Use of Orthogonal or Parallel Plating Techniques to Treat Distal Humerus Fractures

Anatomy

The elbow joint is characterized as being a hinge joint because it only has a single axis of rotation.⁸ This rotation primarily occurs between the semilunar notch at the proximal part of the ulna and the trochlea at the distal end of the humerus. The trochlea is bounded on each side by a bony column, thus forming a bony construct that is analogous to a triangle. If any of the arms of the triangle are disrupted, the entire construct is weakened more than expected.⁹ Therefore, it is important to

Classification schemes

Fractures of the distal humerus have historically been classified based on anatomic considerations. Initially these fractures were classified based on the concept that the distal end of the humerus was made up of condyles. The terms supracondylar, condylar, transcondylar, and bicondylar fractures were used.¹²

Currently, fractures of the distal humerus are more commonly described based on the previously discussed anatomic description of the columnar structure of the distal humerus, which includes

Biomechanical analysis

The literature has had contradictory results with regard to biomechanical testing of these two techniques. Self and colleagues²⁸ assessed the biomechanical aspects of the two techniques using reconstruction plates and found the parallel system to be stronger and stiffer. Jacobson and colleagues²⁹ also assessed the biomechanical aspects of the techniques with reconstruction plates yet found the perpendicular system to be stronger. Both of these studies were performed on cadaveric bone.

Schwartz

Surgical techniques

ORIF should be performed in fractures with any amount of significant displacement involving the articular surface because outcomes are superior to nonsurgical treatment of these fractures. The goals of ORIF include restoration of the elbow joint anatomy with stable fixation to permit early motion.

Complications

Complications arise whether using the orthogonal plating technique or the parallel plating technique. These complications include heterotopic ossification, failure of fixation, nonunion, malunion, infection, ulnar neuropathy, and complex regional pain syndrome.

In the orthogonal plating series of 23 subjects by Gofton and colleagues, about half of the subjects experienced at least one complication, with the presence of heterotopic ossification being the most common (present in 30% of subjects).

Nonunion scenarios

Similar to the difficulties encountered treating distal humerus fractures, treatment of distal humeral nonunions has proven to be a difficult entity for the surgeon. This complication is especially devastating when elbow instability is so severe that the limb cannot be supported against gravity. Treatment of this problem can be achieved with total elbow arthroplasty, however many patients are too young or active for total elbow arthroplasty to be the optimal treatment. Therefore, some

Summary

Distal humerus fractures continue to be a complex fracture for the surgeon to treat. This article describes two techniques that can be used to tackle these difficult fractures. Both of these techniques have yielded excellent outcomes after ORIF; however, both techniques have significant complications associated with them. Use of parallel plating or orthogonal plating will depend on surgeon preference and the fracture pattern present. Orthogonal plating may be preferred in cases of an anterior