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 DCP's,
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:
- 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;

- posterolateral column:
- most often the plate is applied posteriorly;
- 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 inorder to apply a valgus contour to the distal end
of the plate, and subsequently, the distal end of the plate is contoured to
accomadate 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 thru 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.