What is the recommended approach for plating in a patient with a distal humerus fracture, considering factors such as age, underlying medical conditions, and bone health?

Surgical Approach for Distal Humerus Fracture Plating

For displaced distal humerus fractures requiring operative fixation, dual-plate fixation using either parallel or perpendicular plate orientation is recommended, with parallel plating offering biomechanical advantages particularly in osteoporotic bone. 1, 2

Dual-Plate Fixation Technique

Plate Orientation Options

Both parallel and perpendicular plating configurations achieve satisfactory outcomes for intra-articular distal humerus fractures:

• Parallel plating (both plates in sagittal plane) provides superior biomechanical stability, particularly in compression and external rotation, and demonstrates greater resistance to axial plastic deformation 2
• Perpendicular plating (90°/90° orientation) achieves comparable clinical outcomes including time to union, elbow range of motion, and Mayo Elbow Performance Index scores 3
• In osteoporotic bone specifically, parallel plating systems show significantly higher stability (p = 0.005 in compression, p = 0.006 in external rotation) and are less sensitive to bone mineral density variations 2

Technical Principles for Maximizing Stability

The following eight technical objectives must be achieved to prevent supracondylar fixation failure 1:

1. Every screw in distal fragments must pass through a plate 1
2. Each screw must engage the opposite fragment that is also fixed to a plate 1
3. Maximize the number of screws placed in distal fragments 1
4. Use the longest possible screws 1
5. Each screw should engage as many articular fragments as possible 1
6. Screws should interdigitate and lock together, creating a fixed-angle construct 1
7. Apply plates to achieve compression at the supracondylar level for both columns 1
8. Plates must be strong and stiff enough to resist breaking or bending before union 1

Surgical Approach Selection

For Distal Diaphyseal-Metaphyseal Fractures

• Anterior approach with dual short plating allows robust fixation through smaller incisions with less soft tissue dissection 4
• Use 4.5-mm narrow locking compression plates combined with 3.5-mm LCP reconstruction plates 4
• This technique achieves 100% union rates with favorable elbow range of motion and average DASH scores of 10.0 4

For Intra-Articular Fractures (AO Type 13-C)

• Dual-column fixation is mandatory for all adult fractures involving both columns 5
• Modern contoured locking compression plates in either parallel or perpendicular configuration produce equivalent clinical outcomes at mean 19.3-month follow-up 3
• The perpendicular system may require additional independent interfragmentary screws in severely osteoporotic bone due to greater sensitivity to bone mineral density 2

Special Considerations by Patient Factors

Age and Bone Quality

• Elderly patients with displaced, comminuted intra-articular fractures not amenable to stable internal fixation: acute total elbow arthroplasty is the preferred treatment 5
• Osteoporotic bone: parallel plating systems provide superior stability and should be strongly considered 2
• In severe metaphyseal comminution with bone loss, manage with supracondylar shortening 1

Fracture Pattern-Specific Approaches

• Displaced coronal shear fractures of the distal humeral articular surface require operative fixation via a lateral approach 5
• Severe comminution: linking plates through bone by interdigitating screws creates an architectural arch offering the greatest biomechanical stability 1

Critical Pitfalls to Avoid

• The outdated concept that plates must be placed perpendicular (90°/90° orientation) is biomechanically unsubstantiated and incorrect 1
• Failure to maximize distal fragment fixation leads to loss of fixation at the supracondylar level, the most common site of construct failure 1
• Inadequate screw interdigitation fails to create the fixed-angle structure necessary for stability 1
• Using plates that are insufficiently strong or stiff risks breaking or bending before supracondylar union occurs 1