TECHNICAL TRICK

Dual Plating for Fractures of the Distal Third of the

Humeral Shaft
Mark L. Prasarn, MD,* Jaimo Ahn, MD, PhD,* Omesh Paul, MD,* Elizabeth M. Morris, BA,*
Stephen P. Kalandiak, MD,† David L. Helfet, MD,* and Dean G. Lorich, MD*

benefit from adequate stabilization that will allow immediate

Summary: In this study, we present a novel method for performing weightbearing through the involved extremity.10–12
dual plating of extra-articular fractures of the distal third of the It is often difficult to obtain rigid fixation in distal
humerus. Since 2006, we have treated 15 such fractures with dual fractures of the humeral diaphysis without compromising the
plates from a single posterior midline incision. In the first part of the elbow. Older techniques recommended placing dynamic
study, we provide the surgical protocol we have used in addressing compression plates posteriorly on the humerus, but very
these fractures. In the second part, the charts of these patients were distal fixation was problematic secondary to impingement on
reviewed retrospectively to examine their clinical and radiographic the olecranon fossa as well as varus malreduction. Levy et al
outcomes. Using this technique, we have achieved an excellent union proposed the use of precontoured plates centrally placed on the
rate without significant complications while allowing early and posterior humerus that provide a flare extending distally for
aggressive range of motion. added fixation.13 We have used such plates in conjunction with
Key Words: humerus, shaft, diaphyseal, elbow, fracture, dual plating, a second lateral plate that serves as a reduction tool in addition
technique, protocol, osteosynthesis to offering enhanced structural support. A recent biomechan-
ical study demonstrated the superiority of two-plate constructs
(J Orthop Trauma 2011;25:57–63) in this anatomic region.14 By placing a second plate laterally,
a 90-90 construct is obtained without having to dissect the
ulnar nerve or strip the medial soft tissues. We have obtained
excellent clinical results with operative intervention of these
fractures using a single posterior midline incision and dual
plating with minimal complications.
INTRODUCTION Surgical Technique
The majority of closed fractures of the humeral
diaphysis can be treated conservatively with the expectation Preparation and Positioning
of union and a good functional outcome.1–7 Even so, there has Basic radiographs of both the humerus and elbow,
been much controversy regarding the treatment of extra- including two orthogonal views, are adequate for planning.
articular distal third fractures of the humerus. Many surgeons These radiographs allow visualization of the fracture
advocate operative intervention with plates and screws, configuration and development of a strategy for reduction
whereas others still prefer functional bracing.7,8 Advocates and placement of surgical implants. The patient is positioned
of conservative treatment feel that surgery places the patient at on a beanbag in the lateral decubitus position. The arm is
unnecessary risk for infection and neurovascular injury.8 They positioned across the chest over a blanket roll, and a sterile
site good clinical results using functional bracing published by tourniquet is placed. If anterior iliac crest bone is to be taken
Sarmiento et al.7 Proponents of surgical intervention state that for grafting, that area is draped simultaneously (Fig. 1).
fracture braces fail to control alignment in this region and that Depending on the surgeon’s handedness and preference, the
elbow function is better preserved with rigid fixation and early surgeon and the first assistant are each on one side of the arm.
range of motion.1,9 The polytrauma patient can also clearly
Exposure
A posterior midline incision is made followed by either
a triceps split for isolated distal fractures or medial retraction
of the lateral and medial heads of the triceps (modified
Accepted for publication March 24, 2010.
From the *Orthopaedic Trauma Service at the Hospital for Special Surgery,
posterior approach) to obtain greater proximal visualization in
New York, NY; and †University of Miami/Jackson Memorial Hospital, more extensive or segmental fractures.15 To facilitate exposure
Miami, FL. and identification of the radial nerve, the procedure is started
Each author certifies that he has no commercial associations (eg, under tourniquet control. In the case of a triceps-splitting
consultancies, stock ownership, equity interest, patent/licensing arrange- approach, the nerve is identified at the proximal end of the split
ments, etc) that might pose a conflict of interest with the submitted article.
Reprints: Mark L. Prasarn, MD, 59 Lac Kine Drive, Rochester, NY 14618 crossing the posterior aspect of the humerus. It is either
(e-mail: [email protected]). mobilized or left in situ depending on the amount of proximal
Copyright Ó 2010 by Lippincott Williams & Wilkins fixation that is deemed necessary. If the modified posterior

J Orthop Trauma  Volume 25, Number 1, January 2011 www.jorthotrauma.com | 57

Prasarn et al J Orthop Trauma  Volume 25, Number 1, January 2011

plate is placed on the lateral side. It is contoured to extend

along the lateral column proximally up the shaft of the
humerus. Two bicortical screws are placed, one proximal and
one distal to the fracture, but are only minimally tightened at
this point. The plate now serves as a provisional reduction
device. Minimal manipulation is still possible and is
performed until an anatomic reduction is achieved. A single
(Verbrugge; Synthes, Paoli, PA) bone clamp is now placed
FIGURE 1. Patient positioning. Use of a sterile tourniquet will around the plate at the fracture site to secure the reduction. A
maximize the sterile operative field. If harvesting of iliac crest 3.5- or 2.7-mm fully threaded lag screw is placed when
bone graft is anticipated, that area should be prepared and possible through the plate to obtain compression and stable
draped as well. Reprinted with permission from Helfet DL, fixation. The plate serves as a ‘‘washer’’ for the lag screw (Fig.
Kloen P, Anand N, et al. ORIF of delayed unions and nonunions 3A). The other two screws previously placed are now firmly
of distal humeral fractures. Surgical technique. J Bone Joint Surg
Am. 2004;86:18–29.

approach is undertaken, then the lower lateral brachial

cutaneous nerve is identified first and traced to its origin
from the radial nerve proper. The intermuscular septum is then
split to allow mobilization of the nerve, and elevation with
medial retraction of the medial and lateral heads of the triceps
is undertaken (Fig. 2).

Fixation
The fracture site is then identified and addressed. Soft
tissue stripping is undertaken with use of a periosteal elevator
and should be strictly limited to the fracture site and to the area
of anticipated plate placement. The fracture is provisionally
reduced and either a 2.7-mm or 3.5-mm pelvic reconstruction

FIGURE 3. (A) Illustration of placement of a 3.5-mm plate on

FIGURE 2. Illustration of the modified posterior approach to the lateral aspect of the distal humerus with insertion of a lag
the humerus. Reprinted with permission from Gerwin M, screw across the fracture using the plate as a ‘‘washer.’’ (B)
Hotchkiss RN, Weiland AJ. Alternative operative exposures of Illustration demonstrating appropriate position of the direct
the posterior aspect of the humeral diaphysis with reference to lateral and posterolateral ‘‘hockey stick’’ plate to the distal
the radial nerve. J Bone Joint Surg Am. 1996;78:1690–1695. humerus.

58 | www.jorthotrauma.com q 2010 Lippincott Williams & Wilkins

J Orthop Trauma  Volume 25, Number 1, January 2011 Dual Plating for Fractures

FIGURE 4. (A) Clinical photograph of

the modified posterior approach to
the humerus in a patient with a distal
third humeral shaft fracture. (B)
Clinical photograph of the same
patient after dual plating of the
fracture.

tightened down. In the presence of significant comminution, With the reduction maintained by the lateral plate,
the lateral plate once again initially serves to maintain length, a second more rigid plate is now applied posterolaterally.
rotation, and alignment, but is left in situ as part of a bridge Recently, we have used a precontoured extra-articular distal
plate construct. humerus locking plate with a ‘‘hockey stick’’ distal

TABLE 1. Patient Demographics

Orthopaedic Trauma Time to
Case Age Dominant Association Lag Bone Follow-Up Union Second
No. (years)/Sex Injury Mechanism Arm Classification Screw Graft (months) (weeks) Complications Procedures
1 24/M Wrestling Y 12-A1.3 Y None 34.0 6.7 None None
2 60/F Fall Y 12-B1.3 Y DBM 31.0 12.1 None None
3 82/F Fall Y 12-A2.3 Y DBM 37.0 6.0 None None
4 79/F Fall Y 12-B1.3 Y DBM 37.0 6.0 None None
5 22/M Throwing baseball N 12-B1.3 Y DBM 32.0 25.4 None None
6 54/F Struck by bicyclist N 12-A1.3 Y None 32.0 13.1 Tenderness over Removal of
hardware hardware
7 57/F Fall N 12-A1.3 Y None 31.0 6.4 None None
8 68/F Fall N 12-A3.3 N DBM 30.0 12.9 None None
9 21/M Gunshot wound Y 12-C3.3 Y None Left AMA Unavailable None None
10 24/M Arm wrestling Y 12-C1.3 Y DBM 29.0 13.7 None None
11 27/M Motor vehicle collision N 12-C1.3 Y DBM 28.0 8.3 None None
12 27/M Wrestling N 12A2.3 Y DBM 13.0 12.4 None None
13 80/F Fall Y 12-C2.3 Y DBM 31.0 12.1 Pulmonary None
embolism
14 27/M Motor vehicle collision Y 12-B1.3 Y None 7.0 6.0 None None
15 86/F Fall Y 12-B1.3 Y DBM 31.0 14.7 None None
M, male; F, female; Y, yes; N, no; DBM, demineralized bone matrix; AMA, against medical advice.

q 2010 Lippincott Williams & Wilkins www.jorthotrauma.com | 59

Prasarn et al J Orthop Trauma  Volume 25, Number 1, January 2011

configuration (Synthes, Paoli, PA). This second plate is 12-A3.3, 12-B1.3, 12-B2.3, 12-B3.3, 12-C1.3, 12-C2.3, and
secured either with locking screws or a hybrid technique and 12-C3.3 fractures (Table 1). There were eight women and
serves as a neutralization plate (Fig. 3B). In the presence of seven men included in this cohort. The average patient age
severe comminution, it becomes part of a bridge plate was 49.8 years (range, 21–86 years). The dominant arm was
construct. If it is deemed necessary, more screws can be involved in nine of the 15 cases. The mechanism of injury was
placed into the lateral plate for added fixation. It is noted which a simple fall in seven patients, a motor vehicle collision in two
holes on both plates the radial nerve crosses; and this is later patients, a bicycle accident in one patient, a gunshot injury in
dictated into the operative report (Fig. 4). The wound is then one patient, a throwing injury in one patient, an arm wrestling
closed in standard fashion over a suction drain. injury in one patient, and a wrestling injury in two patients
(Figs. 5 and 6). Three patients were noted to have radial nerve
Postoperatively palsy before surgical intervention. None of the fractures
No external immobilization is necessary. On the first underwent initial treatment other than gentle closed reduction
postoperative day, passive and active assisted range of motion and temporary splinting for comfort. All fractures were treated
of the elbow and shoulder is begun. Patients are also allowed to within 1 to 14 days (mean, 3 days) with open reduction and
fully weightbear through the involved extremity for transfers internal fixation after their injuries. The indication for open
and ambulation if they have associated fractures of the pelvis reduction and internal fixation was either polytrauma or the
or lower extremities. Aggressive range-of-motion exercises are following radiographic parameters: greater than 15° varus/valgus
continued until radiographic union is achieved, at which point or greater than 3 cm of shortening.
strengthening is begun. Patients are followed in the office until Demineralized bone matrix (Grafton; Osteotech Inc,
radiographic and clinical evidence of union. Eatontown, NJ) was used in 10 fractures secondary to fracture
comminution or bone loss. Lag screws were used in all but one
Clinical Series of the fracture configurations. With the exclusion of one
At our institution, we have used this surgical technique patient who left against medical advice after being treated for
to treat 15 extra-articular fractures of the distal humerus by two gunshot wounds to the chest and right humerus, and another
trauma fellowship-trained orthopaedic surgeons. This included who only had 7-month follow-up and can no longer be located,
Orthopaedic Trauma Association types 12-A1.3, 12-A2.3, the average patient follow-up was 29.57 months (range, 13–37

FIGURE 5. (A) Preoperative anteroposterior and lateral radiographs of an OTA type 12-C1.3 fracture in the dominant arm of a 24-
year-old man that occurred while arm wrestling. (B) Postoperative anteroposterior radiograph after fixation with dual plates and
additional interfragmentary lag screws. (C) Anteroposterior and lateral radiographs demonstrating union of the fracture.

60 | www.jorthotrauma.com q 2010 Lippincott Williams & Wilkins

J Orthop Trauma  Volume 25, Number 1, January 2011 Dual Plating for Fractures

FIGURE 6. (A) Preoperative antero-

posterior and lateral radiographs of
an OTA Type 12-B1.3 fracture in the
dominant arm of a 22-year-old male
pitcher sustained while throwing
a baseball. (B) Anteroposterior and
lateral radiographs after union of the
fracture with use of dual plates with
restoration of alignment and inter-
fragmentary compression.

months). The average time to union was 11.5 weeks (range, postoperatively), she showed no signs of recovery and
6–24 weeks) as defined as absence of pain with weightbearing continues to wear a wrist splint.
and on physical examination, and radiographic bridging of
bone on at least two views. All patients had less than 5° of
angulation in all planes and no appreciable shortening or DISCUSSION
rotation (Fig. 7). No patient had loss of fixation, postoperative Using a plate as a reduction device has been proposed
infection, or delayed union. The mean elbow flexion/extension previously in the literature.16–18 Not only does the lateral plate
arc was 4° to 131°. This average does not include three patients function as a reduction tool, but it also provides structural
who did not have measurements taken at final follow-up. It was support. Dual plating in distal humerus fractures19–21 as well as
noted in the most recent clinical note that these three patients in diaphyseal humerus fractures,14 has been shown to be
had range of motion of the elbow equivalent to the biomechanically superior to other constructs. The 90-90
contralateral side. Of the three patients with preoperative configuration obtained using this protocol also places the
radial nerve palsies, one completely resolved immediately plates in an optimal orientation to the sagittal axis, resulting in
after surgery, one is continuing to improve, and one other has higher resistance to bending and torsion.19,21 In addition, the
not demonstrated any signs of recovery. lateral plate functions as a ‘‘washer’’ for a lag screw that was
In this series, there were a total of two complications, used in all but one fracture configuration in this series. We feel
one of which required secondary surgery. One patient had that obtaining a rigid construct in the distal humeral shaft is
tenderness over the distal posterolateral humerus and essential to allow for early weightbearing and aggressive
underwent implant removal with resolution of symptoms. physical therapy.
The second complication occurred in an 80-year-old woman Jawa et al performed a retrospective comparison of
who fell in Croatia and flew here for treatment of her patients with extra-articular distal third diaphyseal humerus
segmental right humerus fracture and contralateral intertro- fractures treated with either plate fixation or a functional brace.
chanteric femur fracture. She developed a pulmonary embolus In their series, 19 patients underwent open reduction and
for which she was treated with an inferior vena cava filter and internal fixation, whereas 21 patients were managed in
chemical anticoagulation. On presentation to us, she also had a functional brace. In the operatively treated patients, one
a radial nerve palsy. During surgery, she was noted to have had loss of fixation, one had a postoperative infection, and
a contused radial nerve that was interposed between fracture three developed new radial nerve palsies. One of these palsies
fragments. At most recent follow-up (7 months did not resolve and went on to require tendon transfers. They

q 2010 Lippincott Williams & Wilkins www.jorthotrauma.com | 61

Prasarn et al J Orthop Trauma  Volume 25, Number 1, January 2011

FIGURE 7. (A) Preoperative three-dimensional computerized tomography reconstructions of an OTA Type 12-B1.3 fracture in the
dominant arm of an 86-year-old woman after a fall. (B) Immediate postoperative anteroposterior radiograph after fixation with dual
plates. (C) Anteroposterior and lateral radiographs after union of the fracture.

used three different surgical approaches and used four this particular anatomic site. The usefulness of this report lies in
different types of plates implanted by an unmentioned number the presentation of a novel method of fixing these difficult
of surgeons. Every patient was placed in a splint for 1 week fractures with very few complications.
before beginning therapy. Of the 19 operatively treated
patients, all healed with less than 10° of angulation in any
plane.8 CONCLUSION
Levy et al published good results using a posterior Obtaining an anatomic reduction with rigid fixation in
approach and a modified lateral tibial head buttress plate that fractures of the distal third of the humeral shaft can be difficult.
allows added distal fixation over conventional straight plates.13 The technique presented here has made this surgical problem
Using this surgical technique, they operated on 15 patients more manageable. The use of a second laterally placed plate
who all united. There was one deep infection that resolved aids in obtaining and provisionally holding the reduction and
with hardware removal and antibiotics. All of their patients appears to greatly enhance the stability of the overall construct.
healed with ‘‘adequate’’ alignment. There were no reported
postoperative radial nerve palsies.
REFERENCES
In our patient series, we had excellent restoration and 1. Browner BD, Jupiter JB, Levine AM, et al. Skeletal Trauma. 3rd ed.
maintenance of reduction and alignment in those treated with this Philadelphia: Saunders; 2003:1436–1511.
technique. There were no fixation failures, and all fractures united 2. Bohler L. Conservative treatment of fresh closed fractures of the shaft of
at an average of 11.1 weeks. The stability of such a construct the humerus. J Trauma. 1965;5:464–468.
3. Ruedi T, Moshfegh A, Pfeiffer KM, et al. Fresh fractures of the shaft of the
allowed every patient to achieve range of motion near equivalent humerus: conservative or operative treatment? Reconstr Surg Traumatol.
to their contralateral side. Only one patient had a symptomatic 1974;14:65–74.
implant that required removal. The final complication of 4. Sarmiento A, Kimman PB, Galvin EG, et al. Functional bracing of frac-
a pulmonary embolus occurred in an 80-year-old patient who tures of the shaft of the humerus. J Bone Joint Surg Am. 1977;59:596–601.
also had an intertrochanteric femur fracture. She had no 5. Sarmiento A, Zagorski JB, Zych GA, et al. Functional bracing for the
treatment of fractures of the humeral diaphysis. J Bone Joint Surg Am.
significant sequalae from the pulmonary embolus. Although 2000;82:478–486.
the sample size is small, it does compare with other reported 6. Sarmiento A, Latta LL. Functional fracture bracing. J Am Acad Orthop
series dealing specifically with operative treatment of fractures in Surg. 1999;7:66–75.

62 | www.jorthotrauma.com q 2010 Lippincott Williams & Wilkins

J Orthop Trauma  Volume 25, Number 1, January 2011 Dual Plating for Fractures

7. Sarmiento A, Horowitch A, Aboulafia A, et al. Functional bracing of 14. Rubel IF, Kloen P, Campbell D, et al. Open reduction and internal fixation
comminuted, extra-articular fractures of the distal third of the humerus. of humeral nonunions. J Bone Joint Surg Am. 2002;84:1315–1322.
J Bone Joint Surg Br. 1990;72:283–287. 15. Gerwin M, Hotchkiss RN, Weiland AJ. Alternative operative exposures of
8. Jawa A, McCarty P, Doornberg J, et al. Extra-articular distal-third the posterior aspect of the humeral diaphysis with reference to the radial
diaphyseal fractures of the humerus. A comparison of functional bracing nerve. J Bone Joint Surg Am. 1996;78:1690–1695.
and plate fixation. J Bone Joint Surg Am. 2006;88:2343–2347. 16. Mast J, Jakob R, Ganz R. Planning and Reduction Technique in Fracture
9. Aitken GK, Rorabeck CH. Distal humeral fractures in the adult. Clin Surgery. Berlin: Springer-Verlag; 1989.
Orthop Relat Res. 1986;207:191–197. 17. Benirschke SK, Henley MB, Ott JW. Proximal one-third tibial fracture
10. Mast JW, Spiegel PG, Harvey JP Jr, et al. Fractures of the humeral shaft: solutions. Orthop Trans. 1995;18:1055–1056.
a retrospective study of 240 adult fractures. Clin Orthop Relat Res. 1975; 18. Archdeacon MT, Wyrick JD. Reduction plating for provisional fracture
112:254–262. fixation. J Orthop Trauma. 2006;20:206–211.
11. Beauchamp CG, Kellam JK, McMurty RY. The results of plating humeral 19. Helfet DL, Hotchkiss RN. Internal fixation of the distal humerus: a
shaft fractures in patients with multiple injuries. The Sunnybrook biomechanical comparison of methods. J Orthop Trauma. 1990;4:260–264.
experience. J Bone Joint Surg Br. 1985;67:293–296. 20. Schemitsch EH, Tencer AF, Henley MD. Biomechanical evaluation of
12. Tinstad EM, Wolinsky PR, Shyr Y, et al. Effect of immediate methods of internal fixation of the distal humerus. J Orthop Trauma.
weightbearing on plated fractures of the humeral shaft. J Trauma. 1994;8:468–475.
2000;49:278–280. 21. Korner J, Gerd D, Azdorf M, et al. A biomechanical evaluation of methods
13. Levy JC, Kalandiak SP, Hutson JJ, et al. An alternative method of of distal humerus fracture fixation using locking compression plates
osteosynthesis for distal humeral shaft fractures. J Orthop Trauma. 2005; versus conventional reconstruction plates. J Orthop Trauma. 2004;18:
19:43–47. 286–293.

q 2010 Lippincott Williams & Wilkins www.jorthotrauma.com | 63