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A New Minimally Invasive Anteromedial Approach for Plate Osteosynthesis of Distal Third Humeral Shaft Fractures

March 01, 2019

Contributors: Jose Bonilla Alarcon Sr; Sabina Cañada-Oya, MD; Alberto D Delgado-Martinez; Carlos Herraiz Montalvo Sr; Cristina Zarzuela Jiménez, MD; Hermenegildo Cañada-Oya Sr, MD; Hermenegildo Cañada-Oya Sr, MD

Fractures of the distal one-third of the humerus are a challenge to manage. Plate osteosynthesis is the preferred method for the management of distal third humeral shaft fractures. Current minimally invasive approaches to the distal humerus are associated with a high risk of radial nerve injury and do not allow for adequate fixation of distal fractures. This video demonstrates a new minimally invasive anteromedial approach for plate osteosynthesis of distal third humeral shaft fractures. An anatomic study was performed. Eight specimens were dissected to determine the distances of the vascular and nervous structures that may be at risk during the procedure and to define the technique. This video meticulously describes the approach. An extra-articular distal humerus plate designed to be applied to the posterior zone of the lateral epicondyle during open surgery is used. The plate is inverted and applied to the distal anterior flat area of the epitrochlea. Because the plate is not designed to be applied to this anatomic area, it must be molded with the use of two forceps, inverting the distal posterior curve, to be correctly assembled. A distal incision is made medial to the pronator muscle, and the plate is introduced under the brachial muscle belly to avoid damage to the main neurovascular structures in the arm. The proximal incision is similar to that used in the classical minimally invasive approach. This new approach was successful in eight patients, all of whom had excellent outcomes in main upper extremity functional scales. In some of the patients, three-dimensionally printed anatomic models of the fractures were built so the plate could be molded preoperatively. This video discusses the case presentation of a 22-year-old man with a distal humerus fracture. General anesthesia is used, and the procedure is performed without a tourniquet. Before inserting the plate, an external fixator, with the distal pin in the rotational center of the humeral condyles, is used to maintain reduction during the procedure and reduce the risk of radial nerve palsy, which may occur with excessive manipulation of the fracture. Postoperative radiographs are satisfactory, and radial nerve palsy is not present. The anatomic study demonstrated that the vessels and nerves of the arm are safe throughout the procedure. This new minimally invasive anteromedial approach for plate osteosynthesis of extra-articular, distal third diaphyseal humerus fractures is safe and results in satisfactory clinical outcomes. Radial nerve injury is avoided, and adequate fixation achieved. Using this technique, far distal fractures of the humerus can be safely synthesized via a minimally invasive approach.