Executive Editor: Chris Colton

Authors: Mariusz Bonczar, Daniel Rikli, David Ring

Distal humerus 13-B1 Open reduction; lag screw and protection plate

back to skeleton

Glossary

1 Introduction top

enlarge

Fracture assessment

Take care when approaching an apparent lateral condylar fracture as these are unusual. Preoperative imaging including computed tomography can be used to identify associated articular fractures.


enlarge

Indication

Screw fixation alone will only provide adequate stability for immediate active exercises when the bone quality is excellent, and the fracture simple and non-fragmented.

In practice, screw fixation alone is used primarily in skeletally immature patients that can be immobilized for 3-4 weeks in a cast without getting too stiff.

Most lateral condylar fractures in adults are fixed with a plate and screws to allow more confident immediate active motion.


enlarge

Plate position

The plate can be applied either directly lateral or posterior to neutralize a lag screw.

In this module, we demonstrate a posterior plate neutralizing a lag screw.

2 Open reduction top

enlarge

Mobilize the fragment

Elevate the triceps and anconeus off of the posterior aspect of the lateral column.

Open the fracture site by mobilizing the fragment.


enlarge

Clean the fracture site

Clean out the fracture by removing blood clots, loose pieces of bone, and interposed tissue.

Inspect the joint to ensure that no intraarticular fracture component was missed when examining the imaging.


enlarge

Reduction

Realign the fracture.

Monitor fracture reduction by realigning the metaphyseal fracture lines.

Depending on the extent of exposure, you can check the anterior and posterior fracture lines, including the articular surface.

3 Plate preparation top

enlarge

Planning for plate placement

The posterior aspect of the lateral column is nonarticular. The plate is contoured to the back of the posterior aspect of the lateral column, including the lateral condyle.

A posterior plate is best used to protect one or two screws, inserted as described below.

The screws must avoid the olecranon fossa and the articular surface. In particular the distal screws should be unicortical so that they do not penetrate the articular cartilage of the capitellum anteriorly.


enlarge

Radial nerve

The radial nerve is safer when a posterior plate is used, but should be identified if a very long plate is indicated, as in more complex fracture combinations.


enlarge

4 Provisional fixation top

enlarge

Placement of K-wires

The fracture is preliminarily stabilized with smooth K-wires, at least 1.5 mm in diameter. The wires should be placed carefully so that they do not hinder plate placement, either.

Through a plate screw hole or adjacent to the plate.


enlarge

Screw insertion

One or two lag screws are inserted across the fracture plane, as described for noncannulated screw fixation.

5 Plate application top

enlarge

Distal plate screw insertion

The order of plate screw insertion may vary. In general, it is best to insert the most distal screw first, in order to ensure that the plate is not placed too distally.

The distal screws must be unicortical to avoid violating the anterior articular surface of the capitellum, or the coronoid fossa.


enlarge

Remaining screws

Insert the screws first distally and then proximally.

v1.0 2016-10-21