Humeral fracture: Transcondylar distal fracture fixation with Synthes 27mm/35mm Variable Angle Locking Compression Plate, triceps sparing approach
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This surgical case describes the use of the Depuy Synthes 2.7mm/3.5mm Variable Angle Locking Compression Plate Elbow System to internally fix a displaced transcondylar fracture of the distal humerus through a posterior triceps sparing approach. The anatomical approach has the advantage of avoiding the need to detach and subsequently repair the triceps tendon insertion to the proximal ulnar or performing an olecranon osteotomy which both add to the morbidity of surgery and, assuming accurate fracture reduction and rigid internal fixation allows confident early active elbow movement which will optimise final outcome. Potential morbidity of alternative approaches relate to symptoms such as pain or weakness from a triceps repair or delayed on non-union of an olecranon osteotomy.
The triceps sparing approach would be used for a unilateral plate either medial or lateral and this approach for using double plates simply combines those two. A direct posterior triceps splitting approach is best used for more proximal diaphyseal fractures and those not requiring double plating or best served with a single medial or lateral plate. Some surgeons may have concerns that there is insufficient access to a more complex fracture but confidence increases when it’s used regularly. If however despite best releases and soft tissue mobilisation access for a more complex fracture is insufficient then the surgeon can perform an olecranon osteotomy.
This case adheres to the AO basic principles of fracture fixation first conceived in the 1950s of anatomic reduction, stable fixation, preservation of blood supply and early active mobilisation. The option of using locking screws is useful to enhance fixation with a fixed angle construct of plate and screw to bone particularly if the bone is of poor quality. Whilst many other trauma implant companies have their own version of periarticular locking plate systems, the Synthes VA plating system has anatomically contoured and shaped plates based on detailed analysis of over 100 skeletal specimens. Part of this innovative design is a rounded profile to help reduce the risk of soft tissue irritation. Medial plates are available for left or right humeri in short (1 diaphyseal hole), medium (2 diaphyseal holes), long (4 diaphyseal holes) or extra long (6, 8 or 10 diaphyseal holes). The extended medial plates wrap further around the medial epicondyle and are available in the same sizes. The lateral distal humeral plates have similar sizes short (1 diaphyseal hole), medium (2 diaphyseal holes), long (5 diaphyseal holes) or extra long (7, 9 or 11 diaphyseal holes).
Medial and lateral plates would be used in parallel configuration but if fracture pattern or surgeon preference requires perpendicular technique then posterolateral plates are available with similar size profiles with or without a small extended lateral support arm. There are also proximal olecranon plates, standard olecranon plates and extra-articular proximal ulna plates to complete the system. The 2.7mm variable angle locking screws allow a fixed angle construct, 15 degrees off normal axis or variable angle within a 30 degree cone. The variable angle screw holes feature four points of threaded locking between the plate and the variable angle locking screw to create a fixed angle construct at the desired screw angle.
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(With acknowledgement to Sam Chan FRCS (Tr & Orth) for providing images of his surgical case)
Author: Mark Crowther FRCS (Tr & Orth)
Institution: The Avon Orthopaedic centre, Southmead Hospital, Bristol, UK.
Clinicians should seek clarification on whether any implant demonstrated is licensed for use in their own country.