0
Scientific Articles   |    
Complex Distal Humeral Fractures: Internal Fixation with a Principle-Based Parallel-Plate Technique
Joaquin Sanchez-Sotelo, MD, PhD1; Michael E. Torchia, MD1; Shawn W. O'Driscoll, PhD, MD1
1 Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Medical Sciences Building 3-69, Rochester, MN 55905. E-mail address for S.W. O'Driscoll: odriscoll.shawn@mayo.edu
View Disclosures and Other Information
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. One or more of the authors received, in any one year, payments or other benefits in excess of $10,000 or a commitment or agreement to provide such benefits from a commercial entity (Acumed) Also, a commercial entity (Acumed) paid or directed in any one year, or agreed to pay or direct, benefits in excess of $10,000 to a research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which one or more of the authors, or a member of his or her immediate family, is affiliated or associated.
A video supplement to this article is being developed by the American Academy of Orthopaedic Surgeons and JBJS and will be available at the JBJS web site, www.jbjs.org. To obtain a copy of the video, contact the AAOS at 800-626-6726 or go to their web site, www.aaos.org, and click on Educational Resources Catalog.
Investigation performed at the Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2007 May 01;89(5):961-969. doi: 10.2106/JBJS.E.01311
5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

Abstract

Background: Severe comminution, bone loss, and osteopenia at the site of a distal humeral fracture increase the risk of an unsatisfactory result, often secondary to inadequate fixation. The purpose of this study was to determine the outcome of treating these fractures with a principle-based technique that maximizes fixation in the articular fragments and stability at the supracondylar level.

Methods: Thirty-four consecutive complex distal humeral fractures were fixed with two parallel plates applied (medially and laterally) in approximately the sagittal plane. The technique was specifically designed to satisfy two principles: (1) fixation in the distal fragments should be maximized and (2) screw fixation in the distal segment should contribute to stability at the supracondylar level. Twenty-six fractures were AO type C3, and fourteen were open. Thirty-two fractures were followed for a mean of two years. The patients were assessed clinically with use of the Mayo Elbow Performance Score (MEPS) and radiographically.

Results: Neither hardware failure nor fracture displacement occurred in any patient. Union of thirty-one of the thirty-two fractures was achieved primarily. Five patients underwent additional surgery to treat elbow stiffness. There was one deep infection that resolved without hardware removal and did not impede union. At the time of the most recent follow-up, twenty-eight elbows were either not painful or only mildly painful, and the mean flexion-extension arc was 99°. The mean MEPS was 85 points. The result was graded as excellent for eleven elbows, good for sixteen, fair for two, and poor for three.

Conclusions: Stable fixation and a high rate of union of complex distal humeral fractures can be achieved when a principle-based surgical technique that maximizes fixation in the distal segments and stability at the supracondylar level is employed. The early stability achieved with this technique permits intensive rehabilitation to restore elbow motion.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article
    Sign In to Your Personal ProfileSign In To Access Full Content
    Not a Subscriber?
    Get online access for 30 days for $35
    New to JBJS?
    Sign up for a full subscription to both the print and online editions
    Register for a FREE limited account to get full access to all CME activities, to comment on public articles, or to sign up for alerts.
    Register for a FREE limited account to get full access to all CME activities
    Have a subscription to the print edition?
    Current subscribers to The Journal of Bone & Joint Surgery in either the print or quarterly DVD formats receive free online access to JBJS.org.
    Forgot your password?
    Enter your username and email address. We'll send you a reminder to the email address on record.

     
    Forgot your username or need assistance? Please contact customer service at subs@jbjs.org. If your access is provided
    by your institution, please contact you librarian or administrator for username and password information. Institutional
    administrators, to reset your institution's master username or password, please contact subs@jbjs.org

    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
    CME Activities Associated with This Article
    Submit a Comment
    Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
    Comments are moderated and will appear on the site at the discretion of JBJS editorial staff.

    * = Required Field
    (if multiple authors, separate names by comma)
    Example: John Doe





    Shawn W. O'Driscoll, Ph.D., M.D.
    Posted on June 19, 2007
    Complex Distal Humeral Fractures: Internal Fixation with a Principle-Based Parallel-Plate Technique
    Mayo Clinic

    We thank the authors for taking the time to share their experience and additional technical tips concerning the principle-based parallel- plate technique for fixing complex distal humerus fractures that we published.

    We agree, wholeheartedly, with the recommendations offered and some of them represent details for which there was simply not enough room to permit their inclusion in the article. In fact, one of the illustrations that had to be deleted was an illustration showing compression across the articular fragments with a reduction clamp, as recommended in their first comment.

    We agree with their recommendation for fixing coronal plane fractures with mini screws, but we specifically recommend that those not be inserted until all of the distal screws that go through the plates across to the other side of the distal humerus have been inserted. This permits those small mini screws to interdigitate with the metal structure in the distal humerus and to offer rigid stability of the coronal shear fractures. It is also important that the lateral coronal shear fractures be captured by the screws coming from the medial side before any mini screws are inserted.

    Locking screws have become a current topic of great interest. We would like to emphasize that locking screws are not necessary to achieve rigid stability in the distal humerus if the principles and technical objectives outlined in this article are rigorously adhered to. Obviously the authors of this letter have found the same.

    We agree that varus/valgus alignment must be carefully assessed, while reducing the distal segment to the shaft and confirmed to be correct before supracondylar compression, which is step 4.

    The authors of the letter indicate that they also saw loosening of screws in the distal portion in many patients postoperatively, while being mobilized. I do not know whether they are referring to patients who had been operated on using the technique described in this paper or traditional techniques that we refer to as having been inadequate for some of these complex fractures. I presume it was the latter, as we have not seen this using the current recommended technique.

    Finally, we appreciate the immediate response of authors with experience who have found that this principle-based approach of so-called parallel plating and intensive postoperative rehabilitation does provide excellent results in these very complicated fractures.

    Bhavuk Garg
    Posted on June 07, 2007
    More technical tips for parallel plating of distal humerus
    All India Institute of Medical Sciences

    Dear editor, We read with great interest the article entitled "Complex Distal Humeral Fractures: Internal Fixation with a Principle-Based Parallel-Plate Technique". We are following this technique for last three years and would like to add some technical tips: 1. Compression across articular fragments should be achieved by reduction forceps and preferably no lag screw should be put as it tends to compress the fragments. As a result of which, olecranon fossa may get narrower, resulting in loss of extension postoiperatively.This also justifies the use of fully threaded screws as mentioned by authors. 2. Secondly, we should always look for fractures in coronal plane particularly of trochlea and capitellum and use of mini screws is very useful in this situation. The trochlea is very important for a good function as well as for stability. 3.We also recommend not to use locking screws as it is very difficult to change the direction of screws as interdigitation is needed for the stability of the construct and fixed direction of locking screw may hinder putting up the next locking screw. 4.A careful notice of varus and valgus alignment is also essential while putting screws in proximal portion of plate, attaching distal fragment to proximal fragment. 5. In our cases, we also saw an additional complication of loosening of screws in distal portion in many patients postoperatively, while being mobilized. These were managed by removal of screw under local anaesthesia in OPD setup.

    The combined use of TRAP approach, parallel plating of distal humerus and aggressive postoperative rehabillitation does provide an excellent outcome.

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

    Related Content
    The Journal of Bone & Joint Surgery
    JBJS Case Connector
    Topic Collections
    Related Audio and Videos
    PubMed Articles
    Clinical Trials
    Readers of This Also Read...
    JBJS Jobs
    04/16/2014
    Connecticut - Yale University School of Medicine
    02/05/2014
    Oregon - The Center - Orthopedic and Neurosurgical Care and Research
    04/02/2014
    Illinois - Hinsdale Orthopaedics