Executive Editor: Chris Colton

Authors: Mariusz Bonczar, Daniel Rikli, David Ring

Distal humerus 13-B2.3 Open reduction; plate and screw fixation

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Glossary

1 Introduction top

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Most medial condyle fractures in adults feature complex articular comminution.  Computed tomography—particularly 3D CT - can help define the fracture anatomy and facilitate planning of the surgery.


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The surgeon must be prepared to apply fixation specific to small osteochondral fracture fragments (e.g. headless screws and small threaded K-wires), in addition to standard plate and screw fixation.

Furthermore, autogenous bone grafting from the iliac crest may prove useful for supporting disimpacted articular fragments. 

Extensive access to the articular surface is necessary, so an olecranon osteotomy is preferred.

2 Open reduction top

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Clean the fracture site

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


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Disimpact fracture fragments

Many of the displaced fracture fragments are stable, which may suggest that they are appropriately aligned; however, many are impacted into an incorrect alignment. 

Using carefully controlled force, these fragments must be gently disimpacted and brought into alignment with intact parts of the bone.


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Reduction

Reduce the fracture.

Monitor fracture reduction by realigning the articular and metaphyseal fracture lines.

Small fragments that may need to be discarded can be used as “puzzle pieces” to ensure correct relationships of the major fragments.

3 Plate preparation top

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Planning for plate placement

The plate should wrap around the entire medial epicondyle. The ulnar nerve must be mobilized and transposed.

Complex plate contouring, using a malleable template, is necessary. This is possible with a reconstruction type plate. Alternatively, a precontoured plate may be selected.

It is useful to be able to place a screw through the distal plate hole and across the trochlea below the medial epicondyle.

4 Provisional fixation top

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The osteochondral fragments are realigned and secured provisionally with smooth K-wires.

5 Definitive screw fixation top

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Subchondral fixation

In some cases provisional K-wire stabilisation is not possible.

When there is no intact posterior distal humerus onto which to fix the fragment, or when the fragment is too small to accept a screw, small threaded K-wires, or absorbable pins can be used.

These fragments are stabilized to an adjacent fragment by drilling small threaded K-wires from one fragment to the next in the subchondral bone.


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Buried screws

The articular fragments are usually secured first—either to the intact lateral column or to other large fracture fragments on the medial column. 

Large articular fragments can be secured with headless screws buried beneath the articular surface.

6 Plate application top

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The major medial column fragment is then secured with a plate. 

Start with a distal screw to ensure proper plate placement.

v1.0 2016-10-21