Executive Editor: Chris Colton

Authors: Mariusz Bonczar, Daniel Rikli, David Ring

Distal humerus 13-B1 Open reduction; plate fixation

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Glossary

1 Introduction top

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Fracture assessment

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


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Indication

Only when bone quality is excellent will srew fixation alone provide adequate stability for early active exercises, and when the fracture is simple and non-fragmented.

In practice, screw fixation alone is used primarily in skeletally immature patients, who 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, in order to allow more confident early active motion.


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Plate position

The plate can be applied either directly laterally, or posteriorly in order to protect and buttress a primary lag screw.

In this module, we demonstrate a direct lateral plate.

2 Open reduction top

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Mobilize the fragment

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

Open the fracture site by gently retracting the fragment anteriorly.


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Clean the fracture site

Clear the fracture of any blood clots, loose pieces of bone, or interposed tissue.

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


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Reduction

Realign the fracture.

Monitor fracture reduction by realigning the metaphyseal fracture lines.

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

3 Plate preparation top

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Planning for plate placement

The distal aspect of a direct lateral plate must be contoured to bend anteriorly following the anterior bend of the lateral column. It should also be contoured to fit the lateral surface, although it does not have to fit precisely. A direct lateral plate will sit on the point of the supracondylar ridge. The muscle origins need not be disturbed.


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A direct lateral plate acts in some respects like a buttress plate. Furthermore, all of the screws go through the plate.

The screws must avoid the olecranon fossa and the articular surface.


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Pitfall: Uncontoured plate

A straight plate that is properly applied distally will come off the bone proximally.


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Proximal plate position

A direct lateral plate sits on the apex of the supracondylar ridge.

Provided there is good screw purchase, it is not necessary for the plate to sit on a flat part of the bone.


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Radial nerve

Lateral plates extending fewer than 10 cm from the joint surface are unlikely to place the radial nerve at risk, but care should be taken in smaller patients.


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4 Provisional fixation top

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Insertion of K-wires

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

Provisional wires can be inserted through a plate screw hole, or adjacent to the plate.

5 Plate application top

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Drilling

The order of screw insertion may vary. In general, it is best to insert the most distal screw first.

A 2.5 mm drill is used to drill a pilot hole across the fracture site in the condylar mass.


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Distal screw insertion

The screw length is measured and the screw inserted. If a fully threaded screw is used, a 3.5 mm gliding hole should be drilled in the near fragment. For non-selftapping screws, remember to tap prior to screw insertion.

The screws that cross the fracture site should normally only have thread purchase in the low fragment so as to apply interfragmentary compression. Only when there is marked comminution of the trochlea, when compression may crugh the multi fragmentary zone, should a fully threaded, position screw be used.


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Proximal screw insertion

Next, insert one of the proximal screws to anchor the plate. This screw is a 3.5 mm cortical screw, so a 2.5 mm drill is used.

After initial proximal and distal screw fixation, fracture alignment and implant placement are confirmed, using image intensification.


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Final screw insertion

The remaining screws are placed.

v1.0 2007-06-21