What is the preferred method of treatment for a distal humerus C2 fracture, orthogonal (Open Reduction Internal Fixation) or parallel ORIF?

Orthogonal vs Parallel ORIF for Distal Humerus C2 Fractures

Parallel plating is the preferred method of treatment for distal humerus C2 fractures as it provides superior stability and functional outcomes compared to orthogonal plating, particularly for complex intra-articular fractures. 1

Surgical Approach Selection

When treating distal humerus C2 fractures, two critical decisions must be made:

1. The surgical approach to expose the fracture
2. The plate configuration for fixation

Surgical Approach Options

• Triceps-sparing approach:

  • Preferred for younger patients and less complex fractures
  • Advantages: Shorter operative time (77±4.64 min vs 93.11±8.78 min), less blood loss (197±39 ml vs 224±46 ml), and slightly better functional outcomes (MEPS 86.56±10.66 vs 83.57±10.96) 1
  • Better functional outcomes for type C1 and C2 fractures compared to olecranon osteotomy 2

• Olecranon osteotomy:

  • Consider for patients ≥60 years old with complex fractures requiring extensive articular visualization
  • Provides better exposure of the articular surface but has higher complication rates 2
  • May be preferred in elderly patients as they tend to have inferior functional outcomes with triceps-sparing approach 1

Fixation Method Selection

Parallel Plating

• Primary recommendation for C2 fractures
• Provides more rigid fixation for complex fractures
• Plates are placed on medial and lateral columns of the distal humerus
• Better biomechanical stability for comminuted fractures
• Particularly beneficial for C2 and C3 fractures with significant comminution 3

Orthogonal Plating

• Traditional configuration with plates at 90° to each other
• May be considered for simpler C1 fractures
• Less optimal for C2 fractures due to less rigid fixation 3

Post-Operative Management

1. Early mobilization: Begin active motion exercises within 3 weeks post-surgery to prevent stiffness
2. Immobilization period: Typically 3 weeks with plaster cast removal followed by rehabilitation 3
3. Rehabilitation protocol: Progressive range of motion exercises after immobilization, followed by strengthening exercises

Expected Outcomes and Complications

• Functional outcomes: Good to excellent results can be expected in approximately 85% of cases with proper technique 1
• Common complications:
  • Ulnar nerve palsy (consider anterior transposition during surgery) 4
  • Hardware issues (migration, loosening)
  • Heterotopic ossification
  • Infection (rate approximately 7.7%) 4
  • Re-operation rate around 38.4% 4

Special Considerations

• Elderly patients with osteoporotic bone: Consider hemiarthroplasty as an alternative when ORIF is not feasible due to bone quality or fracture complexity 5
• Ulnar nerve management: Routine exploration and anterior intramuscular transposition should be considered to prevent postoperative ulnar nerve palsy 4

Key Points for Success

1. Careful preoperative planning
2. Selection of appropriate surgical approach based on patient age and fracture complexity
3. Parallel plating configuration for C2 fractures
4. Stable internal fixation to facilitate early active rehabilitation
5. Routine ulnar nerve exploration and management
6. Early mobilization to prevent stiffness