Distal humerus nonunion in adults: Management strategies and contemporary outcomes

Distal humerus nonunion (DHN) in adults is an uncommon but highly disabling condition that poses significant reconstructive challenges. The complexity arises from a combination of poor local biology, limited metaphyseal bone stock, and the biomechanical demands of the elbow joint, often resulting in pain, instability, stiffness, and functional loss. We aim to emphasize current evidence on the pathoanatomy, diagnostic approach, and contemporary management strategies for distal humerus nonunion, with a focus on decision-making between osteosynthesis (including revision fixation of previously operated fractures), arthroplasty, and salvage procedures. This review is based on both published evidence (PubMed, Scopus, and Embase) and our clinical experience, with emphasis on surgical principles and outcomes of revision open reduction and internal fixation (ORIF), total elbow arthroplasty (TEA), and adjunctive biological or reconstructive techniques. Most distal humerus nonunions result from a combination of mechanical instability and biological compromise. Patients typically present with pain, pseudo-motion at the nonunion site, stiffness, and frequent ulnar nerve involvement. Computed tomography plays a crucial role in preoperative planning by defining bone stock and articular integrity. In reconstructable cases, revision ORIF with dual-column fixation and autologous bone grafting provides satisfactory union rates and functional improvement. Restoration strategies are based on stable bicolumnar fixation, biological augmentation, and structured contracture release. Total elbow arthroplasty remains a valuable salvage option in elderly, low-demand patients or in cases with non-reconstructable articular destruction. In selected complex or infected cases, external fixation techniques such as Ilizarov constructs offer effective limb salvage. However, outcomes in these challenging cases are inherently inferior to those of acute distal humerus fractures. The realistic goal is to achieve a stable, pain-free, and functionally acceptable elbow rather than a full, normal range of motion. Expectations must therefore be individualized based on patient factors, local pathology, and reconstructability at presentation. Careful preoperative counselling regarding achievable outcomes plays a crucial role in aligning patient expectations with surgical possibilities. Despite high union rates across modern series, postoperative stiffness remains the most common limitation to optimal functional recovery. Distal humerus nonunion requires an individualized, anatomy-driven treatment strategy that balances reconstructability, patient factors, and functional demands. While revision fixation remains the cornerstone in suitable patients, arthroplasty and salvage procedures play a complementary role. A systematic approach combining stable fixation, biological optimization, and soft tissue release can achieve union and meaningful functional improvement in most patients.