Adult Humeral Inter-condylar Fractures: Plate Application

- 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:

   


   



     



- Complications:
    - elbow flexion contracture:
    - non union:
           Salvage of non-union of supracondylar fracture of the humerus by total elbow arthroplasty.
           Non-union of fractures of the distal end of the humerus.



Intercondylar fractures of the humerus. An operative approach.

Mechanical failures of internal fixation in T and Y fractures of the distal humerus.

Fractures of the distal humerus.

Operative treatment of bicondylar intraarticular fractures of the distal humerus.

Surgical treatment of fractures of the capitellum in adults: a modified technique.

Internal fixation of the distal humerus: a biomechanical comparison of methods.

Fractures of the adult distal humerus. Elbow function after internal fixation.

Intraarticular fractures of the distal humerus. Surgical treatment and results.

Coronal shear fractures of the distal end of the humerus.

Multiplane fracture of the distal humerus.

Unicondylar fractures of the distal humerus: an operative approach.

Distal humeral fractures in the adult.

Biomechanical evaluation of methods of internal fixation of the distal humerus.

Intraarticular fractures of the distal humerus in the adult.

Bicondylar intraarticular fractures of the distal humerus in adults.



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Wednesday, June 13, 2012 7:51 pm