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Length of Plates and Number of Screws for the Fixation of Distal Humerus Fractures: A Finite Element Biomechanical Study

  • Ahmadreza Zarifian
    Affiliations
    Orthopedic Research Center, Mashhad University of Medical Sciences, Mashhad, Iran

    Clinical Research Unit, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
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  • Ali Akbarinezhad Fough
    Affiliations
    Orthopedic Research Center, Mashhad University of Medical Sciences, Mashhad, Iran

    Clinical Research Unit, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
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  • Denise Eygendaal
    Affiliations
    Department of Orthopedic Surgery, Amphia Hospital, Breda, the Netherlands

    Department of Orthopedic Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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  • Michael Rivlin
    Affiliations
    Department of Orthopedic Surgery, Division of Hand Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
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  • Seyed Ali Mousavi Shaegh
    Correspondence
    Seyed Ali Mousavi Shaegh, PhD, Orthopedic Research Center, Mashhad University of Medical Sciences, Mashhad, Iran 99199-91766
    Affiliations
    Orthopedic Research Center, Mashhad University of Medical Sciences, Mashhad, Iran

    Clinical Research Unit, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
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  • Amir R. Kachooei
    Correspondence
    Corresponding author: Amir R. Kachooei, MD, PhD, Rothman Orthopedic Institute, Thomas Jefferson University, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107.
    Affiliations
    Orthopedic Research Center, Mashhad University of Medical Sciences, Mashhad, Iran

    Department of Orthopedic Surgery, Division of Hand Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
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Published:August 31, 2021DOI:https://doi.org/10.1016/j.jhsa.2021.07.010

      Purpose

      We performed a biomechanical analysis using the finite element method to assess the effects of plate length and the number of screws on construct stiffness, stress distribution, and fracture displacement in the fixation of type A2 distal humerus fractures.

      Methods

      A 3-dimensional humerus model was constructed using computed tomography of a healthy man. After creating a 2-mm extra-articular fracture gap, orthogonal double-plate fixation was performed with an incremental increase in plate length and the number of screws, creating 17 fixation models. Four screws were placed in each plate’s distal segment, and the number of screws was increased incrementally in the segment proximal to the fracture, starting from 2 in the medial (M) and 2 in the lateral (L) plate (M2∗L2).

      Results

      The fifth screw proximal to the fracture in the lateral plate (L5) played an essential role in increasing stiffness under bending, axial, and torsional forces surpassing the intact bone, which may have been due to the bypassing of the stress riser area. Minimum construct stiffness was created when 5 (M3∗L2) screws were inserted into the proximal segment. For bending forces, the M4∗L2 construct was stronger than M3∗L3 (total 6 proximal screws), and M5∗L3 was stronger than M4∗L4 (total 8 proximal screws), showing higher stiffness when the plates ended at different levels. The M4∗L2 construct (6 screws) had stiffness comparable with M4∗L3, M4∗L4, and M5∗L4 during bending, showing comparable stiffness with the least instrumentation density.

      Conclusion

      Our findings suggested M3∗L5 as the optimum and M3∗L2 as the minimum construct to resist all bending, axial and torsional forces.

      Clinical relevance

      Applying the results may improve surgical techniques, decrease the rate of complications, including fixation failure and nerve injury, and optimize the time of surgery. Moreover, hardware removal is less cumbersome with fewer screws.

      Key words

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