Executive Editor: Chris Colton

Authors: Mariusz Bonczar, Daniel Rikli, David Ring

Distal humerus 13-C1 Open reduction; perpendicular (biplanar) plating

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Glossary

1 Principles top

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Triangle of stability-concept

The mechanical properties of the distal humerus are based on a triangle of stability, comprising the medial and lateral columns, and the articular surface.
In C-type fractures, all 3 columns have to be restored.

2 Opening the joint top

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Cleaning of the fracture site

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

3 Reconstruction of the articular surface top

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Condylar reassembly

Reduce the articular fragments. In good quality bone, use pointed reduction forceps.


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In poor quality bone, use temporary fixation with a K-wire.


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Definitive fixation

Use a lag screw (a partially threaded screw, or a fully threaded screw with overdrilling the near fragment) to obtain interfragmentary compression.
In osteoporotic bone, use a position screw.
Try to use two screws to avoid rotational instability.


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In very distal fractures, generally only one screw can be inserted.
An additional K-wire can be used to obtain rotational stability.

4 Condylar reattachment top

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Temporary fixation

Reduce the reconstituted articular (condylar) block to the metaphysis and use K-wires for preliminary fixation.


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Plate preparation

The plates must be carefully contoured using an appropriate malleable template.

Place the lateral column plate dorsally and the medial column plate medially. In this position they form an angle of approximately 90 degrees to each other.


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Definitive fixation

First place a 3.5 mm reconstruction plate posterolaterally. It may curve around the capitellum which is non-articular posteriorly.
In a distal fracture (C1.3), the reconstruction plate can be bent all the way to the edge of the articular surface. It will not interfere with the radial head during extension of the joint. The more bone is covered by the plate, the more the stability that can be achieved.


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Placement of the lateral plate
Place a K-wire through the distal hole. Now insert the proximal screw as a load screw. As the plate is pulled proximally, stable contact with the bone is obtained.


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Screw insertion

Fix the plate to the bone by inserting the remaining screws.


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Medial plate

Place another plate medially on the crest of the medial supracondylar ridge, at a right angle to the plane of the lateral plate to increase stability.

It is recommended to insert the distal screw into the trochlea below the medial epicondyle.

5 Osteosynthesis of the olecranon osteotomy top

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Drill hole for wire

Using a 2.5 mm drill, make a coronal hole in the proximal ulna from ulnar to radial side, to pass the figure-of-eight wire.


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Insert wire

Prepare a 0.8 mm  wire by making a loop approximately one third along its length. Insert the shorter segment of the wire through this drill hole.


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Reduction of the olecranon

Reduce the olecranon osteotomy with pointed reduction forceps.


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K-wire location

Use the figure-of-eight tension band wiring technique to obtain stable fixation. Two K-wires are drilled parallel across the osteotomy.


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The K-wires can be directed down the shaft of the ulna, or alternatively aimed anterior so that they engage the anterior ulnar cortex, just distal to the coronoid process: this may help to limit the potential for wire migration.


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Obtain correct K-wire tension

The wire loop has to go underneath the triceps tendon.

Double twist the wire loop to obtain equal tension on both sides. The cut wire loops are then impacted firmly onto the bony cortex of the ulna.

Cut the wires to the appropriate length and bend them. Impact the bend K-wire tip into the olecranon, being sure to bury them beneath the triceps tendon.


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Completed osteosynthesis of olecranon

The illustration shows the completed osteosynthesis of the olecranon.

6 Completed osteosynthesis top

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The illustration shows the completed osteosynthesis.

v1.0 2007-06-21