What is the step-by-step procedure for plating in a fracture of the supracondylar humerus?

Step-by-Step Procedure for Plating of Supracondylar Humerus Fracture

For adult supracondylar humerus fractures, open reduction and internal fixation using double plates in parallel configuration provides the most stable construct and best functional outcomes.

Preoperative Planning

• Obtain appropriate imaging including anteroposterior and lateral radiographs of the elbow to classify the fracture pattern 1
• CT scan may be necessary for complex fracture patterns to better understand the articular involvement 2
• Ensure all necessary equipment is available, including pre-contoured anatomic plates specifically designed for the distal humerus 3
• Position the patient appropriately based on the planned surgical approach 4

Surgical Procedure

Patient Positioning and Approach

• Position the patient in lateral decubitus or prone position with the affected arm supported on an arm board 4
• Use a posterior midline incision centered over the olecranon 2
• Develop full-thickness skin flaps to expose the triceps 2

Exposure Options

• Perform either:
  • Olecranon osteotomy approach (preferred for complex intra-articular fractures) 2
  • TRAP (triceps-reflecting anconeus pedicle) approach 2
  • Triceps-splitting approach (for simpler fracture patterns) 2

Fracture Reduction

• Identify and preserve the ulnar nerve by isolating and protecting it throughout the procedure 2
• Clean the fracture site of hematoma and debris 2
• Anatomically reduce the articular fragments first, using temporary K-wires for provisional fixation 2, 1
• Restore the overall geometry of the distal humerus, including the trochlea and capitellum 2

Plate Application

• Apply two plates in a parallel configuration (medial and lateral columns) 2, 1
• Ensure every screw in the distal fragments passes through a plate 2
• Place as many screws as possible in the distal fragments 2
• Make each screw as long as possible to engage fragments on the opposite side 2
• Create interdigitation of screws to form a fixed-angle construct 2
• Apply compression at the supracondylar level for both columns 2, 1

Final Steps

• Confirm stable fixation by checking range of motion intraoperatively 1
• Ensure no impingement of hardware during flexion and extension 2
• Close the wound in layers after thorough irrigation 1
• If olecranon osteotomy was performed, repair it with tension band wiring or plate fixation 2

Postoperative Management

• Apply a posterior splint with the elbow at 90 degrees for initial comfort 1
• Begin early range of motion exercises within 1-2 weeks as pain allows 1
• Remove hardware only if symptomatic after fracture union 1
• Expect fracture union in approximately 6 months (96% union rate) 1

Expected Outcomes

• Average range of motion of approximately 102° (70°-140°) 1
• Average Mayo Elbow Performance Score of 86 points (60-100) 1
• Approximately 60% of patients can return to previous activity levels 1

Common Pitfalls and How to Avoid Them

• Inadequate fixation in the distal fragments is a common cause of failure - maximize the number and length of screws in the distal fragment 2
• Osteoporotic bone may lead to fixation failure - consider augmentation techniques in elderly patients 5
• Stiffness may occur in approximately 8% of cases requiring additional surgical intervention - emphasize early mobilization 1
• Ulnar nerve injury - carefully identify and protect the nerve throughout the procedure 2
• Failure to restore articular congruity - prioritize anatomic reduction of the articular surface before column reconstruction 2, 1

Special Considerations

• In cases of severe metaphyseal comminution and bone loss, supracondylar shortening may be necessary 2
• For highly comminuted fractures, linking the plates through interdigitating screws creates an architectural equivalent of an arch for maximum stability 2
• Conservative management may be considered for simple, non-displaced fractures, particularly in elderly patients with poor bone quality 5