Lateral Subcutaneous Locking Compression Plate and Small Incision Reduction for Distal-third Diaphyseal Humerus Fractures

Abstract

Objective: Iatrogenic radial nerve injury is a great challenge for orthopaedic surgeons who deal with distal-third diaphyseal humerus fractures. Conventional open reduction and internal fixation (ORIF) remains the gold standard, but complications such as nonunion and iatrogenic radial nerve injury still occur. We fixed the fractures with a lateral locking compression plate (LCP) subcutaneously after small incision reduction to protect the radial nerve. This study reports the clinical and radiographic outcomes of our modified method.

Methods: Thirty-eight patients with distal-third diaphyseal humerus fractures were treated with lateral subcutaneous LCP and small incision reduction at our department between September 2013 and August 2016. There were 33 males and 5 females, with an average age of 30.3 years (range, 17 to 49 years). All the cases were types A or B (AO/OTA classification, type A, 24 cases; type B, 14 cases). Among them, 6 cases were combined with preoperative radial nerve palsy. All patients were diagnosed with closed humeral fractures after X-ray examination, and had typical upper limb pain, swelling, and movement disorders. The operations were performed by a single surgeons' team. Union time, range of motion (ROM), University of California, Los Angeles (UCLA) shoulder rating scale, and Mayo Elbow Performance Index (MEPI) scores were assessed to evaluate the postoperative results.

Results: All patients were followed up for an average of 11.4 months (range, 3 to 36 months). The average operation time was 75.5 min (range, 60 to 150 min) and average intraoperative radiation exposure was 10.5 s (range, 8 to 18 s). Bony union was achieved in all cases after an average of 16.2 weeks (range, 12 to 25 weeks). No complications such as infection or screw and plate fracture occurred, and no iatrogenic radial nerve injury was observed. According to the UCLA shoulder rating scale, the average score was 33.7 (range, 31 to 35), with 33 excellent (86.8%) and 5 good cases (13.2%). They were all excellent according to their MEPI scores (ranging, 94 to 100, with an average of 97.4). The average operation time for secondary removal of the plate was 15.2 min (range, 10 to 20 min), and no complications such as infection or secondary radial nerve injury occurred.

Conclusions: Lateral subcutaneous LCP and small incision reduction may reduce the risk of iatrogenic radial nerve injury significantly in the treatment of distal-third diaphyseal humerus fractures. It also leads to solid fixation, good postoperative function, and convenient removal of the plate without injuring the radial nerve.

Keywords: Humeral fracture; Locking compression plate; Small incision reduction; Subcutaneous.

Figure 1

Flowchart of the selection process and follow‐up for the study. LCP, locking compression plate.

Figure 2

The abridged general view of the distal‐third diaphyseal humerus fracture fixed with lateral subcutaneous locking compression plate (LCP). (A) The anteroposterior view shows the relationship between the plate, the fracture line, and the radial nerve; the LCP is located subcutaneously and is not in contact with the radial nerve. (B) The radial nerve near the bone surface at the distal‐third diaphyseal humerus and below the plate; the locking screws are kept away from the radial nerve.

Figure 3

Preoperative anteroposterior (A) and lateral (B) X‐ray films of a distal‐third diaphyseal humerus fracture. The operative incisions and LCP inserted through the subcutaneous tunnel (C). Anteroposterior (D) and lateral (E) X‐ray films 3 days after surgery show that the fracture achieved good reduction. Anteroposterior (F) and lateral (G) X‐ray films at the 6‐week follow‐up showing well‐maintained linear and positional alignments of the fracture and obvious callus formation at local regions without any implant failure.

Figure 4

Preoperative anteroposterior (A) and lateral (B) X‐ray films of a distal‐third diaphyseal humerus fracture. The preoperative CT three‐dimensional reconstruction (C, D) shows obvious fracture displacement. During the surgery, the forceps were used to assist the fracture reduction through two small percutaneous incisions at anterior and posterior, and LCP was inserted lateral subcutaneously through two small incisions (E). Anteroposterior (F) and lateral (G) intraoperative fluoroscopy after fixation shows that the fracture achieved good reduction and the LCP was unattached to the bone surface. The incisions after suture were small (H). Anteroposterior (I) and lateral (J) X‐ray films 3 days after surgery shows that the fracture was in good position and firmly fixed.