Executive Editor: Chris Colton

Authors: Mariusz Bonczar, Daniel Rikli, David Ring

Distal humerus 13-C3 Open reduction; parallel (uniplanar) plating

back to skeleton

Glossary

1 Principles top

enlarge

Triangle of stability

Stability of the distal humerus is based on 3 columns: Medial, lateral, and the articular surface.
In C-type fractures, all 3 columns have to be restored.

2 Identification of the bony fragments top

enlarge

Recognize fragments

Take your time to identify all bony fragments, and compare them to the x-rays.


enlarge

Mobilize the fragment

Some displaced fragments are not immediately seen after osteotomy. Be sure to account for all fragments. Mobilize the fragments and bring them into the surgical field.
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.

3 Reduction and provisional fixation top

enlarge

Fixation of small articular fragments

Assemble all small fragments covered by cartilage, even if they have no soft tissue connections. A headless screw, or buried threaded wire, or absorbable pin are options for fixing these fragments.


enlarge

K-wire fixation

In parallel plating it is customary to reduce and provisional by secure all of the fracture fragments prior to plate application.

4 Distal plate and screw fixation top

enlarge

Plate selection and contouring

Contoured 3.5-millimeter reconstruction plates or precontoured plates are selected for direct lateral positioning on the lateral column and direct medial positioning on the medial column.

These are usually placed slightly posterior ly and are always placed on top of the soft tissues—do NOT strip the medial and lateral columns.

The plates should extend distally enough to engage all fracture fragments and proximally enough so that 2 or 3 screws in each plate engage the proximal (shaft) fragment.


enlarge

Drilling for distal screws

As many screws as possible are placed in the distal fragments.
Each screw goes through a plate hole.
Smooth K-wires the same diameter as the appropriate drill (e.g. 2.0 mm wire for 2.7mm screw) can be inserted through the plate holes to ensure that the screws, once inserted, do not conflict: this allows the drilling stage to be skipped.


enlarge

Distal screw application

Each of the smooth K-wires is exchanged for a self-tapping screw.

5 Proximal plate fixation top

enlarge

Compression technique

When there is solid bony contact across the articular and proximal fragments, compression is applied with pointed reduction forceps and eccentrically placed load screws, one column at a time.


Alternatives

  1. When a column is comminuted this should be bridged and if necessary, because of missing bone, bone grafted.
  2. When the reassembled condylar mass is short, and non-locking plates are used, long, distal-to-proximal, 3.5 mm column screws will enhance the stability of the fixation. These need to be inserted with great care in the presence of comminution of a column.

6 Osteosynthesis of the olecranon osteotomy top

enlarge

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.


enlarge

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.


enlarge

Reduction of the olecranon

Reduce the olecranon osteotomy with pointed reduction forceps.


enlarge

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.


enlarge

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.


enlarge

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.


enlarge

Completed osteosynthesis of olecranon

The illustration shows the completed osteosynthesis of the olecranon.

7 Completed osteosynthesis top

enlarge

Final fixation

Note that the plates rest on top of the muscle origins and these have NOT been stripped or removed.

v1.0 2007-06-21