Adult Humeral Inter-condylar Fractures: Plate Application : Wheeless' Textbook of Orthopaedics

- Technique Considerations:
- following restoration of fracture anatomy, contour 1/3 tubular, 3.5 pelvic reconstruction, or 3.5 DCPs,
to fit medial and lateral aspect of distal humerus;
- the strongest bone lies along medial and lateral columns and therefore the plate screws should be placed
here rather than central portion of distal end of the humerus;
- some surgeons elect to direct cortical screws toward the olecranon fossa, being careful that only the
screw tip protrude into the fossa (excessively long screws will cause impingment in extension);
- noting the normal 40 deg anterior angulation of the condyles, it is best to place the lateral plate posteriorly &
medial plate in saggital plane;
- w/ this configuration, the two plates will be perpendicular to one another which is also optimizes biomechanical strength;
- fixation principles:
- need to recreate the "roman arch configuration";
- emphasis is on rigid supracondylar fixation since this is often the area of fixation failure;
- each screw is passed through a plate;
- each screw should engage a fragment on the opposite side that is also fixed to a plate;
- as many screws as possible should be placed in the distal fragments;

- screws engaging the distal fragment need to be as long as possible;
- each screw should engage as many fracture fragments as possible;
- medial and lateral column screws "interdigitate" for additional stability;
- plates are applied in compression in the metaphyeal region;
- ref: Optimizing stability in distal humeral fracture fixation- posterolateral column:
- most often the plate is applied laterally inorder to support the "roman arch" configuration;
- consider molding the chosen plate to allow insertion of 1-2 screws in the distal fragment (this is esp important in
transverse frx);
- 3.5 mm DCP or LCDCP can be applied to the posterior surface of the lateral column;
- a plate bending press is required in order to apply a valgus contour to the distal end of the plate, and
subsequently, the distal end of the plate is contoured to accomodate the anterior bow of the lateral
column;
- in the distal portion of the humerus, screws should be directed antero-medially inorder to engage the thickest
bone (more proximally, the screws can be directed straight anteriorly);
- note that the posterior aspect of the lateral condyle has a bare spot just proximal to the articular surface which accomodates posterior plate placement;
- distal screw(s) should be cancellous so as not to penetrate the anterior capetellar cortex;- posteromedial column:
- consider medial plate application placed at a 90 deg angle to lateral fixation;
- medially directed plate fixation takes advantage of avoiding ulnar nerve except when the distal plate screw extends
over the distal-medial portion of the condyle;
- the ulnar nerve must clearly be identified distal to the medial epicondyle;
- note that subperiosteal stripping over the medial epicondyle will encounter a portion of the MCL and the

flexor
pronator mass;
- it is possible to use a DCP along w/ medial column but it is easier to contour a 3.5 mm pelvic recon plate around
the medial epicondyle;- Assessment:
- take the elbow through a range of motion;
- loss of motion may indicate that screws have crossed olecranon fossa;
- ensure that the fixation is relatively stable, otherwise additional fixation is required;
- have the anesthesiologist reverse all paralytics so that the nerve stimulator can confirm adequate function of the ulnar and/or radial nerves;
- ulnar nerve in condylar fractures:
- note that a plate or lag screw placed over the distal-medial edge of the condyle will encroach on the cubital tunnel and may
irritate the ulnar nerve;
- in these patients, anterior transposition may indicated

Examples: