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Background The traditional strategy for fixing intra-articular distal humerus fractures is double plating placed in an orthogonal configuration, based on posterior approach. With a combined medial and lateral approach, a novel configuration of plating (combined anteromedial and anterolateral plating) has been used. In this study, we investigated the biomechanical properties of the novel plating by comparing it with some traditional strategies. Methods Based on the 3D morphology of a healthy subject’s humerus, models of three types of intra-articular distal humeral fractures were established using a variety of different internal fixation methods: (a) treatment of a simple intra-articular fracture of the distal humerus with the novel double plate and a traditional orthogonal plate; (b) treatment of a comminuted fracture of the lower distal humerus with the novel double plate, a traditional orthogonal plate and a traditional orthogonal plate combined with distally extended tension screws; (c) treatment of a coronal shear fracture of the distal humerus with the novel double plate, a traditional orthogonal plate and the intra-articular placement of three screws. The material properties of all plates and screws were isotropic and linearly elastic. The Poisson ratio of the implant and bone was 0.3, and the elastic modulus of the implant was 114,000 MPa. The axial loading is 200 N, the bending loading is 30 N and varus rotation is 7.5 Nm in the longitudinal direction. Results A simple model of intra-articular fracture of the distal humerus (AO C1 type) was established. Under all experimental conditions, the novel double plate showed greater stiffness than the orthogonal double plate. The axial straightening, bending compression and varus torsion increased by 18.00%, 16.00% and 44.00%, respectively. In the model of comminuted fracture of the lower distal humerus, the novel double plate showed the best stiffness under three experimental conditions (163.93 N/mm, 37.97 N/mm, 2697.84 N mm/°), and the stiffness of the traditional orthogonal plate combined with the distally extended tension screws was similar to that of the traditional orthogonal plate (121.21 N/mm, 32.61 N/mm, 1968.50 N mm/°). In the model of coronal shear fracture of the distal humerus, the novel double plate showed the best stiffness under all test conditions (194.17 N/mm, 38.46 N/mm, 2929.69 N mm/°), followed by the traditional plate (153.85 N/mm, 33.33 N/mm, 2650.18 N mm/°), while the stiffness of the three screws was the smallest (115.61 N/mm, 28.30 N/mm, 2180.23 N mm/°). Conclusions In terms of biomechanics, compared with other internal fixation methods, the novel combined anteromedial and anterolateral anatomical locking double-plate showed less stress, less displacement and greater stiffness. The novel double-plate method can be used to treat not only simple intra-articular fractures of the humerus but also complex comminuted fractures of the lower distal humerus and coronal shear fractures of the distal humerus, with a better effect than current traditional internal fixation methods.

Background The treatment of complex 3- and 4-part proximal humeral fractures has been controversial due to numerous postoperative complications. With the further study of medial support and blood supply of humeral head, new techniques and conception are developing. The study aims to illustrate the medial approach of the proximal humeral fracture through cadaver autopsy. Method Upper limbs from 19 cadavers have been dissected to expose the shoulder joint. We selected the coracoid process as the bony reference. Vernier caliper will be used to measure the following data, including distance from coracoid process to circumflex brachial artery, distance between anterior humeral circumflex artery (ACHA) and posterior circumflex brachial artery (PCHA) and their diameters. Assessment included the characteristics of the vascular supply around the humeral head, identification of the structures at risk, quality of exposure of the bony structures, and feasibility of fixation. Results The medial approach is appropriate in 86.84% anatomical patterns. Between the lower part of the shoulder capsule and the insertion of conjoined tendon, the bony surface exposed was limited by the interval between ACHA and PCHA. An interval of 2 to 3 cm (24.29 ± 3.42 mm) was available for medial plate. ACHA (49.35 ± 8.13 mm, 35.14–68.53 mm) and PCHA (49.62 ± 7.82 mm, 37.67–66.76 mm) were about 5 cm away from the coracoid process. Risk structures including ACHA and PCHA originate in common, PCHA originated from the deep brachial artery (DBA), the presence of perforator vessels, musculocutaneous nerve intersects with ACHA, the diameter of PCHA: ACHA < 1.5. In 13.15% anatomical patterns, this risk structure should be taken seriously. Conclusion The medial approach opens a new perspective in the optimal management of complex fractures of proximal humerus. Anatomical research proves that the medial approach is feasible. The interval between ACHA and PCHA is suitable for placement. Anatomical pattern and indication have been discussed, and we hypothesized that ACHA has been destroyed in complex PHFs. With further studies on the anatomy and mechanism of injury, the development of more clinical cases will be an important work of our institution in the future.