Executive Editor: Fergal Monsell General Editor: Chris Colton

Authors: Andrew Howard, Theddy Slongo

Pediatric distal humerus 13-E/4.2

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Glossary

1 Goals top

The main goals of treatment of these fractures are:

  • Anatomical reduction and restoration of the joint surface
  • Avoidance of joint stiffness by early motion
  • Uncomplicated healing
  • Avoidance of malunion or nonunion

2 Preoperative planning top

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Instruments and implants

  • Standard orthopedic instrument set
  • Appropriate plates, according to the size of the child (2.7-3.5 standard plates, recon plates, or anatomically preshaped plates)
  • Lag screws (if possible cannulated)
  • K-wires

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Anesthesia and positioning

General anesthesia is recommended and a sterile tourniquet should be available.

The patient should be placed lateral with the injured arm placed over a padded arm roll or a gutter support.

3 Approach top

A posterior approach is used. The triceps may be split or reflected laterally and medially. Exposure may be enhanced with an olecranon osteotomy when necessary.


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Cleaning of the fracture site

The fracture is cleaned by removing blood clots, loose pieces of bone, and any interposed tissue.

4 Reconstruction of the articular surface top

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Condylar reassembly

The articular fragments are reduced using pointed reduction forceps, a towel clamp, or with the help of two K-wires.

An anatomical reconstruction of the joint surface is mandatory.


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Definitive interfragmentary fixation

A lag screw is used to obtain interfragmentary compression of the articular fracture plane. A partially or fully threaded screw can be used. If a fully threaded screw is used, it is necessary to overdrill the near fragment.

To achieve an optimal mechanical outcome, the physis can be ignored as these children are approaching skeletal maturity.


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If cannulated lag screws are available, the two reduced fragments are temporarily fixed with a K-wire.


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The guide wire for the cannulated screw is inserted through the center of the capitellum, parallel to the joint surface.


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An appropriate screw, depending on the fragment size (3.0, 3.5, or 4.0 mm), is inserted and both wires are removed, unless the first K-wire is required for additional stability.


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Note: Once the condylar mass has been reconstructed, the injury has been converted to a simple supracondylar fracture type.

5 Condylar reattachment with biplanar plates top

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The reconstituted condylar mass is reduced to the metaphysis and crossed K-wires are used for preliminary fixation.


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Plate preparation

The plates must be carefully contoured using appropriate malleable templates. For ease of contouring, reconstruction plates are used.

The lateral column plate is placed posteriorly and the medial column plate medially.

Note: Anatomically precontoured plates can be very useful if the bone size matches the plate shape.


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Definitive fixation

A 3.5 mm reconstruction plate is placed posteriorly. It may curve around the capitellum which is nonarticular posteriorly.

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


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Application of the lateral plate

One or two screws are inserted through the distal portion of the plate and the most proximal screw is then inserted eccentrically as a load screw. As this pulls the plate proximally, the metaphyseal fracture plane is compressed.


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Screw insertion

The plate is fixed to the bone by inserting the remaining screws in neutral mode.


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Medial plate

Another plate is applied onto the crest of the medial supracondylar ridge; its orientation at a right angle to the plane of the lateral plate increases stability.

It is recommended that the distal screw be angled distally to purchase in the trochlea.

Note: Confirm satisfactory fixation by imaging at the conclusion of the operation.

6 Wound closure top

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The triceps dissection or split is closed by continuous resorbable 2/0 suture.

Note: If it has been necessary to perform an olecranon osteotomy, the repair by tension band wiring is as described in the adult surgery reference for fracture types 13-C.

v1.0 2016-12-01