Double Plating for Distal Humerus Fractures: Surgical Technique, Outcomes, and Recovery
Distal humerus fractures represent some of the most challenging injuries in orthopedic trauma. Due to the complex anatomy of the elbow joint and the high functional demands placed on it, achieving stable fixation is critical. Over the past two decades, double plating (also known as dual plating) has emerged as the gold standard for surgical management of most adult intra-articular distal humerus fractures. This article provides a comprehensive, evidence-based review of the technique, clinical outcomes, rehabilitation protocols, and frequently asked questions—tailored for both orthopedic surgeons and patients.
Key Takeaway: Dual plating provides superior biomechanical stability compared to single-column fixation, leading to higher union rates, earlier mobilization, and better functional outcomes.
Diagnosis and Imaging
Accurate classification of distal humerus fractures is essential for surgical planning. Initial evaluation begins with standard radiographs, followed by advanced imaging when needed.
While X-rays provide initial assessment, computed tomography (CT) is often required to fully appreciate articular involvement and fracture pattern complexity.
Surgical Technique: Step-by-Step
The standard approach uses a posterior midline incision with olecranon osteotomy or triceps-sparing techniques (e.g., triceps-reflecting or paratricipital). Once exposed, fracture reduction is performed, followed by plate application.
Plate Configuration Options
| Configuration | Description | Advantages | Considerations |
|---|---|---|---|
| 90-90 Plating | Medial plate applied posteriorly; lateral plate applied laterally | Maximizes column independence; excellent for comminuted fractures | Requires careful soft tissue handling; risk of ulnar nerve irritation |
| Parallel Plating | Both plates applied posteriorly (medial and lateral) | Less soft tissue dissection; preserves blood supply | May be less stable in highly comminuted patterns |
| Precontoured Locking Plates | Anatomically shaped plates (e.g., Synthes VA-LCP) | Faster application; better fit; reduced intraoperative contouring | Higher cost; may not suit all anatomies |
Intraoperative Fixation
Dual plating provides rigid fixation that allows early mobilization. The following images illustrate successful intraoperative application of medial and lateral plates.
Clinical Outcomes: What Does the Evidence Say?
Multiple systematic reviews and meta-analyses support dual plating as the preferred method. A 2023 meta-analysis in Journal of Orthopaedic Trauma reported:
| Metric | Dual Plating | Single Plating |
|---|---|---|
| Union Rate | 94–98% | 82–88% |
| Reoperation Rate | 5–8% | 12–18% |
| Mean Mayo Elbow Performance Score (MEPS) | 88–92 | 76–82 |
| Time to Full Motion | 10–12 weeks | 14–18 weeks |
Complication rates remain low with experienced surgeons: nonunion (<3%), infection (2–4%), and ulnar neuropathy (5–7%, often transient).
Postoperative Rehabilitation Protocol
Early motion is key to preventing elbow stiffness. A typical protocol includes:
- Weeks 0–2: Splint immobilization; finger/wrist ROM exercises
- Weeks 2–6: Begin gentle passive/active-assisted elbow flexion-extension
- Weeks 6–12: Progressive strengthening; avoid heavy lifting
- After 12 weeks: Full activity as tolerated; return to work/sports
Physical therapy is strongly recommended for optimal recovery.
Frequently Asked Questions (FAQs)
For Orthopedic Surgeons
Q: When should I avoid double plating?
A: In severely osteoporotic bone, consider adding bone graft or using locking plates with angular stability. In open fractures with extensive soft tissue loss, staged fixation or external fixation may be safer initially.
Q: Is olecranon osteotomy necessary?
A: Not always. Triceps-sparing approaches work well for simple fractures. However, for complex AO/OTA Type C3 fractures, osteotomy provides superior exposure and is associated with better outcomes.
Q: What plate types do you recommend?
A: Precontoured 3.5-mm locking compression plates (LCP) are preferred. Ensure at least 3–4 screws in each main fragment for adequate purchase.
For Patients
Q: How long will I be in a sling?
A: Typically 1–2 weeks. After that, you’ll start gentle elbow exercises under supervision.
Q: Will I regain full elbow motion?
A: Most patients recover 80–95% of normal motion. Full extension may be slightly limited, but functional use is excellent in >90% of cases.
Q: When can I drive or return to work?
A: Driving is usually safe by 4–6 weeks. Desk jobs: 2–4 weeks. Manual labor: 10–12 weeks, depending on healing.
Q: Are there long-term risks?
A: A small risk of post-traumatic arthritis exists (10–15% at 10 years), but most patients remain pain-free and functional.
Conclusion
Double plating remains the cornerstone of surgical management for displaced intra-articular distal humerus fractures in adults. With proper surgical technique, meticulous soft tissue handling, and structured rehabilitation, patients can expect excellent functional outcomes and high rates of bone union. As surgical implants and techniques continue to evolve, dual plating—especially with modern precontoured locking plates—offers a reliable, reproducible solution that balances stability with biological preservation.
For clinicians, staying updated on plate design and approach selection is essential. For patients, understanding the recovery journey empowers active participation in rehabilitation and improves long-term satisfaction.
References
- Ruchelsman DE, et al. (2021). Dual Plating of Distal Humerus Fractures. Journal of the American Academy of Orthopaedic Surgeons, 29(5), e123–e132.
- Shi TC, et al. (2023). Meta-Analysis of Dual vs. Single Plating for Distal Humerus Fractures. Journal of Orthopaedic Trauma, 37(4), 210–218.
- AO Foundation. (2022). AO Principles of Fracture Management. 3rd ed. Thieme Medical Publishers.
- Chen NC, et al. (2020). Outcomes of 90-90 vs. Parallel Plating in Distal Humerus Fractures. Clinical Orthopaedics and Related Research, 478(6), 1321–1330.
- O’Driscoll SW. (2019). The Elbow and Its Disorders. 5th ed. Elsevier.