within 6 months. In recent years, several surgeons have recommended the early excision of HO to avoid a long period of functional impairment, with satisfactory clinical results and a low recurrence rate being reported. Excessively delayed treatment (> 12 months) is associated with a high failure rate due to soft tissue contractures and degenerative development of the joint 13.

Surgical treatment of HO is often based on the lateral and/or the medial column procedure, which consists in excising ectopic bone and scar tissues; neurolysis in situ or anterior transposition of the ulnar nerve is often associated with this procedure. Late treatment (> 12 months) associated with cartilage injury and anterior HO is a negative prognostic factor in this type of surgery 14.

The administration of indomethacin for HO prophylaxis remains a controversial issue, with the literature available on this topic being very limited. Although the most recent literature does not provide unequivocal evidence of its benefits in HO prophylaxis, several elbow surgeons have stated that they routinely use indomethacin (50-100 mg/daily for 4 weeks) in clinical practice, especially in traumatic and post-traumatic conditions. Mini-invasive and tissue sparing surgery, as well as early and gentle rehabilitation, are considered other factors that help to prevent HO formation.

Elbow stiffness

The incidence of severe stiffness is estimated to be 10%-20%, though it is higher in elderly patients 15,75. Highly comminuted and displaced fractures and extended post-operative immobilization are negative prognostic factors for the development of a stiff elbow 16,17. Pathoanatomic features include soft tissue retraction, periarticular osteophytosis, hypertrophic callus formation, HO, nonunions, malunions and hardware impingement.

Surgery is indicated when conservative treatment fails in extrinsic stiffness (> 4/6 months) and in all cases of intrinsic stiffness with significant pain or limitations in daily activities. Extrinsic stiffness requires open arthrolysis with capsular-ligamentous release (bicolumn procedure), HO and osteophyte excision and, occasionally, implant removal. The treatment of intrinsic stiffness treatment is more complex owing to the presence of joint deformities. Prosthetic replacement is recommended in elderly patients affected by malunions and intra-articular nonunions, with good outcomes expected in the majority of cases. By contrast, the treatment of intrinsic contractures in younger patients is often challenging as it requires corrective osteotomies, interposition arthroplasty, nonunion debridement with autologous bone grafting and new fixation. These procedures should be considered as better options than prosthetic replacement in young adults.

Transolecranon osteotomy-related complications

The transolecranon approach is the most common procedure in DHF osteosynthesis 18. However, the complication rate associated with this procedure is high: hardware failure with secondary displacement, delayed union and nonunion are described in 0-31% of cases 4,19-21. Olecranon healing failure has been more commonly observed when a dynamic tension band or an intramedullary screw rather than plate-screw fixation are used 19,22. CT scan is indispensable to evaluate the grade and extension of the nonunion. No surgical treatment should be considered in asymptomatic patients when partial bone healing occurs and the proximal fragment is stable.

The correct timing of treatment is essential to avoid excessive resorption of the olecranon: whenever delayed healing is observed, one or two cycles of shockwave therapy should be administered. Early surgical intervention is recommended if physical treatment fails. The type of treatment depends on the location and the extension of the nonunion. In case of bony resorption of the olecranon tip, the excision of the latter and tricipital reinsertion is the first-choice procedure: these cases are often caused by an osteotomy that has been performed too proximally or an excessive time interval between nonunion onset and surgical treatment.

In other cases with large proximal olecranon fragment, pseudoarthrosis debridement, autologous bone grafting and internal fixation with plate is indicated. The main goal of surgery is to maintain the dimensions of the greater sigmoid notch: this may be achieved by positioning a tricortical bone graft along the iliac crest after debridement of the nonunion. Compression with a stable ORIF is mandatory in such cases to ensure bone graft integration and healing.

Delayed union/nonunion of distal humerus

Despite a significant reduction in the incidence of nonunions in DHF over the past 30 years, the failure to heal is still reported in as many as 10% of cases 23,24.

Unstable osteosynthesis, fragment comminution with bone devascularization and infections are the main risk factors in the development of pseudoarthrosis 25. In 2004, Ali et al. reported that fixation was unstable in 12 (75%) of the 16 cases with a distal humerus nonunion treated by them 26. Other factors associated with the occurrence of nonunions are smoking habit, immunosuppressive drugs, osteoporosis and extensive soft tissue injuries, e.g. in open fractures; aggressive surgical techniques with extended periosteum devascularization and dissection of bone fragments from contiguous soft tissues are another important risk factor for nonunions.

The type of nonunions observed in DHF are frequently oligotrophic lesions involving the supracondylar region alone or combined with the intra-articular surface. Typical symptoms include pain (70%), abnormal joint mobility (20%) and stiffness (66%) 27: surgical treatment is often indicated in such cases. By contrast, asymptomatic nonunions associated with mild functional limitations should not be surgically treated, especially if a single column is involved, or in elderly low-demand patients.

In a young, active population with extra-articular or intra-articular fractures with preserved joint surface, nonunion debridement, internal fixation and autologous bone grafting leads to operative success in over 80% of cases. However, bone healing is not always correlated with satisfactory clinical results because of the high risk of developing significant post-operative stiffness or ulnar neuropathy 25,28. These complications may be avoided, however, by combining nonunion treatment procedures with capsular release, nerve decompression and transposition. Customized treatment with careful pre-operative evaluation of associated lesions can significantly improve clinical outcomes in over 90% of patients and lead to pain relief and ROM improvement 29,30.

In young patients with nonunions associated with a severely damaged articular surface, one treatment option that has been described is interposition arthroplasty and external fixation; the success rate of this treatment is, however, low, especially in cases of infection, elbow instability, severe deformity or high functional demands. Total elbow arthroplasty (TEA) is the first treatment option in elderly patients because it provides some notable advantages, such as rapid restoration of elbow motion, whilst avoiding complications related to debridement and internal fixation and bone grafting, with satisfactory clinical outcomes being reported in 80-91% of cases 31,32. TEA can also lead to good clinical outcomes in compliant and low-demand young patients, though such patients should be made aware of the functional limitations and the risk of future implant revisions associated with this option. TEA is contraindicated in infected DHF nonunions, in high-demand patients or in cases with a severe hand function impairment. Although olecranon nonunion is not an absolute contraindication to TEA, the surgical technique required may be more challenging. Distal humerus hemiarthroplasty (DHH) represents another effective option in DHF nonunions. It can be performed in patients with very distally located pseudoarthrosis and severe humeral cartilage impairment; preserved ulnar and radial articular surfaces are required if good functional outcomes are to be achieved. The main advantage of DHH over TEA is the reduced functional limitation associated with the former resulting from the absence of the prosthetic linked hinge. DHH is also indicated in intra-articular malunions and in avascular necrosis of articular fragments, whereas it is not recommended in case of infection, poor medial and/or lateral column bone-stock, unreconstructable collateral ligaments, severe elbow instability and degeneration of radial head and ulnar cartilage.

Long-term outcomes of DHH are as yet unknown, though promising short and mid-term results have been reported. DHH needs to be studied further to shed more light on the true potential and limitations associated with these implants in DHF nonunions.


Malunions are a well-known and thoroughly studied complication in pediatric traumatology, whereas very little is known about the incidence, treatment options and expected outcomes in the adult population.

Malunions can be diaphyseal, metaphyseal or intra-articular and are usually related to improper reduction or unstable fixation with secondary displacement. Deformity can occur on different spatial axes, often generating triplanar complex deformities, though varus-valgus and procurvatus-recurvatus defects are more common in the extraarticular region of the distal humerus; in these cases, sagittal deformities cause F/E loss, whereas coronal defects can cause severe aesthetic impairment, joint instability, ulnar neuropathy and secondary osteoarthritis. Intra-articular malunions often cause complex deformities that are clinically associated with pain and stiffness.

There are several surgical strategies worth considering when managing these conditions. Correction osteotomies can restore ROM and correct aesthetic defects, but these are challenging procedures and often contraindicated in case of severe post-traumatic osteoarthritis, poor bone-stock and in aged and/or non-compliant patients. Osteotomies can be performed at intra or extra-articular sites, with results being better in the latter. Correction of varus-valgus and recurvatus-procurvatus deformities can be achieved by performing full-thickness osteotomies, as humeral shortening is generally well tolerated, or wedge osteotomies, which remain the first-choice technique. Intra-articular osteotomy is performed by realigning each condyle separately together with iliac crest bone autografting. This is a technically challenging surgical procedure with very few indications as it is sometimes nearly impossible to achieve anatomical reconstruction of the articular trochlea. The few studies that do provide data on this technique, such as those by McKee et al. 33, Kazuki et al. 34 and Marti et al. 35, report good overall clinical and functional outcomes. Malunions due to shear fractures are corrected by coronal osteotomies that pass through the fracture plane; bone grafting may be required in such cases to restore the articular shape.

Prosthetic joint replacement, whether it be TEA or DHH, is indicated in elderly and low-demand patients, as well as in all cases with associated severe osteoarthritis, even though further studies are needed to shed more light on the long-term clinical outcomes following this procedure. In this regard, humeral deformities have been known to significantly complicate the positioning of prosthetic implants and to be associated with a high risk of early implant mobilization and failure because of stem loosening and bushing wear. Arthrodesis may be considered in aged non-compliant patients or in high-demand patients who are not prepared to tolerate the limitations imposed by a prosthesis.

Post-traumatic osteoarthritis (PTOA)

Post-traumatic osteoarthritis, which results from damage to the cartilage layer, is a common complication in all elbow fractures, whether it is caused by the trauma itself or by the chronic consequences of an inadequate fracture reduction and/or joint instability. Intra-articular loose fragments, osteonecrosis and hardware impingement are other risk factors associated with PTOA.

The onset of PTOA may occur either gradually or rapidly and may have varying clinical consequences. TEA represents a good treatment option, with a positive outcome expected, in elderly low-demand patients with pain and stiffness 36,37.

In younger patients, TEA is associated with a higher rate of late complications and reinterventions (37%) that are due to the improper use of the arm and may lead to long-term failure 38. Interposition arthroplasty may be an adequate treatment option in high-demand patients, especially in the absence of marked deformity, though it should be borne in mind that some authors have reported high failure rates when they adopted this technique (61-66%) 39,40. This procedure should thus be considered as a “bridge solution” to postpone TEA as long as possible while preserving bone-stock and relieving pain and stiffness.

Wound complications and infections

The thin soft tissues envelope at the elbow places this joint at risk for major post-operative wound complications and secondary deep infections. Wound complications can lead to significant comorbidity with the need for further surgical procedures, and may influence the outcomes of the initial treatment of DHF. Although wound problems in DHF are well-known, it is surprising to observe that only one study directly focused on this topic 41: Lawrence et al. studied 89 DHF treated with ORIF. Fourteen patients (15.7%) developed a major wound complication requiring on average 2.5 (range, 1-6) additional surgical procedures. Six patients required plastic surgical soft tissue coverage with flexor carpi ulnaris flap or radial forearm flap. The great majority of wound complications in this study were successfully treated with debridement and primary or delayed wound closure. All 14 fractures complicated by wound problems healed. In this study, minor self-resolving wound complications, occurred much less frequently (3%). Fracture healing rates and elbow range of motion did not appear to be affected by wound complications when they were rapidly and properly managed. The authors also highlighted that an olecranon osteotomy approach and plate fixation increases the risk of major wound complications by 13 times.

When major wound complications are neglected, deep soft tissues and bone infection may occur, thus affecting the final outcomes. Indeed, these cases require surgical treatments consisting of premature hardware removing, wide tissue debridement and intravenous antibiotics; in these patients nonunion frequently occurs and further surgical procedures are required.

In the last decade, negative pressure wound therapy (NPWT) efficacy emerged, simplifying management of wound complications and avoiding more complex surgical procedures. A recent review 42 including 404 upper extremities cases, reported good results in 90% of cases, highlighting that NPWT could be considered not only a temporary management tool but even a definitive treatment in selected patients. Minor and some major wound complications are nowadays best treated with oral antibiotics associated with NPWT: this treatment can resolve the majority of cases, often avoiding premature hardware removal.

Infective complications range between 0 43 and 22% 44 and correlate with type of fractures (close vs open), grade of exposure, soft tissue involvement and general health status of patients. Robinson et al. 1 found an overall incidence of infection of 4.7%, but only 1.6% developed deep sepsis. Sanchez-Sotelo et al. 45 found wound complication in 6% and deep infection in 3%. In a recent case-report including 62 patients with DHF and treated with ORIF, Somerson et al. 46 reported a wound dehiscence and infection rate in 14.5%. Kundel et al. 47 documented higher infection rates in open fractures (14%) compared with the closed injuries (8%). Grade III open fractures were associated with a higher risk of infections. Furthermore, the use of a plate construct to stabilize the olecranon osteotomy is considered to be another significant risk factor for wound complications and secondary infections.

Few studies have investigated the management of this uncommon but severe complication in DHF. Open fractures present additional challenges to the surgeon and frequently require a staged approach involving an initial irrigation, debridement and external fixation followed by delayed definitive ORIF when the soft tissues are deemed satisfactory and infections excluded. Infection should be suspected in any patient with persistent drainage and delayed union or nonunion of the DHF as well as in patients with significant night pain and stiffness. In unclear cases, when subacute infection is suspected, MRI, autologous WBC radiolabeled scintigraphy and incisional biopsy may be useful. Specific antibiotic therapy, serial debridements with preservation of internal fixation are an effective treatment for acute non-aggressive infections. However, if multiple debridements and systemic antibiotics fail to treat the infection, implants should be removed and a more thorough debridement should be performed. Further studies are required to better define shared therapeutic algorithms in post-operative DHF infections.

Figures and tables

Author (year) Patients N/mean age Follow-up (mean) Complication type
Henley et al. 53(1987) 33/32 18 months 9 Olecranon osteotomy complications 2 Heterotopic ossifications2 Infections2 Nonunions
Kundel et al. 8(1996) 98/54 40 months 29 Heterotopic ossifications26 Ulnar neuropathies10 Deep infections10 Nonunions8 Wound infections4 Hardware failures1 Avascular necrosis
McKee et al. 48(2000) 26/44 51 months 4 Delayed unions2 Wound infections2 Symptomatic hardware1 Deep infection1 Radial neuropathy
McKee et al. 49(2000) 25/47 37 months 3 Hardware impingements3 Ulnar neuropathies2 Stiffness1 Wound infection1 Radial neuropathy1 Nonunion (hardware failure)1 Malunion
Gupta et al. 70(2002) 55/39 48 months 5 Hardware failures3 Ulnar neuropathies3 Heterotopic ossifications2 Deep infections1 Wound complications1 Malunion
Pajarinen et al. 23(2002) 21/44 25 months 2 Nonunion1 Deep infection1 Olecranon osteotomy complication
Ring et al. 30(2003) 21/50 40 months 6 Stiffness2 Ulnar neuropathies1 Symptomatic hardware1 Hardware failure
Gofton et al. 4(2003) 23/53 45 months 7 Heterotopic ossifications3 Stiffness2 Olecranon osteotomy complications1 Hardware impingement1 Wound infection1 Deep infection1 Avascular necrosis
Frankle et al. 57(2003) 12/74 57 months 3 Hardware failure1 Infection1 Stiffness1 Heterotopic ossifications
Tyllianakis et al. 54(2004) 26/46 70 months 4 Olecranon osteotomy complications3 Heterotopic ossifications3 Symptomatic hardware2 Hardware failures1 Delayed union1 Deep infection1 Wound infection1 Ulnar neuropathy1 Wound infection
Soon et al. 60(2004) 15/43 12 months 4 Stiffness3 Hardware failures2 Ulnar neuropathies1 Wound infection1 Nonunion
Korner et al. 71(2005) 45/73 87 months 32 Post-traumatic osteoarthritis12 Implant failures6 Ulnar neuropathies2 Wound infections
Huang et al. 72(2005) 19/72 96 months 15 Post-traumatic osteoarthritis1 Wound infection1 Ulnar neuropathy
Srinivasan et al. 73(2005) 28/85 42 months 3 Wound complications2 Nonunions1 Olecranon osteotomy complication1 Deep infection1 Heterotopic ossifications
Sanchez-Sotelo et al. 45 (2007) 32/58 24 months 5 Heterotopic ossifications2 Wound infections2 Post-traumatic osteoarthritis2 Ulnar neuropathies1 Deep infection1 Nonunions
Liu et al. 74(2009) 32/68.7 25 months 7 Heterotopic ossifications2 Wound infections2 Ulnar neuropathies
Atalar et al. 61(2009) 21/47 28 months 7 Heterotopic ossifications1 Deep infection1 Post-traumatic osteoarthritis
McKee et al. 59(2009) 32/69 24 months 2 Stiffness1 Ulnar neuropathy1 Nonunion
Shin et al. 51(2010) 35/54 31 months 11 Symptomatic hardware6 Ulnar neuropathy4 Heterotopic ossifications2 Stiffness2 Nonunions
Singh et al. 64(2010) 14/33 58 months -
Mighell et al. 66(2010) 18/45 26 months 5 Post-traumatic osteoarthritis3 avascular necrosis3 Heterotopic ossifications1 Stiffness1 Wound infection
Giannicola et al. 65(2010) 15/47 29 months 2 Post-traumatic osteoarthritis1 Radial neuropathy1 Wound infection1 Nonunion
Huang et al. 71(2011) 14/76.8 51 months 2 Post-traumatic osteoarthritis1 Hardware failure1 Stiffness1 Heterotopic ossifications
Egol et al. 58(2011) 11/76 13 months 2 Stiffness1 Nonunion
Brouwer et al. 67(2011) 30/49 34 months 8 Nonunions3 Infections
Erpelding et al. 50(2012) 24/47 27 months 5 stiffness2 Ulnar neuropathy1 Post-traumatic osteoarthritis
Schmidt-Horloe et al. 62 (2012) 31/50 12 months 10 Post-traumatic osteoarthritis7 Olecranon osteotomy complications4 Heterotopic ossifications2 Symptomatic hardware
Heck et al. 68(2012) 15/36 59 months 8 Post-traumatic osteoarthritis
Ducrot et al. 56(2013) 43/80 25 months 6 Ulnar neuropathies4 Heterotopic ossifications4 Symptomatic hardware2 Infection2 Nonunion1 Hardware failure
Bilsel et al. 69(2013) 18/45 44 months 1 Heterotopic ossifications1 Olecranon osteotomy complication1 Stiffness
Lee et al. 52(2014) 67/56 30 months 21 Symptomatic hardware5 Heterotopic ossifications5 Ulnar neuropathies3 Stiffness2 Hardware failure1 Wound infection1 Olecranon nonunion
Flinkkila et al. 55(2014) 47/60 47 months 13 Symptomatic hardware4 Ulnar neuropathies3 Infections2 Nonunions1 Malunion1 Olecranon nonunion
Kural et al. 63(2017) 24/47 28 months 6 Post-traumatic osteoarthritis2 Olecranon osteotomy complications1 Infection
Table I.DHF complications rates: review of the literature.


  1. Robinson CM, Hill RM, Jacobs N. Adult distal humeral metaphyseal fractures: epidemiology and results of treatment. J Orthop Trauma. 2003; 17:38-47. DOI
  2. Babhulkar S, Babhulkar S. Controversies in the management of intra-articular fractures of distal humerus in adults. Indian J Orthop. 2011; 45:216-25. DOI
  3. Shin R, Ring D. The ulnar nerve in elbow trauma. J Bone Joint Surg. 2007; 89:1108-16. DOI
  4. Gofton WT, Macdermid JC, Patterson SD. Functional outcome of AO type C distal humeral fractures. J Hand Surg Am. 2003; 28:294-308. DOI
  5. Theivendran K, Duggan PJ, Deshmukh SC. Surgical treatment of complex distal humeral fractures: functional outcome after internal fixation using precontoured anatomic plates. J Shoulder Elbow Surg. 2010; 19:524-32. DOI
  6. Sanchez-Sotelo J, Torchia ME, O’Driscoll SW. Complex distal humeral fractures: internal fixation with a principle-based parallel-plate technique. J Bone Joint Surg Am. 2007; 89:961-9. DOI
  7. Garland DE, O’Hollaren RM. Fractures and dislocations about the elbow in the head-injured adult. Clin Orthop Relat Res. 1982; 168:38-41.
  8. Kundel K, Braun W, Wieberneit J. Intra-articular distal humerus fractures. Factors affecting functional outcome. Clin Orthop Relat Res. 1996; 332:200-8.
  9. Chen G, Liao Q, Luo W. Triceps-sparing versus olecranon osteotomy for ORIF: analysis of 67 cases of intercondylar fractures of the distal humerus. Injury. 2011; 2:366-70. DOI
  10. Garland DE. A clinical perspective on common forms of acquired heterotopic ossification. Clin Orthop Relat Res. 1991; 263:13-29.
  11. Summerfield SL, Di Giovanni C, Weiss APC. Heterotopic ossification of the elbow. JBJS. 1997. DOI
  12. Viola RW, Hanel DP. Early “simple” release of post-traumatic elbow contracture associated with heterotopic ossification. J Hand Surg Am. 1999; 24:370-80. DOI
  13. Lazarus MD, Guttmann D, Rich CE. Heterotopic ossification resection about the elbow. Neuro Rehabilitation. 1999; 12:145-53. DOI
  14. Baldwin K, Hosalkar HS, Donegan DJ. Surgical resection of heterotopic bone about the elbow: an institutional experience with traumatic and neurologic etiologies. J Hand Surg Am. 2011; 36:798-803. DOI
  15. Frattini M, Soncini G, Corradi M. Mid-term results of complex distal humeral fractures. Musculoskelet Surg. 2011; 95:205-13. DOI
  16. Cobb TK, Morrey BF. Total elbow arthroplasty as primary treatment for distal humeral fractures in elderly patients. J Bone Joint Surg Am. 1997; 79:826-32. DOI
  17. Korner J, Lill H, Müller LP. The LCP-concept in the operative treatment of distal humerus fractures – biological, biomechanical and surgical aspects. Injury. 2003; 34:B20-30. DOI
  18. Dakouré PW, Ndiaye A, Ndoye JM. Posterior surgical approaches to the elbow: a simple method of comparison of the articular exposure. Surg Radiol Anat. 2007; 29:671-4. DOI
  19. Gainor BJ, Moussa F, Schott T. Healing rate of transverse osteotomies of the olecranon used in reconstruction of distal humerus fractures. J South Orthop Assoc. 1995; 4:263-8.
  20. Soon JL, Chan BK, Low CO. Surgical fixation of intra-articular fractures of the distal humerus in adults. Injury. 2004; 35:44-54. DOI
  21. Aslam N, Willett K. Functional outcome following internal fixation of intra-articular fractures of the distal humerus (AO type C). Acta Orthop Belg. 2004; 70:118-22.
  22. Henley MB, Bone LB, Parker B. Operative management of intra-articular fractures of the distal humerus. J Orthop Trauma. 1987; 1:24-35. DOI
  23. Pajarinen J, Björkenheim JM. Operative treatment of type C intercondylar fractures of the distal humerus: results after a mean follow-up of 2 years in a series of 18 patients. J Shoulder Elbow Surg. 2002; 11:48-52. DOI
  24. Fu EC, Ring D. Shoulder and elbow trauma and its complications. Woodhead Publishing: Amsterdam; 2016. DOI
  25. Mitsunaga MM, Bryan RS, Linscheid RL. Condylar nonunions of the elbow. J Trauma. 1982; 22:787-91. DOI
  26. Ali A, Douglas H, Stanley D. Revision surgery for nonunion after early failure of fixation of fractures of the distal humerus. J Bone Joint Surg Br. 2005; 87:1107-10. DOI
  27. Ackerman G, Jupiter JB. Nonunion of fractures of the distal end of the humerus. J Bone Joint Surg Am. 1988; 70:75-83.
  28. Jupiter JB, Goodman LJ. The management of complex distal humerus nonunion in the elderly by elbow capsulectomy, triple plating, and ulnar nerve neurolysis. J Shoulder Elbow Surg. 1992; 1:37-46. DOI
  29. Helfet DL, Kloen P, Anand N. Open reduction and internal fixation of delayed unions and nonunions of fractures of the distal part of the humerus. J Bone Joint Surg Am. 2003; 85:33-40. DOI
  30. Ring D, Gulotta L, Jupiter JB. Unstable nonunions of the distal part of the humerus. J Bone Joint Surg Am. 2003; 85:1040-6. DOI
  31. Figgie MP, Inglis AE, Mow CS. Total elbow arthroplasty for complete ankylosis of the elbow. J Bone Joint Surg Am. 1989; 71:513-20.
  32. Morrey BF, Adams RA. Semiconstrained elbow replacement for distal humeral nonunion. J Bone Joint Surg Br. 1995; 77:67-72.
  33. McKee M, Jupiter J, Toh CL. Reconstruction after malunion and nonunion of intra-articular fractures of the distal humerus. Methods and results in 13 adults. J Bone Joint Surg Br. 1994; 76:614-21.
  34. Kazuki K, Miyamoto T, Ohzono K. Intra-articular corrective osteotomy for the malunited intercondylar humeral fracture: a case report. Osaka City Med. 2002; 48:95-100.
  35. Marti RK, Doornberg J. Intra-articular osteotomy for distal humerus malunion. Case Rep Med. 2009; 2009:631306. DOI
  36. Throckmorton T, Zarkadas P, Sanchez-Sotelo J. Failure patterns after linked semiconstrained total elbow arthroplasty for post-traumatic arthritis. J Bone Joint Surg Am. 2010; 92:1432-41. DOI
  37. Schneeberger AG, Meyer DC, Yian EH. Coonrad-Morrey total elbow replacement for primary and revision surgery: a 2- to 7.5-year follow-up study. J Shoulder Elbow Surg. 2007; 16:S47-5. DOI
  38. Celli A, Morrey BF. Total elbow arthroplasty in patients forty years of age or less. J Bone Joint Surg Am. 2009; 91:1414-8. DOI
  39. Larson AN, Morrey BF. Interposition arthroplasty with an Achilles tendon allograft as a salvage procedure for the elbow. J Bone Joint Surg Am. 2008; 90:2714-23. DOI
  40. Nolla J, Ring D, Lozano-Calderon S. Interposition arthroplasty of the elbow with hinged external fixation for post-traumatic arthritis. J Shoulder Elbow Surg. 2008; 17:459-64. DOI
  41. Lawrence TM, Ahmadi S, Morrey BF. Wound complications after distal humerus fracture fixation: incidence, risk factors, and outcome. J Shoulder Elbow Surg. 2014; 23:258-64. DOI
  42. Shine J, Efanov JI, Paek L. Negative pressure wound therapy as a definitive treatment for upper extremity wound defects: a systematic review. Int Wound J. 2019; 16:960-7. DOI
  43. Obert L, Ferrier M, Jacquot A. Distal humerus fractures in patients over 65: complications. Orthop Traumatol Surg Res. 2013; 99:909-13. DOI
  44. Södergård J, Sandelin J, Böstman O. Post-operative complications of distal humeral fractures. Acta Orthop Scand. 1992; 63:85-9. DOI
  45. Sanchez-Sotelo J, Torchia ME, O’Driscoll SW. Complex distal humeral fractures: Internal fixation with a principle-based parallel-plate technique. J Bone Joint Surg Am. 2007; 89:961-9. DOI
  46. Somerson JS, Morrey ME, Sanchez-Sotelo J. Predictors of reoperation after internal fixation of intra-articular distal humerus fractures. J Shoulder Elbow. 2020; 0:1-8. DOI
  47. Kundel K, Braun W, Wieberneit J. Intra-articular distal humerus fractures. Factors affecting functional outcome. Clin Orthop Relat Res. 1996; 332:200-8.
  48. McKee MD, Kim J, Kebaish K. Functional outcome after open supracondylar fractures of the humerus. J Bone Joint Surg. 2000; 82-B:646-51. DOI
  49. McKee MD, Wilson TL, Winston L. Functional outcome following surgical treatment of intra-articular distal humeral fractures through a posterior approach. J Bone Joint Surg Am. 2000; 82:1701-7. DOI
  50. Erpelding JM, Mailander A, High R. Outcomes following distal humeral fracture fixation with an extensor mechanism-on approach. J Bone Joint Surg Am. 2012; 94:548-53. DOI
  51. Shin SJ, Sohn HS, Do NH. A clinical comparison of two different double plating methods for intra-articular distal humerus fractures. J Shoulder Elbow Surg. 2010; 19:2-9. DOI
  52. Lee SK, Kim KJ, Park KH. Comparison between orthogonal and parallel plating methods for distal humerus fractures: a prospective randomized trial. Eur J Orthop Surg Traumatol. 2014; 24:1123-31. DOI
  53. Henley MB, Bone LB, Parker B. Operative management of intra-articular fractures of the distal humerus. J Orthop Trauma. 1987; 1:24-35. DOI
  54. Tyllianakis M, Panagopoulos A, Papadopoulos AX. Functional evaluation of comminuted intra-articular fractures of the distal humerus (AO type C). Long term results in twenty-six patients. Acta Orthop Belg. 2004; 70:123-30.
  55. Flinkkilä T, Toimela J, Sirniö K. Results of parallel plate fixation of comminuted intra-articular distal humeral fractures. J Shoulder Elbow Surg. 2014; 23:701-7. DOI
  56. Ducrot G, Bonnomet F, Adam P. Treatment of distal humerus fractures with LCP DHP™ locking plates in patients older than 65 years. Orthop Traumatol Surg Res. 2013; 99:145-54. DOI
  57. Frankle MA, Herscovici D, Di Pasquale TG. A comparison of open reduction and internal fixation and primary total elbow arthroplasty in the treatment of intra-articular distal humerus fractures in women older than age 65. J Orthop Trauma. 2003; 17:473-80. DOI
  58. Egol KA, Tsai P, Vazques O. Comparison of functional outcomes of total elbow arthroplasty vs plate fixation for distal humerus fractures in osteoporotic elbows. Am J Orthop (Belle Mead NJ). 2011; 40:67-71.
  59. McKee MD, Veillette CJ, Hall JA. 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; 18:3-12. DOI
  60. Soon JL, Chan BK, Low CO. Surgical fixation of intra-articular fractures of the distal humerus in adults. Injury. 2004; 35:44-54. DOI
  61. Atalar AC, Demirhan M, Salduz A. Functional results of the parallel-plate technique for complex distal humerus fractures. Acta Orthop Traumatol Turc. 2009; 43:21-7. DOI
  62. Schmidt-Horlohé K, Wilde P, Bonk A. One-third tubular-hook-plate osteosynthesis for olecranon osteotomies in distal humerus type-C fractures: a preliminary report of results and complications. Injury. 2012; 43:295-300. DOI
  63. Kural C, Ercin E, Erkilinc M. Bicolumnar 90-90 plating of AO 13C type fractures. Acta Orthop Traumatol Turc. 2017; 51:128-132. DOI
  64. Singh AP, Singh AP, Vaishya R. Fractures of capitellum: a review of 14 cases treated by open reduction and internal fixation with Herbert screws. Int Orthop. 2010; 34:897-901. DOI
  65. Giannicola G, Sacchetti FM, Greco A. Open reduction and internal fixation combined with hinged elbow fixator in capitellum and trochlea fractures. Acta Orthop. 2010; 81:228-33. DOI
  66. Mighell M, Virani NA, Shannon R. Large coronal shear fractures of the capitellum and trochlea treated with headless compression screws. J Shoulder Elbow Surg. 2010; 19:38-45. DOI
  67. Brouwer KM, Jupiter JB, Ring D. Nonunion of operatively treated capitellum and trochlear fractures. J Hand Surg Am. 2011; 36:804-7. DOI
  68. Heck S, Zilleken C, Pennig D. Reconstruction of radial capitellar fractures using fine-threaded implants (FFS). Injury. 2012; 43:164-8. DOI
  69. Bilsel K, Atalar AC, Erdil M. Coronal plane fractures of the distal humerus involving the capitellum and trochlea treated with open reduction internal fixation. Arch Orthop Trauma Surg. 2013; 133:797-804. DOI
  70. Gupta R, Khanchandani P. Intercondylar fractures of the distal humerus in adults: a critical analysis of 55 cases. Injury. 2002; 3:511-5. DOI
  71. Korner J, Lill H, Müller LP. Distal humerus fractures in elderly patients: results after open reduction and internal fixation. Osteoporos Int. 2005; 16:S73-9. DOI
  72. Huang TL, Chiu FY, Chuang TY. The results of open reduction and internal fixation in elderly patients with severe fractures of the distal humerus: a critical analysis of the results. J Trauma. 2005; 58:62-9. DOI
  73. Srinivasan K, Agarwal M, Matthews SJ. Fractures of the distal humerus in the elderly: is internal fixation the treatment of choice?. Clin Orthop Relat Res. 2005; 434:222-30. DOI
  74. Liu JJ, Ruan HJ, Wang JG. Double-column fixation for type C fractures of the distal humerus in the elderly. J Shoulder Elbow Surg. 2009; 18:646-51. DOI
  75. Korner J, Lill H, Müller LP. Distal humerus fractures in elderly patients: results after open reduction and internal fixation. Osteoporos Int. 2005; 16:S73-9. DOI


Giuseppe Giannicola

Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, Sapienza University, Rome, Italy

Sebastien Prigent

Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, Sapienza University, Rome, Italy

Giorgio Iacono Quarantino

Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, Sapienza University, Rome, Italy

Ciro Villani

Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, Sapienza University, Rome, Italy


© Ortopedici Traumatologi Ospedalieri d’Italia , 2020

How to Cite

Giannicola, G., Prigent, S., Quarantino, G.I. and Villani, C. 2020. Sequelae of distal humeral fractures. Lo Scalpello - Journal. 34, 1 (Mar. 2020), 19-29. DOI:
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