Executive Editor: Chris Colton

Authors: Mariusz Bonczar, Daniel Rikli, David Ring

Distal humerus 13-A2.3 Open reduction; plate fixation

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Glossary

1 Principles top

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The typical patient with this fracture is an elderly woman with osteoporotic bone.
This example shows a very distal transcondylar extraarticular distal humerus fracture (13-A2.3).
Articular involvement may be present, but not obvious from initial x-rays. For this reason, a posterior approach is preferred.
Since the distal fragment is very short and the bone quality is poor, fixation with conventional implants is difficult.
The Distal Humeral Plate offers two major advantages:

  • Three 2.4 mm screws can be inserted even in very small distal fragments of each column
  • Angular stability enhances the purchase of the implant in the bone.

2 Reduction and preliminary fixation top

Reduction

The distal fragment is manually reduced to the radial and ulnar columns.


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Preliminary fixation

Preliminarily stabilize the reduction with two K-wires introduced from the distal fragment into each column.
It may be difficult to align the fracture correctly in flexion/extension.


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Pearl: Joystick

A K-wire introduced into the trochlea can be used as a joystick to rotate the distal fragment and restore the angle of forward inclination of the lateral condylar mass in relation to the humeral shaft axis.

3 Plate fixation top

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Plate selection and contouring

Precontoured anatomic plates have been produced. If these are not available, a one-third tubular plate may be used on the crest of the medial supracondylar ridge, and a reconstruction plate on the posterior aspect of the lateral column. If a stronger plate is required, a small fragment dynamic condylar plate may be used, but this is more difficult to contour.


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Determining implant length

Plate length should be determined so that the plates end at different levels on the humeral shaft to prevent a stress riser.

Screw length should be checked under image intensification, to avoid penetration into the joint.


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Screw fixation

At least three screws proximal to the fracture and as many distal screws as possible are preferred. Fixation using locking screws may give more stable fixation, particularly in osteoporotic bone, sufficient to allow for early functional rehabilitation.

 

Note
In fractures with very short distal segments, additional stability can be gained by inserting long, distal-to-proximal, 3.5 mm column screws.

v1.0 2016-10-21