There is an increasing concern about the distal humerus fractures in the elderly. The concern is about the increasing frequency of this injury in patients with poor bone stock. These patients are usually in their 80s or 90s and pose difficulties in their treatment due to the high levels of activity combined with challenging injuries around the elbow. Open reduction and internal fixation remains the treatment of choice. However, when there is poor bone density fixation can be challenging and the option of total elbow replacement should be entertained. In the years to come orthopaedic surgeons will be doing a lot more total elbow replacements for the reasons explained above.
The following case is an elderly patient who presented with a distal humerus fracture after a fall. She is physiologically a lot younger than her chronologic age and decided to proceed with operative treatment of the fracture. We prefer, when possible, to do "a triceps on" surgical approach and avoid olecranon osteotomy. The trans-olecranon approach is mandatory when there are multiple intra-articular fragments that require visualization for anatomic reduction and restoration of the smoothness of the articular surface. Xrays before and after surgery are shown and the options of parallel versus biplanar plating are discussed below. In this case two lag screws and orthogonal plating was used for the 3 part distal humerus fracture
Parallel plating
There may be times when it is not possible, because of the specific anatomy of a fracture complex, to place the lateral plate posteriorly, and it has to lie on the crest of the lateral column. In such a scenario, the planes of the two plates will be parallel.
Some surgeons use parallel plating as the preferred method, on the basis that a posterolateral plate permits only short unicortical screws distally, whereas a lateral plate allows the use of longer distal screws.
The choice of method will be determined by the bone quality, the fracture anatomy, the availability of locking plates and individual surgical philosophy.
Biplanar plating
The use of two plates on the distal humerus for C-fractures greatly assists the reconstruction of the triangle of stability.
When one plate lies on the crest of the medial column, and the other lies on the posterior aspect of the lateral column, which is nonarticular, the two plates lie in planes that are at 90 degrees to each other – perpendicular, or biplanar, plating.
Such a construct is considered to confer good biomechanical stability in good quality bone, but this has not been proven experimentally.
When one plate lies on the crest of the medial column, and the other lies on the posterior aspect of the lateral column, which is nonarticular, the two plates lie in planes that are at 90 degrees to each other – perpendicular, or biplanar, plating.
Such a construct is considered to confer good biomechanical stability in good quality bone, but this has not been proven experimentally.
