J Shoulder Elbow Surg (2011) 20, S97-S106
www.elsevier.com/locate/ymse
Distal humeral fractures: fixation versus arthroplasty
Thomas L. Mehlhoff, MD*, James B. Bennett, MD
Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, TX, USA
The management of the distal humeral fracture in the
adult elbow continues to be problematic. The bony anatomy
of the distal humerus challenges fixation of the fracture,
especially when compromised by comminution and osteo-
porotic bone. There is little controversy that a well-
performed open reduction and internal fixation will yield
a superior outcome to the historical ‘‘bag of bones’’ treat-
ment.15,17,21,27,41,43,45 New techniques for exposure and
precontoured plates with locking technology have enhanced
the potential for fixation of these fractures. Still, internal
fixation using plates is not without complications and
sometimes unsatisfying results.
Osteoporosis in the elderly often leads to severe commi-
nution, which may render open reductioneinternal fixation
(ORIF) impossible. Total elbow arthroplasty (TEA) in the
elderly has been shown to be a viable option,3,5,9,14,19,23,26,29,39
but it has its own complications and mandates permanent
lifting restrictions. Distal humeral hemiarthroplasty elimi-
nates polyethylene wear, but not loosening, and its medium- to
long-term results, need for restrictions, and potential compli-
cations are yet unknown.
This review will present the challenges for management
of the highly comminuted type C distal humeral fracture.
The treatment principles to better achieve ORIF in these
complex cases will be discussed, followed by suggestions
regarding when to consider arthroplasty. Finally, we present
an algorithm for the treatment of distal humeral fractures to
assist decision making for the orthopaedic surgeon.
Investigational Review Board approval was not necessary for this review
article.
*Reprint requests: Thomas L. Mehlhoff, MD, Fondren Orthopedic
Group, Texas Orthopedic Hospital, 7401 S Main St, Houston, TX 77030-
4509.
E-mail address: kw41@fondren.com (T.L. Mehlhoff).
1058-2746/$ - see front matter Ó 2011 Journal of Shoulder and Elbow Surgery Board of Trustees.
doi:10.1016/j.jse.2010.11.012
Fracture classification
Elbow fractures account for 7% of all adult fractures, and
fractures of the distal humerus account for 30% of elbow
fractures.2 The intercondylar fracture pattern of the distal
humerus is most common, though with wide variations
through the metaphysis and articular surface and with
varying degrees of comminution. Fractures of the single
condyle account for only 5% of distal humeral fractures,
and isolated fractures of the capitellum account for only 1%
of fractures.
The classification of the distal humeral fracture was tradi-
tionally descriptive, based on the columns and the location of
the fracture. These fractures were broadly grouped as supra-
condylar (above the olecranon fossa), transcondylar (through
the olecranon fossa), or intercondylar. Riseborough and
Radin41 classified intercondylar fractures based on displace-
ment, rotation, and then comminution. Jupiter and Mehne18
classified fractures based on intraoperative findings, and they
described high T, low T, Y, H, medial lambda, and lateral
lambda patterns. The more universal AO-OTA system has
divided these fractures into type A (extra-articular), type B
(partial articular, involving 1 column), and type C (complete
articular, involving 2 columns).24,28,32 Types A, B, and C are
then further subdivided into subtypes based on increasing
complexity of the fracture pattern (Fig. 1).
Epidemiology
The incidence of distal humeral fractures in adults is 5.7 per
100,000 per year.42 The bimodal distribution of these frac-
tures has been well documented. Fractures in young patients
peak during the second decade of life, and they often involve
high-energy trauma, such as a motor vehicle accident,
S98
Figure 1 OA/OTA classification system for fractures of distal humerus.
gunshot wound, or fall from a height. The second group of
distal humeral fractures peaks in elderly women aged greater
than 60 years and typically occur from a low-energy fall.
The needs and expectations of these 2 groups are quite
dissimilar and must be considered in the treatment plan.
The young patient will obviously need a durable func-
tioning elbow and should have reasonable bone mineral
density despite displacement or comminution. Fragility
fractures of the distal humerus in the elderly patient are
expectedly quite osteoporotic and often highly commi-
nuted. This may limit the surgeon’s ability to achieve
fixation. Although motion of the elbow is important, elderly
patients will still have weight-bearing demands on their
arms, such as when using a walker, stabilizing transfers, or
rising up out of a chair, and the potential high mechanical
demands on an elbow implant with these activities should
not be underestimated when deciding treatment.
T.L. Mehlhoff, J.B. Bennett
As the population ages, the incidence of these fragility
fractures will certainly increase.33,34 When the trends of
osteoporotic fractures were studied in Finnish women from
1970 to 1995, there was a 2-fold increase in distal humeral
fractures for women aged greater than 60 years and a 9-fold
increase in distal humeral fractures for women aged greater
than 80 years.33 Without a doubt, the frequency of patients
with comminuted type C distal humeral fractures present-
ing for orthopaedic care will increase, and these are the
very fractures that will provide the greatest challenges.
Evaluation
The usual radiographic examination of the elbow in the
emergency department will include anteroposterior and
lateral radiographs but rarely will these views be orthogonal
Distal humeral fractures: fixation versus arthroplasty
because of the elbow deformity. The fracture fragments are
rotated and overlap, especially with shortening and angu-
lation through the metaphysis, making evaluation of the
fracture difficult.
Computed tomography (CT) scan of the elbow has been
shown to assist preoperative planning. A 2-dimensional CT
scan can be helpful but must be formatted in the plane of
the fracture fragments for the best information. A 3-
dimensional (3D) reconstruction of the CT scan can
compensate for oblique scans and will allow for subtraction
of the radius and ulna to better visualize the fracture of the
humerus. Whereas the 3D CT scan improved intraobserver
and interobserver reliability for classification of the frac-
tures in a blinded study,12 this did not necessarily translate
to better interobserver agreement for treatment decisions.
Perhaps the most useful radiographic test is an intra-
operative traction view of the elbow with the patient under
anesthesia in the operating room before the skin prepara-
tion. Fragments that are rotated and impacted may align,
giving optimism for a potential ORIF, taking the ‘‘hopeless
ORIF’’ to the ‘‘possible ORIF’’ fracture.
Treatment
Surgical intervention is considered the standard of care for
the displaced distal humeral fracture.13,15,17,38,41,45,48
Nonsurgical management is reserved for elderly patients
with unstable medical problems, dementia, or stroke
paralysis. In this setting, the ‘‘bag of bones’’ treatment may
be indicated. Functional bracing of an extra-articular
supracondylar fracture or a distal one-third humeral shaft
fracture may be considered if the condylar shaft angle can
be maintained within 20 of normal.37
The most challenging group of distal humeral fractures
will be the highly comminuted low transcondylar type C
fracture in the elderly patient with osteoporosis. The
treatment of these fractures is difficult because of (1) the
complex anatomy, (2) the articular and metaphyseal
comminution, and (3) the osteoporotic bone.
The surgeon must be familiar with the variety of surgical
exposures available, knowing the extent and limitations for
each approach. He or she must be adept at a variety of
internal fixation techniques for articular fragments and
metaphyseal fractures and should be knowledgeable and
experienced in implant arthroplasty techniques.
Open treatment of the distal humeral fracture with ORIF
must accomplish (1) anatomic reduction of the articular
surface, (2) stable fixation of the articular fragments to the
shaft (even if the shaft is shortened), and (3) early range of
motion to minimize stiffness. Failure to achieve any of
these tenets may lead to an unsatisfactory result. Inadequate
reduction will lead to arthritis. Inadequate fixation will lead
to nonunion. Failure to allow early range of motion (<3
weeks)21 will encourage stiffness and limited motion.
Reported complication rates for ORIF of distal humeral
S99
fractures range from 11% to 48%,15,17,27,43 including
contracture, malunion, nonunion, failure of fixation, ulnar
neuropathy, symptomatic hardware, heterotopic ossifica-
tion, and arthritis.
Known adverse factors that will affect the outcome for
distal humeral fractures include multiple trauma, open
fracture, severely comminuted joint surface, and bone
loss.22 Salvage elbow procedures in the most severe situa-
tions such as severe bone deficiency, severe soft-tissue loss,
burns, or infection may require external fixation, resection
arthroplasty, or elbow arthrodesis.20
Several excellent review articles on the management of
distal humeral fractures have been written recently.13,38,48
These articles provide excellent reviews of the current
treatment strategies for distal humeral fractures and
summarize the available literature.
Surgical approaches: Pros and cons
Surgical approaches for the management of distal humeral
fractures include olecranon osteotomy, triceps-reflecting
approach,6 triceps-splitting approach, triceps-reflecting
anconeus pedicle approach (TRAP),31 anconeus flap
transolecranon approach, and para-tricipital (‘‘triceps on’’)
approaches. More complex fractures with more comminu-
tion will require more extensile exposure. In an anatomic
study, Wilkinson and Stanley47 attempted to identify the
amount of articular surface able to be visualized with
a variety of exposures. They found that 57% of the articular
surface could be visualized with olecranon osteotomy,
whereas 46% of the articular surface was visualized with
a triceps-reflecting approach and only 35% of the articular
surface was visualized with a triceps-splitting approach.
Olecranon osteotomy seems to provide the best exposure
for internal fixation of distal humeral fractures, but it does
have drawbacks, including the potential for nonunion,
possible need to remove symptomatic hardware,10,40 and
increased technical difficulty if intraoperative conversion to
TEA is required.
To minimize complications with the olecranon osteot-
omy, authors have advised an apex distal chevron osteot-
omy of the proximal olecranon through the bare area of the
olecranon surface.10,13,38,48 The initial cut is made with an
oscillating saw, but the osteotomy is completed with an
osteotome. This will minimize shortening of the olecranon
caused by bone loss and will allow better approximation of
the articular surface during repair. Repair of the olecranon
osteotomy can then be performed with a cancellous lag
screw, tension-band wiring, or compression plating with
satisfactory union rates.15,43 Pre-drilling the olecranon for
an intramedullary screw or pre-drilling the holes for the
plate fixation before the osteotomy will make the repair
easier.
The triceps-splitting approach does afford good expo-
sure and is familiar to most surgeons who routinely perform
S100
TEA. The triceps-splitting approach does not compromise
the bailout for salvage TEA, and it does not have risks for
nonunion of the proximal olecranon or symptomatic hard-
ware. However, even with repair of the triceps, early range
of motion should be protected, and some long-term triceps
weakness (25%) has been documented after surgery.27 The
exposure of the articular surface with the triceps-splitting
approach can be increased with judicious resection of the
olecranon tip. Overall, the triceps-splitting approach is very
serviceable for exposure of most distal humeral fractures.
The para-tricipital approaches or ‘‘triceps on’’ exposures
allow for the experienced surgeon to work through
windows medial and lateral to the mobilized triceps. The
‘‘triceps on’’ exposure does not weaken the triceps and will
allow early range of motion. This exposure can be con-
verted to an olecranon osteotomy if more extensive anterior
comminution is found at surgery. The para-tricipital
approaches are especially useful for the single-column
fracture of the distal humerus. TEA can be accomplished
with the ‘‘triceps on’’ exposure, although preparation of the
ulnar canal and insertion of the ulnar component are more
challenging than with the triceps-splitting approach.
While considering the pros and cons of surgical expo-
sures for the distal humerus, surgeons are obliged to iden-
tify and protect the ulnar nerve at the elbow. The ulnar
nerve is at risk during fracture exposure and hardware
placement. The ulnar nerve should always be identified
early in the procedure and then either left in situ or trans-
posed anteriorly according to the surgeon’s preference or
clinical indications. Gofton et al15 showed that routine
anterior transposition of the ulnar nerve in their series
resulted in a 0% incidence of ulnar neuropathy. McKee
et al25 reported a 7% incidence of ulnar neuropathy in their
series, which was satisfactorily addressed with neurolysis
and anterior transposition of the ulnar nerve at a later time.
Open reductioneinternal fixation
Decisions regarding ORIF of the distal humeral fracture
will be dictated by the fracture pattern and comminution.
ORIF should be considered in all patients who are candi-
dates for surgery and in whom stable fixation of the bone
can be obtained. Despite displacement, small articular
fragments of the distal humerus are often salvageable and
have a surprisingly low incidence of avascular necrosis
after stable fixation. Bicolumnar stabilization of the distal
humerus should be achieved, either with 90 -90 orthog-
onal plate configuration (Fig. 2) or the parallel plate tech-
nique (Fig. 3). The addition of a third plate to the ORIF
may even be considered for comminution of the posterior
and lateral column or for fixation of fragments in the
coronal plane for highly unstable fractures.15 If adequate
stability cannot be obtained with fixation, application of an
external fixator to the elbow can unload and protect ques-
tionable fixation, and upgrade the fixation to allow for
T.L. Mehlhoff, J.B. Bennett
postoperative range of motion.11 Elderly patients with
fractures of the distal humerus have been treated with a ring
fixator with satisfactory results.7 External fixation may be
mandated by a grade 3 open fracture of the distal humerus
(Fig. 4).
Considerable controversy has existed regarding the best
plate construct, whether orthogonal plates (90 -90 ) or
parallel plates (medial or lateral).4,44,46 Stoffel et al46 per-
formed an excellent biomechanical study comparing the
stability of precontoured perpendicular and parallel plating
systems with locking screws. Elderly female cadaveric
humeral specimens were confirmed to have osteoporosis
and then divided into perpendicular plating and parallel
plating groups. A 10-mm comminuted zone was simulated
above the olecranon fossa before plating. Biomechanical
testing showed that the parallel plating construct proved
stiffer in compression and external rotation and showed
significantly better resistance to plastic deformation with
cyclic axial loading. Park et al35 recently studied the 3D
osseous micro-architecture of the distal humerus, finding
the weakest trabecular bone in the posterolateral distal
condyle. They concluded that parallel plate fixation along
the ridges may have an advantage over perpendicular
plating because of better cortical and trabecular bone than
for the posterolateral surface of the humerus. These recent
biomechanical and micro-architecture studies suggest
parallel plating to be superior to perpendicular plating.
Sanchez-Sotelo et al43 showed that stable fixation and
a high rate of union can be achieved with parallel plating in
challenging type C3 distal humeral fractures using a prin-
ciple-based technique that maximizes fixation of screws
into the distal fragments through the parallel plates.
O’Driscoll30 enumerated the ‘‘rules’’ for bicolumnar fixa-
tion of the distal humerus when using parallel plates. With
these principles, every screw has a purpose. This principled
application of internal fixation maximizes the ‘‘arch’’
configuration of the distal humerus, often likened to a spool
held by 2 fingers. According to his principles, (1) every
screw in a distal fragment should pass through a plate, (2)
every 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 into the distal fragment, (4) each screw
should be as long as possible, (5) each screw should engage
as many articular fragments as possible, (6) the screws in
the distal fragment should lock together by interdigitation,
creating a fixed angle structure, (7) the plates should be
applied such that compression is achieved at the supra-
condylar level for both columns, and (8) the plates must be
strong enough and stiff enough to resist breaking or
bending before union occurs at the supracondylar level.
Applying these principles, Sanchez-Sotelo et al reported no
hardware failures or fracture displacement in a series of
34 elbows. Union was achieved in all but 1 elbow. Five
elbows required further surgery for stiffness.
The functional outcomes for ORIF of type C distal
humeral fractures have been reported, with the mean
Distal humeral fractures: fixation versus arthroplasty
Figure 2 Postoperative anteroposterior (A) and lateral (B) radiographs of ORIF distal humeral fracture treated with perpendicular plates
and triceps-splitting approach (15-year follow-up).
Figure 3 Postoperative anteroposterior (A) and lateral (B) radiographs of ORIF distal humerus treated with parallel plates and olecranon
osteotomy.
flexion-extension arc of the elbow measuring from 89 to
122 of total motion.15,17,21,27,43 The most common
outcome is limited extension, but function is usually
reported to be good, with only a mild impairment on the
Disabilities of the Arm, Shoulder and Hand (DASH) and
Mayo Elbow Performance Score (MEPS) questionnaires.
McKee et al27 reported on the functional outcome of
displaced intra-articular distal humeral fractures treated
with ORIF using a posterior approach with medial and
lateral plates. Despite some limited range of motion, the
flexion-extension arc was 108 , and patients reported that
they could still maintain their general health and activity.
Six of twenty-five had reoperation, although three of these
surgeries were to remove hardware from the olecranon
osteotomy. Huang et al17 performed a critical analysis of
19 patients undergoing ORIF aged over 65 years, with
a mean age of 72 years. The flexion-extension arc for the
S101
group was 111 , with a range of motion from 17 to 128 of
flexion. Seventy-nine percent of patients reported no
significant pain at follow-up.
In the event of a nonunion of the distal humerus in
a younger patient after ORIF, repeat ORIF, bone grafting,
and aggressive contracture release have been shown to be
successful.16,40 Contracture in a healed distal humeral
fracture can be addressed with joint release. Late ulnar
nerve symptoms can be addressed with neurolysis and
anterior transposition of the ulnar nerve.25
Arthroplasty
TEA has become a predictable procedure for the manage-
ment of arthritis, with acceptable complication rates and
survivorship. Just as hemiarthroplasty is used to treat
S102 T.L. Mehlhoff, J.B. Bennett

Figure 4 Preoperative anteroposterior (A) and postoperative anteroposterior (B) and lateral (C) radiographs of comminuted grade 3 open
distal humeral fracture treated with Ilizarov external fixation.

Figure 5 Postoperative anteroposterior (A) and lateral (B) radiographs of comminuted type C distal humeral fracture treated with TEA
in 90-year-old woman.

displaced femoral neck fractures of the hip, it was only
natural that TEA might be considered for unreconstructable
intra-articular fractures of the distal humerus (Fig. 5).
In 1997 Cobb and Morrey9 reported on 21 TEAs per-
formed for fracture of the distal humerus at a mean age of
72 years (range, 48 to 92 years). This represented 21 of 129
distal humeral fractures treated over a 10-year period.
Eleven patients were aged greater than 65 years, and ten
patients had rheumatoid arthritis. The outcomes for the
procedures were reported as excellent in 15 and good in 5.
One patient was lost to follow-up because of death. The
mean range of motion was 25 to 130 of flexion, with
a mean arc of motion of 115 . One revision of an ulnar
component was necessary for fracture after a fall. This
article stirred the controversy for fixation versus arthro-
plasty for the type C distal humeral fracture in the elderly
patient. Cobb and Morrey were very clear to state that TEA
was not an alternative to osteosynthesis in younger patients
and should only be performed in the absence of any suitable
alternative treatment.
The subset of rheumatoid arthritis patients reported by
Cobb and Morrey9 underlies another important indication
for TEA. The surgical outcomes for TEA in this inflam-
matory arthritis group were excellent. It appears that TEA
Distal humeral fractures: fixation versus arthroplasty
is the treatment of choice in patients with pre-existing
inflammatory arthritis (particularly rheumatoid arthritis)
who might sustain a distal humeral fracture.
Kamineni and Morrey19 later reported on 49 total elbow
replacements for distal humeral fractures, including 5 type
A, 5 type B, and 33 type C fractures. Fourteen patients died
before the end of the review. The mean range of motion was
24 to 131 of flexion. A complication rate of 29% was
reported, including the need for 5 revisions at a later date.
Again, these authors cautioned that TEA should be
restricted to the older, lower-demand patient.
Although TEA can be performed successfully for
a severely comminuted type C distal humeral fracture in the
properly selected patient, the arthroplasty implant mandates
a permanent lifetime 5-lb lifting restriction. The arthro-
plasty implant also carries long-term risks for component
loosening, periprosthetic fracture, and limited survivorship.
Cil et al8 reported a series of 91 patients treated with linked
elbow replacement for salvage of distal humerus
nonunions. The prosthesis survival rate was 96% at 2 years,
82% at 5 years, and 65% at 10 and 15 years. The highest
incidence of implant failure occurred for patients aged
under 65 years, with 2 or more preceding surgical proce-
dures and a history of infection. Prasad and Dent39 reported
on TEA as a primary surgery for fracture, as well as after
failed internal fixation or nonoperative treatment for type C
distal humeral fractures. Fifteen patients were treated
primarily with TEA and had a 93% survivorship at follow-
up. Another 17 patients underwent late TEA for salvage of
failed internal fixation or failed nonoperative treatment and
had a 76% survivorship at follow-up. Although TEA may
save the day in the operating room, the surgeon must be
prepared to carry the responsibility for long-term compli-
cations, including component loosening, periprosthetic
fracture, late infection, or polyethylene wear.
Perhaps the strongest evidence for justification of TEA
for a select group of type C distal humeral fractures can be
found in the excellent level I multicenter, prospective,
randomized controlled trial of ORIF versus TEA for dis-
placed intra-articular distal humeral fractures in elderly
patients reported by McKee et al26 in 2009. Forty-two
patients were enrolled in the study. Two died of unrelated
causes before follow-up could be completed. Twenty
patients were randomized to ORIF, and twenty were
randomized to TEA. The number of complications was
similar for the ORIF and TEA groups. However, 25% of
ORIF patients had to be converted to TEA by experienced
surgeons because of intraoperative findings, making the
strongest statement yet for the existence of a select group
that cannot be fixed and will require TEA.
Hemiarthroplasty
Finally, a promising alternative to the highly comminuted
low transcondylar fracture in the osteoporotic elderly
S103
patient may be distal humeral hemiarthroplasty.1,29,36 Two
systems that currently allow distal humeral hemi-
arthroplasty are the Sorbie-Questor Total Elbow (Wright
Medical Technology, Arlington, TN) and the Lattitude
Total Elbow (Tornier, Edina, MN) (Fig. 6). This hemi-
arthroplasty may be particularly indicated for a low trans-
condylar fracture with intact columns or a shear fracture of
the distal humerus that is not reconstructable in the elderly
patient.36 The implant has the hypothetical advantage of
more durability and a lower rate of loosening, but it could
yield more arthrosis because of cartilage wear, and it
definitely has a higher risk for instability. The literature
does not support this approach for use in younger
patients.29 To perform distal humeral hemiarthroplasty, one
or both columns must be reconstructed, and the surgeon
must be able to repair the ligaments. Long-term data
regarding distal humeral hemiarthroplasty as an option are
not yet available. Although an early report may be
encouraging,1 the use of this implant has not been approved
by the Food and Drug Administration and is still ‘‘off
label.’’
Algorithm
A treatment algorithm is proposed to guide decision
making for the distal humeral fracture in the adult (Fig. 7).
The bimodal groups are separated by age and expected
bone quality.
Young patients
Every attempt should be made to achieve ORIF for the distal
humeral fracture in the young patient, and hence this is the
‘‘must fix’’ group. TEA is not an option for this group. Good
bone stock is expected, despite displacement, rotation, or
comminution. Extra-articular high T and Y fractures are
more common and should be treated with bicolumnar fixa-
tion as discussed. Intra-articular fragments are well
addressed with headless screw fixation, achieving high
healing rates with a low incidence of avascular necrosis. If
necessary, third-plate fixation for posterior and lateral
comminution should be considered. In extreme cases,
application of an external fixator may be required for
management of an open grade 3 fracture of the distal
humerus or a severely comminuted fracture after a gunshot
wound.
Any hardware failure or nonunion in the young patient
group after fixation should be addressed with a revision ORIF,
bone grafting, and aggressive capsular releases.40 Contracture
alone may be addressed satisfactorily with late joint release. In
the event of post-traumatic arthritis, fascial interposition
arthroplasty with a hinged external fixator may be the only
possible option for a young patient, because implant arthro-
plasty will not be durable and will fail over time.
S104 T.L. Mehlhoff, J.B. Bennett

Figure 6 Postoperative anteroposterior (A) and lateral (B) radiographs of comminuted distal humeral fracture treated with distal humeral
replacement using ‘‘triceps on’’ approach in elderly patient.

Figure 7 Algorithm for management of displaced distal humeral fractures regarding fixation (ORIF) versus arthroplasty (TEA).

Elderly patients
Fractures of the distal humerus in the elderly patient group
(>65 years) present the greatest challenges. The consider-
ation is not age22,45 but rather the degree of comminution,
osteoporotic bone, poor quality of soft tissue, intolerance for
joint immobilization, and demands for weight bearing with
the arm. These considerations lead to 3 groups for the elderly:
the ‘‘can fix,’’ ‘‘cannot fix,’’ and ‘‘should not fix’’ groups.
Good outcomes for ORIF have been reported in the
literature for distal humeral fractures in the elderly patient
when well performed.15-17,21,27,41,43,45 Bone quality is often
more adequate than expected, and as experience with these
fractures increases, this is the ‘‘can fix’’ group. Bicolumnar
fixation with precontoured plates, locking screw tech-
nology, and headless screw fixation of small articular
fragments has expanded the indications for ORIF in oste-
oporotic bone and should always be the first preference for
the adult elderly patient. The durability and long-term
function of a healed distal humeral fracture, even if with
some limited motion, cannot be matched by any elbow
arthroplasty and is less fraught with impending complica-
tion or activity restrictions.
Hardware failure or nonunion in the elderly patient
after ORIF can still be later addressed with TEA, if needed.
The outcomes for salvage TEA after nonunion or failed
Distal humeral fractures: fixation versus arthroplasty
internal fixation can equal those for primary TEA after
fracture.8,39
Even for the experienced surgeon, however, some frac-
tures of the distal humerus in the older osteoporotic patient
just ‘‘cannot be fixed.’’26 The bone will not hold screws, even
with cement. There are too many articular fragments for the
joint surface to be assembled. In this select group, TEA has
been shown to be a viable option. Previous authors have
adequately warned us that this procedure should only be
performed in the absence of any other suitable alternative
treatment.9,19,26 The patient must be able to live with a 5-lb
lifting restriction. The surgeon must be able to live with the
knowledge that disaster is only one fall away for the patient,
and must be prepared to perform a future revision arthro-
plasty for loosening or a periprosthetic fracture. Distal
humeral hemiarthroplasty may later prove to be another
alternative but as of yet has an unproven record.
Finally, patients with pre-existing inflammatory arthrop-
athy, such as rheumatoid arthritis, ‘‘should not be fixed’’ and
should be considered for primary TEA if they sustain a distal
humeral fracture.9 Even the best-performed ORIF will not
address the arthritis of the joint. TEA for this fracture group
has shown excellent results in the literature, probably
because of lower patient demand postoperatively.
Final thoughts on ORIF versus TEA
Treatment decisions for type C distal humeral fractures will
be affected by the surgeon’s training, surgeon’s bias, and
patient’s demand.
Most patients will be best served with a well-performed
ORIF. Distal humeral fractures must be fixed in the young
population, and ORIF should be the first choice in elderly
patients as well.
With the advent of precontoured periarticular locked
plates and improved fixation technology, coupled with
improved fixation principles, ORIF of osteoporotic and
comminuted fractures has become more achievable even in
‘‘hopeless’’ cases.
Patients with a pre-existing inflammatory arthropathy of
the elbow, such as rheumatoid arthritis, should be treated
with TEA after distal humeral fracture.
The most challenging group of distal humeral fractures
will be the highly comminuted low transcondylar type C
distal humeral fracture in the elderly patient with severe
osteoporosis. In this group, TEA or an off-label distal
humerus hemiarthroplasty may be the only viable option.
Disclosure
The authors, their immediate families, and any research
foundations with which they are affiliated have not
received any financial payments or other benefits from any
commercial entity related to the subject of this article.
S105
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