Distal Humeral Fracture Fixation with an Extensor Mechanism-on Approach

[Introduction][1] Open treatment of extra-articular and intra-articular distal humeral fractures can be effectively accomplished through an extensor mechanism-on approach. [Step 1: Preoperative Planning][2] Assess all images for multiplane fracture lines involving the capitellum or trochlea. ![Figure][3] ![Figure][3] [Step 2: Operative Setup][4] Verify with fluoroscopy that the patient and arm positions allow for adequate imaging of the distal part of the humerus. ![Figure][3] ![Figure][3] ![Figure][3] [Step 3: Surgical Approach][5] Perform medial and lateral arthrotomies posterior to the collateral ligament complexes and excise the intra-articular fat pad and posterior aspect of the capsule. ![Figure][3] ![Figure][3] ![Figure][3] ![Figure][3] ![Figure][3] ![Figure][3] ![Figure][3] [Step 4: Fracture Reduction and Provisional Fixation][6] Reduce the distal humeral fragments anatomically under direct visualization posteriorly and indirectly with fluoroscopy using the intact sigmoid notch as a template for reduction. ![Figure][3] ![Figure][3] ![Figure][3] [Step 5: Definitive Fixation][7] Place multiple screws distally through the plates medially and laterally; each screw should be of maximal length and engage the opposite column. ![Figure][3] ![Figure][3] ![Figure][3] ![Figure][3] [Step 6: Wound Closure and Postoperative Management][8] Remove the dressing on postoperative day two and begin full active-assisted elbow range of motion and grip-strengthening therapy program. [Results][9] In our series of thirty-seven patients[12][10], all fractures healed primarily with a median motion arc of 126° (range, 60° to 141°). The median triceps strength loss was 10% (range, 0% to 49%). [What to Watch For][11] [Indications][12] [Contraindications][13] [Pitfalls & Challenges][14] [Introduction][1] Open treatment of extra-articular and intra-articular distal humeral fractures can be effectively accomplished through an extensor mechanism-on approach. [Step 1: Preoperative Planning][2] Assess all images for multiplane fracture lines involving the capitellum or trochlea. ![Figure][3] ![Figure][3] [Step 2: Operative Setup][4] Verify with fluoroscopy that the patient and arm positions allow for adequate imaging of the distal part of the humerus. ![Figure][3] ![Figure][3] ![Figure][3] [Step 3: Surgical Approach][5] Perform medial and lateral arthrotomies posterior to the collateral ligament complexes and excise the intra-articular fat pad and posterior aspect of the capsule. ![Figure][3] ![Figure][3] ![Figure][3] ![Figure][3] ![Figure][3] ![Figure][3] ![Figure][3] [Step 4: Fracture Reduction and Provisional Fixation][6] Reduce the distal humeral fragments anatomically under direct visualization posteriorly and indirectly with fluoroscopy using the intact sigmoid notch as a template for reduction. ![Figure][3] ![Figure][3] ![Figure][3] [Step 5: Definitive Fixation][7] Place multiple screws distally through the plates medially and laterally; each screw should be of maximal length and engage the opposite column. ![Figure][3] ![Figure][3] ![Figure][3] ![Figure][3] [Step 6: Wound Closure and Postoperative Management][8] Remove the dressing on postoperative day two and begin full active-assisted elbow range of motion and grip-strengthening therapy program. [Results][9] In our series of thirty-seven patients[12][10], all fractures healed primarily with a median motion arc of 126° (range, 60° to 141°). The median triceps strength loss was 10% (range, 0% to 49%). [What to Watch For][11] [Indications][12] [Contraindications][13] [Pitfalls & Challenges][14] [1]: #sec-10 [2]: #sec-11 [3]: pending:yes [4]: #sec-12 [5]: #sec-13 [6]: #sec-14 [7]: #sec-15 [8]: #sec-16 [9]: #sec-17 [10]: #ref-12 [11]: #sec-18 [12]: #sec-19 [13]: #sec-20 [14]: #sec-21