A Pitfall in Fixation of Distal Humeral Fractures with Pre-Contoured Locking Compression Plate

Document Type: CASE REPORT

Authors

1 Oxford University Massachusetts General Hospital and Harvard Medical School

2 Hand and Upper Extremity Service. Massachusetts General Hospital and Harvard Medical School.

Abstract

Anatomically precontoured locking plates are intended to facilitate the fixation of articular fractures and particularly those associated with osteoporosis. Fractures of the distal humerus are relatively uncommon injuries where operative intervention can be exceptionally challenging. The distal humeral trochlea provides a very narrow anatomical window through which to pass a fixed-angle locking screw, which must also avoid the olecranon, coronoid, and radial fossae. We describe 3 patients (ages 27, 49, and 73 years) with a bicolumnar fracture of the distal humerus where very short distal locking screws were used. Intra-articular screw placement was avoided but loss of fixation occurred in two patients and a third was treated with a prolonged period of immobilization. We postulate that fixed-angle screw trajectories may make it difficult for the surgeon to place screws of adequate length in this anatomically confined region, and may lead to insufficient distal fixation. Surgical tactics should include placement of as many screws as possible into the distal fragment, as long as possible, and that each screw pass through a plate without necessarily locking in.

Keywords


  1. Jupiter JB, Neff U, Holzach P, Allgower M. Intercondylar fractures of the humerus. An operative approach. J Bone Joint Surg Am. 1985; 67:226-39.
  2. Ring D, Jupiter JB. Fractures of the distal humerus. Orthop Clin North Am. 2000;31(1):103-13.
  3. Jupiter JB. Complex fractures of the distal part of the humerus and associated complications. Instr Course Lect. 1995; 44: 187-98.
  4. Cornell CN, Ayalon O. Evidence for success with locking plates for fragility fractures. HSS J. 2011; 7(2):164-9.
  5. Ducrot G, Bonnomet F, Adam P, Ehlinger M. Treatment of distal humerus fractures with LCP DHP™ locking plates in patients older than 65 years. Orthop Traumatol Surg Res. 2013; 99(2):145-54.
  6. Haidukewych GJ, Ricci W. Locked plating in orthopaedic trauma: a clinical update. J Am Acad Orthop Surg. 2008;16(6):347–55.
  7. Maratt JD, Peaks YS, Doro LC, Karunakar MA, Hughes RE. An integer programming model for distal humerus fracture fixation planning. Comput Aided Surg. 2008;13:139–47.
  8. Hungerer S, Wipf F, von Oldenburg G, Augat P, Penzkofer R. Complex distal humerus fractures - Comparison of polyaxial locking and non-locking screw configurations - a preliminary biomechanical study. J Orthop Trauma. 2014; 28(3):130-6.
  9. Korner J, Lill H, Müller LP, Hessmann M, Kopf K, Goldhahn J, et al., Distal humerus fractures in elderly patients: results after open reduction internal fixation. Osteoporos Int. 2005; 16:73-9.
  10. O’Driscoll SW. Optimising stability in distal humeral fracture fixation. J Shoulder Elbow Surg. 2005;14:186-94.