Executive Editor: Chris Colton

Authors: Mariusz Bonczar, Daniel Rikli, David Ring

Distal humerus 13-C3 Open reduction; perpendicular (biplanar) plating

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Glossary

1 Principles top

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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

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Recognize fragments

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


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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 Reconstruction of the articular surface top

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Condylar reassembly

Reduce and hold the articular fragments using cannulated screw guide wires.


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Assemble all small fragments covered by cartilage, even if they have no soft tissue connection. A headless screw is often a good choice for fixing some of these fragments.


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Definitive fixation of articular fragments

Insert a cannulated screw over the guide wire after pre-drilling the pil of hole. Alternatively, insert a non-cannulated screw in the standard manner parallel to the wire, and then remove the wire.

Insert the screw from the lateral to the medial side, so that the screw head does not irritate the ulnar nerve and conflict with the planned position of the medial plate.


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If possible, insert a second screw to improve rotational stability.


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Bone stock quality

Use the lag screw technique only in good bone quality and when anatomical reconstruction of all articular fragments is possible.

In osteoporotic bone, or when bone graft has to be added to fill an articular gap, use a position screw to avoid deformation of the articular surface.


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Pitfall

In inferior bone quality, or when a fragment is missing, use of a lag screw, producing interfragmentary compression, will deform the articular surface.


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Missing bone

In case of missing bone, always use bone graft or fill the defect with the remaining small fragments.


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4 Condylar reattachment top

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Temporary fixation

Reduce the reconstituted articular mass 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.

Pace the lateral column plate dorsally and the medial column plate medially. In this position their planes 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 has no cartilage cover posteriorly.

The comminution is bridged if it can not be precisely reduced and fixed with absolute stability. A slightly longer plate is used to provide additional stability.

In a more distal fracture, the reconstruction plate extend bent all the way to the edge of the capitellar articular surface. It will not interfere with the radial head during the extension of the joint. The more bone is covered by the plate, the greater is the stability achieved.


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Placement of the lateral plate

Insert a K-wire through the distal hole. As the plate is pulled proximally, stable contact with the bone is obtained.
Now insert the proximal screw.


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Remaining screws

Insert the remaining screws.


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Medial plate

Place another plate medially on the crest of the medial supra candylar ridge, its plane at right angles to 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 x-rays shows the completed osteosynthesis.

v1.0 2007-06-21