1 Principles topenlarge
In osteoporotic bone, the distal articular fragment may be very short, and varying degrees of metaphyseal comminution may be present in the ulnar or radial column.
The most difficult task is to stabilize a very short articular fragment when the bone quality is poor. This can be achieved with standard techniques, preferably with a precontoured angular-stable plate.
In these fractures, two types of plate application are used:
- Compression plating for the non-comminuted column
Bridge plating for the comminuted column
2 Reduction top
Cleaning of the fracture site
Clean out of the fracture by removing blood clots, loose pieces of bone, and interposed tissue.
Reduction of non-comminuted column
Reduction of the articular block to the shaft is easier on the side without metaphyseal comminution.
The reduction is held with an axial K-wire.
Reduction of comminuted column
With one column preliminarily stabilized, reduction of the other column can be achieved.
Insert a K-wire to secure the reduction preliminarily.
Correct reduction of the articular block in flexion / extension may be difficult.
3 Plate preparation topenlarge
Plate selection and contouring
Precontoured anatomic plates have been produced. If these are not available, a reconstruction plate is used both on the medial and the lateral sides. If a stronger plate is required, a small fragment dynamic condylar plate may be used, but this is more difficult to contour.
The plate length should allow for at least 2 screws in each fragment. On the lateral side, the plate can be placed very distally onto the posterior aspect of the capitellum. On the medial side, the plate is bent around the epicondyle, as necessary.
To facilitate contouring, malleable templates are used.
If standard implants are used, the plates must be perfectly adapted to the bone.
4 Plate application topenlarge
Non-comminuted column: compression
Start with the non-comminuted column.
The plate is fixed distally with two screws. Compression on the fracture site can be achieved with eccentrically placed screws in the proximal fragment.
When the plate is securely in place, the lateral K-wire is withdrawn.
Comminuted column: bridging
The metaphyseal comminution is bridged. No compression should be exerted. The plate is fixed with 2 screws in each main fragment.
In fractures with very short distal segments, additional stability can be gained by inserting long, distal-to-proximal, 3.5 mm column screws.
5 Pearls topenlarge
Pearl I: Column screw
If the articular fragment on the medial side is very short, the plate can be bent around the epicondyle.
A long screw through the plate, up the medial column, into the opposite cortex of the shaft, provides additional stability.
Pearl II: Distal humeral plate
In this clinical case, the Locking Distal Humeral Plates were used. These plates allow insertion of three 2.4 locking screws, even in very short distal fragments. Moreover, the locking screws provide better purchase in poor quality bone.