A new anatomical plate fixation verse dual plates fixation in the treatment of extra-articular distal humeral fractures: a retrospective study of 30 cases

A new anatomical plate fixation verse dual plates fixation in the treatment of extra-articular distal humeral fractures: a retrospective study of 30 cases | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A new anatomical plate fixation verse dual plates fixation in the treatment of extra-articular distal humeral fractures: a retrospective study of 30 cases Wenbo Wang, Liping Xia, Fanxiao Liu, Jiajun Xu, Zhanchuan Yu, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6314432/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The study aims to evaluate the clinical and functional outcomes of extra-articular distal humeral fractures (EADHFs) treated with a new anatomical plate compared with dual plates-plate fixation. Methods From January 2018 to June 2023, patients with EADHFs who underwent internal fixation with either the new anatomical plate or dual plates were recruited, and divided into two groups (new plate vs dual-plate group). Data were recorded and analyzed, including operation time, blood loss, and hospitalization costs. Clinical outcomes were assessed using the indictors of interests, such as healing time and the complications, including wound infection, vascular and nerve damage, and nonunion. The shoulder and elbow function was evaluated using the University of California Los Angeles (UCLA) shoulder score and Mayo Elbow Performance Score (MEPS) respectively. Results A total of 30 patients (21males, 9 females) with a mean age of 32.97 years were included, with 12 patients in the new plate group, and 18 patients in the dual-plate group. The mean postoperative follow-up duration was 14.50 ± 1.07 months (range, 13–17 months). Preoperative data showed no significant difference in age, sex, or cause of EADHF between the groups. Interestingly, patients treated with the new anatomical plate have shorter operation times, lower hospitalization costs, and faster healing process than those treated with dual plates. However, no significant differences were found between the two groups in clinical and functional outcomes assessed using the MEPS and UCLA shoulder score. Conclusion The new anatomical plate for EADHF treatment demonstrates advantages such as reduced surgical time, lower costs, and shorter healing duration, making it a viable alternative treatment option. However, larger-scale studies with longer follow-up periods are necessary to fully confirm its efficacy and long-term benefits. extra-articular distal humeral fracture new anatomical plate dual plates Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Background Humeral shaft fractures are relatively common, accounting for 3–5% of all fractures[ 1 ]. Among these, extra-articular distal humeral fractures (EADHFs) constitute approximately 16% of humeral fractures[ 2 , 3 ]. These fractures occur between the humeral shaft and the supracondylar region, often presenting with displacement, comminution, and relatively small fracture fragments[ 4 ]. Treatment outcomes are frequently associated with elbow stiffness, weakness, and pain. A pain-free, stable, and mobile elbow joint is essential for performing daily activities[ 5 ]. Additionally, these fractures carry a high risk of complications such as nonunion and radial nerve injury following treatment. Given the limited treatment options, managing these fractures remains a significant challenge for orthopedic surgeons. The goal of EADHF treatment is to achieve stable fixation and proper alignment, allowing for early mobilization of the elbow and shoulder joints[ 6 ]. Because of the unique morphology of the distal humerus and the muscular forces acting on the fracture site, conservative treatment often fails to achieve therapeutic objectives and may lead to elbow joint stiffness and an increased incidence of nonunion[ 7 , 8 ]. A randomized controlled trial demonstrated that surgical treatment for EADHF results in better outcomes than conservative management[ 9 ]. Surgical options for EADHFs include internal and external fixation techniques. External fixation is primarily used for temporary stabilization or in emergency situations. However, it carries risks such as fracture loosening and pin-track infections[ 10 ]. Open reduction and internal fixation (ORIF) is widely regarded as the gold standard for treating these fractures and including plate fixation and intramedullary nailing (IMN) [ 11 ]. However, IMN requires sufficient bone stock at the distal fracture site and an adequate area for effective fixation. The small size of the distal humeral fragments and the narrow medullary canal make securing intramedullary devices challenging[ 12 ]. Therefore, most surgeons opt for plate fixation in patients with EADHFs. However, the failure rate for traditional single-plate fixation in distal humeral fractures is approximately 5%, with a reported nonunion rate of 2–6%[ 13 , 14 ]. Dual-plate fixation is commonly employed to provide multiple fixation points to the distal fragments[ 4 ], offering greater resistance to torsional forces and improved stability under lateral stress[ 15 ]. However, this technique presents challenges, such as difficulty in prebending the steel plate, a relatively complex surgical procedure, and extensive soft tissue stripping around the fracture, which can affect blood supply and prolong the surgery duration[ 16 ]. To address these issues, various plating techniques have been proposed, including the lambda plate, metaphyseal plates, and extra-articular locking plates for the distal humerus[ 4 , 17 , 18 ]. However, their reliability and effectiveness have yet to be conclusively proven. Research into EADHF treatment continues, and a new type of plate has been developed specifically for these fractures. The new plate is a pre-contoured, anatomically shaped locking plate specifically designed for EADHF. We refer to it as the Distal Humeral Subcondylar Locking Plate (Double Medical, Xiamen, China). This retrospective study was performed to compare the clinical and functional outcomes of EADHF treatment using the new anatomical plate versus dual-plate fixation. Additionally, we sought to evaluate the safety, efficacy, and potential benefits of the new plate for patients. Methods and materials Ethics and patients This study was approved by the Ethics Committee of our institution. All patients provided written informed consent, and the patient representing the typical case in this study also gave consent for their image to be published. Data from patients treated with either the new anatomical plate or dual plates for EADHF at our trauma center between January 2018 and June 2023 were retrospectively collected. Initially, 56 patients were identified. After applying the inclusion and exclusion criteria, 30 patients were included in the study. Inclusion and exclusion criteria The inclusion criteria in this retrospective study were as follows: (1) age ≥ 18 years; (2) a diagnosis of EADHF based on medical history, physical examination, and imaging, such as radiography or CT; (3) treatment by ORIF with either dual plates or the new anatomical plate; and (4) a follow-up period of more than 12 months. The exclusion criteria were as follows: (1) age < 18 years; (2) any additional injuries around the elbow besides EADHF; (3) pathological fractures, open fractures, or fractures with neurovascular injury; (4) a history of shoulder disease or shoulder surgery; (5) a history of elbow disease or shoulder surgery; and (6) a history of mental illness. Patients were then categorized into two groups: those treated with the new anatomical plate (the new plate group) and those treated with dual plates (the dual-plate group) (Fig. 1 ). The new anatomical plate The new plate is a specially designed locking plate with a pre-contoured anatomical shape specifically for EADHF. Its design aligns with the natural shape of the humerus, eliminating the need for bending, ensuring excellent conformity, and reducing soft tissue irritation. The plate features a dual-row, multi-hole, multi-angle configuration of distal screw holes, allowing for multiple locking screws. This design enhances angular stability and provides strong shear resistance. The distal end of the plate includes a low-profile notch, enabling it to extend up to the area above the capitellum of the humerus. It is positioned above the joint capsule of the lateral epicondyle, preserving the joint capsule and maintaining elbow mobility. Additionally, the arched design of new plate allows for preservation of the deltoid muscle insertion point during surgery, minimizing damage to the deltoid muscle. This design helps address the issue of internal fixation failure caused by the influence of the deltoid muscle insertion position[ 19 ](Fig. 2 ). Surgical method New anatomical plate group The surgery was performed by the same group of surgeons with the patient under general anesthesia and in the supine position on the operating table. The upper limb was abducted to a neutral position. Surgical incisions were made using an anterolateral approach, with the appropriate length determined based on the location of the fracture along the line connecting the deltoid muscle insertion point and the lateral humeral condyle. The skin and subcutaneous tissue were incised, followed by fascial flap dissection. At the elbow plane, blunt dissection was performed to expose the brachialis, brachioradialis, and biceps brachii muscles. The lateral cutaneous nerve of the forearm was identified in the interval between the biceps brachii and brachialis and was protected with a rubber band. The interval between the brachioradialis and brachialis was then explored to locate the radial nerve, which was retracted and protected using a rubber band. The interval between the brachioradialis and biceps brachii was sharply incised, and the biceps were retracted to expose the lateral and anterolateral aspects of the distal humeral shaft. The dissection was extended proximally to further expose the humerus. Once exposure was complete, the hematoma and soft tissue around the fracture site were removed, and the fracture ends were meticulously debrided under the periosteum. During fracture reduction, a simple spiral fracture was held in place using reduction clamps and stabilized with K-wires. In cases of comminuted fractures, the main fragments were reduced first, with the smaller fragments addressed afterward while preserving soft tissue attachments to promote healing. C-arm fluoroscopy was then used to confirm the adequacy of the reduction. The appropriate length of the new anatomical plate was selected, with the proximal end positioned on the lateral aspect of the middle to upper humerus and the distal end placed anterolaterally over the lateral epicondyle of the humerus. Screws were used for fixation, with at least three securing the proximal end and at least four securing the distal end. Compression screws were also utilized at the fracture site if necessary. Alignment and plate fixation were verified using C-arm X-ray fluoroscopy to ensure satisfactory fracture reduction and internal fixation. After extensive irrigation, a single negative-pressure drainage tube was placed inside the incision. The incision was then closed in layers, followed by the application of sterile dressings and a pressure bandage (Fig. 3 ). Dual-plate group The fractures were exposed either through an anterolateral surgical incision using the previously described technique or, alternatively, through a posterior incision. For the posterior approach, the incision was made along a line connecting the posterolateral aspect of the acromion and the olecranon, with the length tailored to the specific location of the fracture. After making the incision, the skin, subcutaneous tissue, and fascia were divided to locate the distal tendon of the triceps brachii. Proximally, blunt dissection was performed to separate the interval between the long head and lateral head of the triceps brachii. The radial nerve was identified at the proximal portion of the medial head of the triceps brachii and was then retracted and protected with a rubber band. Distally, a sharp longitudinal split was made in the triceps tendon. The muscle tissue was retracted to either side, allowing exposure of the distal humeral fracture site. After fracture reduction, double plates of appropriate length were selected. One pre-bent plate was used for fixation on the lateral or posterolateral side, supported by a pre-bent plate on the anterolateral side. Postoperative management Both groups followed the same postoperative management plan. The condition of the distal nerves and blood vessels was evaluated and documented, and signs of infection at the surgical site were monitored. Routine antibiotic treatment was administered within the first 24 hours postoperatively to prevent wound infection, after which antibiotics were gradually discontinued based on the individual condition of patients. All patients had their wounds covered with bandages postoperatively and their arms secured in slings for 4 to 6 weeks. Additionally, nonsteroidal anti-inflammatory drugs (NSAIDs) were prescribed to alleviate acute pain. Closed negative-pressure drainage was maintained until the drainage volume fell below 20 mL within a 24-hour period. On the first day postoperatively, once the pain had subsided, the patients were encouraged to begin passive range-of-motion exercises for the shoulder and elbow joints of the injured limb, while movement of the unaffected limbs remained unrestricted. During the first week, active and assisted arm movements were performed while in the sling. Following radiographic evidence of bone healing, further weight-bearing and resistance activities were permitted. Evaluation criteria for clinical effectiveness The interval between injury and surgery, surgical duration, blood loss, hospitalization duration, total cost, fracture healing time, complications, and functional assessments were collected and reviewed. Complications included surgical site infections, nonunion of fractures, and iatrogenic radial nerve palsy. All patients underwent regular follow-up examinations, including clinical and radiological assessments, to evaluate their healing progress and the occurrence of complications. At the final follow-up, the same surgeon assessed shoulder and elbow function using the University of California at Los Angeles (UCLA) shoulder score and the Mayo Elbow Performance Score (MEPS). Statistical analysis All results were analyzed using SPSS 26.0 for Windows (IBM, Armonk, NY, USA) and are expressed as mean ± standard deviation. Fisher’s exact test was used to compare differences in patient characteristics between the two groups, including sex, mechanism of injury, and fracture classification, as well as clinical and radiological outcomes. Student’s t-test was employed to compare age, surgical duration, blood loss, total costs, length of hospital stay, healing time, and functional scores between the two groups. Fisher’s exact test was also used to assess the incidence of complications, including nerve injuries, elbow stiffness, and nonunion of fractures. A p -value of < 0.05 was considered statistically significant. Results General information A total of 30 patients who underwent orthopedic surgery for EADHF from January 2018 to June 2023 were included in the study cohort. Based on the matching method, the patients were divided into the new plate group and the dual-plate group. The new plate group comprised 12 patients with a mean age of 37.00 ± 18.18 years (range, 18–68 years). The dual-plate group comprised 18 patients with a mean age of 32.56 ± 11.92 years (range, 18–57 years). The initial injuries were caused by traffic accidents in 7 patients, falls in 16, and arm wrestling in 7. According to the AO/OTA classification[ 20 ], the new plate group included 3 patients with type A fractures, 6 with type B fractures, and 3 with type C fractures. The dual-plate group included 3 patients with type A fractures, 10 with type B fractures, and 5 with type C fractures. All patients were followed up for at least 1 year, with no cases of death or loss to follow-up. There were no significant differences between the two groups in terms of mean age, sex composition, or fracture type. The baseline characteristics are listed in Table 1 . Table 1 Comparison of baseline characteristics and demographic data between the two groups New plate group Dual-plate group p -value Number of cases 12 18 Gender (male/female) 9/3 12/6 0.704 Age (years) 37.00 ± 18.18 32.56 ± 11.92 0.424 Extremity side (right/left) 8/4 9/9 0.465 Injury mechanism 0.887 Fall 7 9 Arm wrestling 2 5 Traffic accident 3 4 Fracture type (AO/ OTA Classification) 0.889 A 3 3 B 6 10 C 3 5 Follow-up (months) 14.42 ± 1.08 14.56 ± 1.10 0.735 Data are presented as n or mean ± standard deviation. Operative records The mean operative time was significantly lower in the new plate group than in the dual-plate group (137.58 ± 13.04 vs. 152.67 ± 10.64 minutes in the new plate and dual-plate group, respectively, p = 0.002). However, there was no significant difference in blood loss between the two groups (168.33 ± 32.78 vs. 181.39 ± 29.35 mL in the new plate and dual-plate group, respectively; p = 0.264). These results are summarized in Table 2 and presented graphically in Fig. 4 . Table 2 Comparison of results of different treatment methods New plate group Dual-plate group p -value Interval between injury and surgery (days) 3.08 ± 1.98 3.61 ± 1.94 0.475 Operation time (min) 137.58 ± 13.04 152.67 ± 10.64 0.002 Blood loss (ml) 168.33 ± 32.79 181.39 ± 29.35 0.264 Hospital stays 7.92 ± 1.88 8.22 ± 2.16 0.693 Hospitalization cost (yuan) 28,729.66± 4,051.13 36,953.69± 3,269.30 <0.001 Union time (weeks) 19.42 ± 1.88 21.17 ± 1.65 0.031 UCLA score 33.17 ± 0.87 34.17 ± 0.38 0.632 MEPS 95.83 ± 1.35 95.56 ± 1.21 0.983 Data are presented as mean ± standard deviation. UCLA, University of California at Los Angeles; MEPS, Mayo Elbow Performance Score. Hospitalization costs The difference in hospitalization costs between the two treatment groups was statistically significant ( p < 0.001). The mean hospitalization cost was lower in the new plate group than in the dual-plate group (28,729.66 ± 4,051.13 vs. 36,953.69 ± 3,269.30 yuan in the new plate and dual-plate group, respectively; Table 2 , Fig. 4 ). Fracture union The difference in the fracture union time between the two treatment groups was statistically significant ( p = 0.031). Patients in the new plate group experienced a shorter union time than those in the dual-plate group (19.42 ± 1.88 vs. 21.17 ± 1.65 months in the new plate and dual-plate group, respectively; Table 2 , Fig. 4 ). Functional outcomes All patients in both groups were able to return to their previous jobs. There was no significant difference in the mean UCLA shoulder score between the new plate group and the dual-plate group (33.17 ± 0.87 vs. 34.17 ± 0.38 in the new plate and dual-plate group, respectively; p = 0.632) at the last follow-up. Similarly, the mean MEPS showed no significant difference between the new plate group and the dual-plate group (95.83 ± 1.35 vs. 95.56 ± 1.21 in the new plate and dual-plate group, respectively; p = 0.938) at the last follow-up. These results are summarized in Table 2 and presented graphically in Fig. 4 . Complications All patients achieved good clinical and radiological outcomes, with no complications requiring a second surgery at the last follow-up, such as wound infections, implant fractures, nonunion, or neurovascular compromise. In the new plate group, one patient underwent removal of the internal fixation for personal reasons 14 months postoperatively. In the dual-plate group, one patient experienced postoperative radial nerve symptoms, which resolved spontaneously after 11 weeks of conservative treatment. Case presentation Case 1 An 18-year-old man sustained an EADHF from a fall and was treated with the new plate 3 days later. Postoperatively, regular follow-ups were conducted. The fracture fully healed 18 weeks after the injury, and the patient underwent removal of the internal fixation after 14 months for personal reasons. At the last follow-up, the elbow and shoulder joints had returned to normal function (Fig. 5 ). Case 2 A 20-year-old man sustained an EADHF in a traffic accident and was treated with dual plating 3 days later. Postoperatively, regular follow-ups were conducted. The fracture fully healed 20 weeks after the injury, and the patient did not require a second surgery. At the last follow-up, the elbow and shoulder joints had returned to normal function (Fig. 6 ). Discussion This study demonstrates that both the anatomical plate and dual plates are effective in treating EADHF, with patients achieving favorable outcomes. All patients tolerated the internal fixation well, and no complications required reoperation. Compared with traditional dual-plate fixation, the new anatomical plate resulted in a shorter surgery duration, lower overall costs, and faster fracture healing, offering significant advantages in the management of these fractures. The distal humerus transitions from a cylindrical shape in the diaphysis to a wider triangular prism at the distal end, where the cortex is thinner and the bone structure is weaker. EADHFs occur at the junction of these shapes, making it the mechanically weakest point of the humerus. The proximity of the fracture site to the joint, along with the presence of comminuted small bone fragments, complicates treatment. EADHF treatment failure is primarily due to instability of the initial fixation, accounting for 75% of cases[ 21 ]. Although conservative treatment methods can avoid the risks associated with surgery and reduce costs, they may lead to rotational and angular deformities, as well as instability of fixation, ultimately impairing shoulder and elbow function[ 22 , 23 ]. Additionally, Jawa et al. [ 16 ] compared functional bracing with plate and screw fixation, concluding that surgical treatment provides better fracture alignment and improved functional outcomes. Furthermore, with improvements in living standards, surgical treatment has become increasingly popular because it effectively shortens the recovery time, which is particularly important for younger patients[ 24 ]. In the surgical treatment of EADHF, rigid fixation and early mobilization of the elbow joint are essential to minimize the risk of nonunion during fracture healing. However, because of the strong torsional forces exerted by surrounding muscles and the difficulty in securing small distal fragments, there is no clear consensus on the optimal choice of implants for this type of fracture. Most practitioners prefer using plates to stabilize fractures in this region, requiring proximal and distal extension for effective fixation. Distal extension necessitates the plate reaching the posterior non-articular portion of the lateral column, making traditional straight plates challenging to use. Additionally, with traditional single-plate fixation, inserting three screws (engaging six cortices) in the distal fragment is often difficult. The most distal screw may only achieve single-cortex fixation, increasing the risk of pull-out, particularly in patients with osteoporosis. This inadequate fixation can lead to delayed union or nonunion of the fracture. As a result, dual-plate fixation is often required to stabilize the distal fragment by ensuring the placement of a sufficient number of screws[ 25 ]. Dual-plate fixation allows at least four screws with eight cortical fixation points to secure the distal fracture, providing greater resistance to stress[ 26 ]. A biomechanical study[ 27 ] has demonstrated that the fixation strength of dual plates combined with multiple screws surpasses that of single-plate fixation. However, dual-plate fixation requires extensive soft tissue dissection, which can prolong the surgical duration and disrupt the blood supply, increasing the risks of infection, nonunion, and nerve injury [ 16 , 28 ]. In a study by El Mahboub [ 29 ] involving 30 patients with EADHF treated with dual-plate fixation, 2 patients experienced delayed healing, necessitating bone grafting. Additionally, dual-plate fixation requires manual bending to match the bone structure, which can lead to excessive deformation of the screw holes, reducing resistance of the plate and potentially resulting in fatigue failure[ 30 ]. To address these challenges, experts have explored various methods, including the use of plates designed for different anatomical locations. Parmaksizoglu[ 31 ] utilized titanium cobra head plates, originally designed for the distal tibia, to treat distal humeral fractures, achieving complete healing in all 23 patients. However, these plates require customization to match pre-measured angles of inclination, ensuring proper conformity to the distal humeral anatomy. Li et al.[ 32 ] creatively repurposed the proximal humeral interal locking system (PHILOS) plate, originally designed for the proximal humerus, by inverting it for use in treating EADHFs. The authors reported favorable outcomes in all 20 patients, none of whom required reoperation for complications. Some researchers have also recommended altering the angle of plate placement to enhance stabilization. Moran[ 33 ] employed an oblique posterior plate set at an angle of 5 to 8 degrees relative to the longitudinal axis of the humerus, improving distal fragment fixation but compromising the stabilization of proximal fragments. Following a similar principle, Yang et al.[ 34 ] used an oblique metaphyseal end locking compression plate to stabilize fractures, achieving a healing success rate of 84.4%; however, because of medial deviation of the proximal plate end, fixation in long oblique and spiral fractures extending toward the diaphysis was less than ideal. Other single-plate designs have also emerged. Saragaglia et al.[ 17 ] developed a “Lambda” plate for EADHF, featuring an inverted Y-shaped design with a stem and two branching arms that can be reshaped to match fracture specifics. However, as a compression plate without locking holes, it carries a risk of inadequate fixation in comminuted and osteoporotic bones. Spitzer et al.[ 18 ] reported encouraging results using a “hybrid” metaphyseal plate for distal humeral fractures, featuring 4.5-mm locking holes on one end and 3.5-mm locking holes on the other; all 21 fractures healed within an average of 4.5 months without infection or implant failure. Trikha et al.[ 4 ] used an Extra-Articular Distal Humeral Locking Plate (EADHP), a “J”-shaped titanium plate designed for the posterolateral surface of the distal humerus. They reported successful healing in 34 patients within 3 months, restoration of elbow range of motion, and a mean MEPS of 90.8 ± 9.9. However, most patients experienced susceptibility to hardware prominence on the lateral aspect of the elbow, particularly in slender individuals, with nearly all reporting lateral elbow pain when struck by an object. Collectively, these studies suggest that specialized single-plate designs can provide effective fixation for rehabilitation, offering advantages such as reduced periosteal stripping and faster fracture healing. With the emergence of anatomically pre-contoured locking plates, the fixation of distal humeral extra-articular fractures has improved, reducing the need for dual plating,[ 35 ] including in this study. The main advantage of our study is the introduction of a strong fixation technique using a new plate, improving the shortcomings of conventional single-plate and dual-plate fixation for EADHF. The new plate is a single-plate system that allows for the placement of a higher number of screws in the distal segment, combining the advantages of single-plate use with enhanced postoperative stability through increased distal screw density. Additionally, as a locking plate system, it provides greater rigidity, helping to resist bending and torsional stresses[ 27 ]. The placement of the plate on the anterolateral aspect of the distal humerus offers higher torsional strength than does posterolateral plate placement[ 36 ]. Designed with evenly distributed screws, the new anatomical plate provides sufficient spacing between screws to disperse stress, preventing proximal screw failure by utilizing a longer plate with a uniform screw distribution[ 37 ]. In our study, no instances of internal fixation device or screw failure were observed. It has been reported that single-plate fixation is more time-efficient than dual-plate fixation [ 38 ], which aligns with the findings of this study. Our results showed that using the new plate significantly reduced the surgery duration ( p = 0.002). This can be attributed to the fact that the new plate requires fewer screws than dual-plate fixation. The increased number of screws in dual plating is unavoidable, leading to a prolonged surgical time. Additionally, the new anatomical plate features a pre-contoured structure that conforms to the regional anatomy, eliminating the need for bending and adjustments, further contributing to a shorter operative time. A reduced surgical duration also minimizes the exposure of the surgical site to the operating room environment, thereby lowering the risk of postoperative infection[ 39 ]. Scolaro et al.[ 28 ] demonstrated that a single anatomical plate can achieve rigid fixation and reliable healing, with a 95% success rate for treating EADHF without the need for bone grafting. In our study, the new anatomical plate achieved complete healing, with a significantly faster healing rate than dual plating ( p = 0.031). Dual-plate fixation typically requires more extensive dissection of the soft tissues around the fracture site, whereas the placement of the new plate involves less soft tissue disruption. This reduced dissection minimizes periosteal detachment from the bone, helping to preserve the blood supply at the fracture ends. By maintaining better vascularity, the biological healing potential of the fracture is maximized, leading to an accelerated healing process and allowing patients to begin early mobilization and return to work sooner. With advancements in the medical field, commercialization and consumerism have contributed to growing dissatisfaction among patient populations, particularly in response to rising healthcare costs. Patients have increasingly begun to question the motivations of their physicians, which can exacerbate tensions in the doctor–patient relationship[ 40 ]. In our study, the use of the new anatomical plate was associated with a significant reduction in total hospitalization costs ( p < 0.001). This decrease in overall expenses may help alleviate conflicts between doctors and patients, ultimately enhancing patient satisfaction. In our study, all patients who received the new anatomical plate achieved complete recovery, with no postoperative complications observed. However, special attention must be given to the risk of intraoperative radial nerve injury when treating EADHF. The radial nerve is located close to the distal humeral shaft, making it particularly vulnerable to iatrogenic injury during surgical procedures in this area[ 41 ]. Studies indicate that radial nerve palsy occurs in up to 29% of humeral fractures, and because of the nerve’s proximity to the distal humerus, the risk of iatrogenic injury may increase during plate fixation treatments[ 42 ]. In our study, there were no instances of radial nerve injury in the new anatomical plate group, whereas one patient in the dual-plate group experienced postoperative radial nerve palsy. However, this condition resolved by the 11th week of follow-up and did not result in significant functional limitations. We believe this difference may be related to surgical techniques. Yang et al.[ 34 ] reported an incidence of iatrogenic radial nerve palsy of 5.3% with single-plate fixation, which is slightly lower than the 10.1% reported by Vazquez et al [ 43 ]. A possible explanation for this discrepancy is that dual-plate techniques require extensive soft tissue dissection. Because the radial nerve is located distally and laterally to the humerus, it faces a heightened risk of injury due to the greater degree of soft tissue manipulation and handling of the fracture during dual-plate fixation. The limitations of this study include its small sample size and relatively short follow-up period, necessitating further follow-up to evaluate long-term outcomes. Additionally, the retrospective nature of our study introduces inherent limitations compared with prospective designs. Future research should focus on multicenter, large-sample, and sufficiently powered randomized controlled trials to comprehensively assess the effectiveness of the new plate in the treatment of EADHF. Conclusion Both the new single-plate and dual-plate fixation methods effectively stabilize EADHF, leading to successful fracture healing. The new anatomical plate has demonstrated promising results, significantly reducing the surgery time, shortening the healing duration, and lowering treatment costs. It presents a viable alternative treatment option for these fractures. However, larger-scale studies and longer-term follow-ups are necessary to fully confirm its efficacy and long-term benefits. Abbreviations EADHFs Extra-articular distal humeral fractures UCLA University of California Los Angeles MEPS Mayo Elbow Performance Scale ORIF Open reduction and internal fixation IMN Intramedullary nailing NSAIDs Nonsteroidal anti-inflammatory drugs PHILOS Proximal humeral interal locking system Declarations Acknowledgments Not applicable Author contributions DJL contributed to the idea of this study; WWB wrote the manuscript; LLX and DJL performed surgeries; XJJ and YCH collected the follow-up data; XLP , YXC and LS performed statistical analysis and data management; LLX and XWC supervised the study; DJL, LFX and XLP were major contributor in the revision of this manuscript. All authors revised the manuscript and approved the final version. Funding This study was supported by funds from the Shandong Province Major Scientific and Technical Innovation Project (No. 2021SFGC0502), Shandong Provincial Natural Science Foundation (No. ZR2022MH056), Shandong Provincial Natural Science Foundation (No. ZR2021QH307) and the Shandong Provincial Natural Science Foundation (No. ZR2023QH498). Data availability Data can be provided upon reasonable request from the corresponding author. Ethics approval and consent to participate All experimental procedures were approved by the Human Ethics Committee of Shandong Provincial Hospital Affiliated to Shandong First Medical University (SWYX: NO.2022-590). All aspects of this study were conducted with adherence to the current version of the Declaration of Helsinki, the guidelines established by the International Conference on Harmonization of Good Clinical Practice, and the laws of China. All participants signed informed consent forms before enrollment. Consent for publication Written informed consent was obtained from the patient for publication of this case report and any accompanying images. Competing interests The authors declare that they have no competing interests Disclaimer The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article. References Singh AK, Narsaria N, Seth RR, Garg S. Plate osteosynthesis of fractures of the shaft of the humerus: comparison of limited contact dynamic compression plates and locking compression plates. J Orthop Traumatol. 2014;15:117–22. Ekholm R, Adami J, Tidermark J, Hansson K, Törnkvist H, Ponzer S. Fractures of the shaft of the humerus: an epidemiological study of 401 fractures. J Bone Joint Surg Br. 2006;88:1469–73. Zhao J-G, Wang J, Meng X-H, Zeng X-T, Kan S-L. 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A single-centre prospective randomized study. Int Orthop. 2020;44:2113–21. Matsunaga FT, Tamaoki MJS, Matsumoto MH, Netto NA, Faloppa F, Belloti JC. Minimally Invasive Osteosynthesis with a Bridge Plate Versus a Functional Brace for Humeral Shaft Fractures: A Randomized Controlled Trial. J Bone Joint Surg Am. 2017;99:583–92. Scaglione M, Fabbri L, Dell’ Omo D, Goffi A, Guido G. The role of external fixation in the treatment of humeral shaft fractures: A retrospective case study review on 85 humeral fractures. Injury. 2015;46:265–9. Shin S-J, Kwak J-W, Sohn H-S. Comparison between anterior and posterior plating systems in extra-articular distal-third diaphyseal humeral fractures. Int Orthop. 2022;46:2119–26. Zimmerman MC, Waite AM, Deehan M, Tovey J, Oppenheim W. A Biomechanical Analysis of Four Humeral Fracture Fixation Systems. J Orthop Trauma. 1994;8:233–9. Carroll EA, Schweppe M, Langfitt M, Miller AN, Halvorson JJ. Management of humeral shaft fractures. J Am Acad Orthop Surg. 2012;20:423–33. Gallucci G, Boretto J, Vujovich A, Alfie V, Donndorff A, De Carli P. Posterior minimally invasive plate osteosynthesis for humeral shaft fractures. Tech Hand Up Extrem Surg. 2014;18:25–30. Kosmopoulos V, Luedke C, Nana AD. Dual small fragment plating improves screw-to-screw load sharing for mid-diaphyseal humeral fracture fixation: a finite element study. Technol Health Care. 2015;23:83–92. Jawa A, McCarty P, Doornberg J, Harris M, Ring D. Extra-articular distal-third diaphyseal fractures of the humerus. A comparison of functional bracing and plate fixation. J Bone Joint Surg Am. 2006;88:2343–7. Saragaglia D, Rouchy R-C, Mercier N. Fractures of the distal humerus operated on using the Lambda® plate: Report of 75 cases at 9.5 years follow-up. Orthop Traumatol Surg Res. 2013;99:707–12. Spitzer AB, Davidovitch RI, Egol KA. Use of a “hybrid” locking plate for complex metaphyseal fractures and nonunions about the humerus. Injury. 2009;40:240–4. Mills WJ, Hanel DP, Smith DG. Lateral approach to the humeral shaft: an alternative approach for fracture treatment. J Orthop Trauma. 1996;10:81–6. Meinberg EG, Agel J, Roberts CS, Karam MD, Kellam JF. Fracture and Dislocation Classification Compendium-2018. J Orthop Trauma. 2018;32 Suppl 1:S1–170. Oliver WM, Searle HKC, Ng ZH, Molyneux SG, White TO, Clement ND, et al. Factors associated with humeral shaft nonunion. J Shoulder Elbow Surg. 2021;30:2283–95. Ring D, Jawa A, Cannada L. Clinical Faceoff: Are Distal-third Diaphyseal Humerus Fractures Best Treated Nonoperatively? Clin Orthop Relat Res. 2016;474:310–4. Papasoulis E, Drosos GI, Ververidis AN, Verettas D-A. Functional bracing of humeral shaft fractures. A review of clinical studies. Injury. 2010;41:e21–7. Gottschalk MB, Carpenter W, Hiza E, Reisman W, Roberson J. Humeral Shaft Fracture Fixation: Incidence Rates and Complications as Reported by American Board of Orthopaedic Surgery Part II Candidates. J Bone Joint Surg Am. 2016;98:e71. Kharbanda Y, Tanwar YS, Srivastava V, Birla V, Rajput A, Pandit R. Retrospective analysis of extra-articular distal humerus shaft fractures treated with the use of pre-contoured lateral column metaphyseal LCP by triceps-sparing posterolateral approach. Strategies Trauma Limb Reconstr. 2017;12:1–9. Kosmopoulos V, Nana AD. Dual Plating of Humeral Shaft Fractures: Orthogonal Plates Biomechanically Outperform Side-by-Side Plates. Clin Orthop Relat Res. 2014;472:1310–7. Watts A, Weinhold P, Kesler W, Dahners L. A biomechanical comparison of short segment long bone fracture fixation techniques: single large fragment plate versus 2 small fragment plates. J Orthop Trauma. 2012;26:528–32. Scolaro JA, Voleti P, Makani A, Namdari S, Mirza A, Mehta S. Surgical fixation of extra-articular distal humerus fractures with a posterolateral plate through a triceps-reflecting technique. J Shoulder Elbow Surg. 2014;23:251–7. Mahboub NE, Arafat W. Open reduction and internal fixation of extra-articular comminuted distal humerus fractures by double-plating osteosynthesis. The Egyptian Orthopaedic Journal. 2012;47:393–8. Krishna KR, Sridhar I, Ghista DN. Analysis of the helical plate for bone fracture fixation. Injury. 2008;39:1421–36. Parmaksizoglu A, Özkaya U, Bilgili F, Mutlu H, Çetin Ü. Fixation of extra-articular distal humeral fractures with a lateral approach and a locked plate: an alternative method. Acta Orthop Traumatol Turc. 2015;50:132–8. Li G, Cui Y, Hua X, Liu F, Li D, Lu J, et al. Management of extra-articular fracture of the distal humerus with the upside-down use of PHILOS plates in front of the humerus: a retrospective study of 20 patients after 28.3 months. BMC Musculoskelet Disord. 2024;25:952. Moran MC. Modified Lateral Approach to the Distal Humerus for Internal Fixation. Clin Orthop Relat Res. 1997;340:190–7. Yang Q, Wang F, Wang Q, Gao W, Huang J, Wu X, et al. Surgical Treatment of Adult Extra-Articular Distal Humeral Diaphyseal Fractures Using an Oblique Metaphyseal Locking Compression Plate via a Posterior Approach. Med Princ Pract. 2012;21:40–5. Gösling T, Schandelmaier P, Marti A, Hufner T, Partenheimer A, Krettek C. Less Invasive Stabilization of Complex Tibial Plateau Fractures: A Biomechanical Evaluation of a Unilateral Locked Screw Plate and Double Plating. J Orthop Trauma. 2004;18:546–51. Mutlu H, Polat A, Çetin MÜ, Mutlu S, Demir T, Parmaksizoğlu AS. A NEW ANATOMICAL PLATE FOR EXTRA-ARTICULAR DISTAL HUMERAL FRACTURES: BIOMECHANICAL STUDY. Acta Ortop Bras. 2022;30:e248473. Jain D, Goyal GS, Garg R, Mahindra P, Yamin M, Selhi HS. Outcome of anatomic locking plate in extraarticular. Indian J Orthop. 2017;51. Aggarwal S, Kumar V, Bhagwat KR, Behera P. AO extra-articular distal humerus locking plate: extended spectrum of usage in intra-articular distal fractures with metaphyseal extension—our experience with 20 cases. Eur J Orthop Surg Traumatol. 2014;24:505–11. Cheng H, Chen BP-H, Soleas IM, Ferko NC, Cameron CG, Hinoul P. Prolonged Operative Duration Increases Risk of Surgical Site Infections: A Systematic Review. Surg Infect (Larchmt). 2017;18:722–35. Harbishettar V, Krishna K, Srinivasa P, Gowda M. The enigma of doctor-patient relationship. Indian J Psychiatry. 2019;61:776. Walker M, Palumbo B, Badman B, Brooks J, Van Gelderen J, Mighell M. Humeral shaft fractures: a review. J Shoulder Elbow Surg. 2011;20:833–44. Shao YC, Harwood P, Grotz MRW, Limb D, Giannoudis PV. Radial nerve palsy associated with fractures of the shaft of the humerus: a systematic review. J Bone Joint Surg Br. 2005;87-B:1647–52. Vazquez O, Rutgers M, Ring DC, Walsh M, Egol KA. Fate of the ulnar nerve after operative fixation of distal humerus fractures. J Orthop Trauma. 2010;24:395–9. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6314432","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":446793882,"identity":"a5826f4f-4f3b-48ed-a986-529180ad7fb3","order_by":0,"name":"Wenbo Wang","email":"","orcid":"","institution":"Shandong Provincial Hospital, Shandong First Medical University","correspondingAuthor":false,"prefix":"","firstName":"Wenbo","middleName":"","lastName":"Wang","suffix":""},{"id":446793883,"identity":"fdded63b-c7f9-4846-9301-a84d76972879","order_by":1,"name":"Liping Xia","email":"","orcid":"","institution":"Chinese PLA General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Liping","middleName":"","lastName":"Xia","suffix":""},{"id":446793884,"identity":"7d21edae-1fa9-4def-a5a0-0c9f344b6c6d","order_by":2,"name":"Fanxiao Liu","email":"","orcid":"","institution":"Shandong Provincial Hospital, Shandong First Medical University","correspondingAuthor":false,"prefix":"","firstName":"Fanxiao","middleName":"","lastName":"Liu","suffix":""},{"id":446793885,"identity":"378cfd32-74c8-4634-91c1-7cc4f35f47a2","order_by":3,"name":"Jiajun Xu","email":"","orcid":"","institution":"Shandong Provincial Hospital, Shandong First Medical University","correspondingAuthor":false,"prefix":"","firstName":"Jiajun","middleName":"","lastName":"Xu","suffix":""},{"id":446793887,"identity":"cbf06748-5187-48b3-8fbb-5b375e733e0a","order_by":4,"name":"Zhanchuan Yu","email":"","orcid":"","institution":"Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Zhanchuan","middleName":"","lastName":"Yu","suffix":""},{"id":446793889,"identity":"e40093e0-c8d0-4498-8572-1874b9cb3e69","order_by":5,"name":"Changhao Yang","email":"","orcid":"","institution":"Shandong Provincial Hospital, Shandong First Medical University","correspondingAuthor":false,"prefix":"","firstName":"Changhao","middleName":"","lastName":"Yang","suffix":""},{"id":446793891,"identity":"68ea1b65-d43e-49ee-8d9a-e43e4e5fa5cd","order_by":6,"name":"Shun Lu","email":"","orcid":"","institution":"Shandong Provincial Hospital, Shandong First Medical University","correspondingAuthor":false,"prefix":"","firstName":"Shun","middleName":"","lastName":"Lu","suffix":""},{"id":446793893,"identity":"6bb36bad-bff2-4365-83d4-246864e4b2e5","order_by":7,"name":"Weicheng Xu","email":"","orcid":"","institution":"Shandong Provincial Hospital, Shandong First Medical University","correspondingAuthor":false,"prefix":"","firstName":"Weicheng","middleName":"","lastName":"Xu","suffix":""},{"id":446793895,"identity":"2ee22f7e-7855-4c4a-902f-fc598f3074a1","order_by":8,"name":"Lianxin Li","email":"","orcid":"","institution":"Shandong Provincial Hospital, Shandong First Medical University","correspondingAuthor":false,"prefix":"","firstName":"Lianxin","middleName":"","lastName":"Li","suffix":""},{"id":446793897,"identity":"0875091a-7232-4782-8bee-c2ddee36bcc8","order_by":9,"name":"Jinlei Dong","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0ElEQVRIiWNgGAWjYDCCA0AsYcAgw8DMfODAhx8kaOFhYGZLPDizh1gtQMADRMaHOdiI0MF3vPfwC4uCOzz87DwfDgN1yvOLHcCvRfLMuTQLCYNnPJLNvBsOF1gwGM6cnYBfi8GNHDMDCYPDPAaHgVpm8DAkGNwmVov9YZ4Hh3nYiNNi/ABsCzMPA3FaJM+cMWMAaZE4zGYADGQJwn7hO95j/Fniz2E5/v7Djz98+GEjzy9NQAsQsElLIDgSuNUhAeaPH4hSNwpGwSgYBSMWAAAiRUO8EzHzMQAAAABJRU5ErkJggg==","orcid":"","institution":"Shandong Provincial Hospital, Shandong First Medical University","correspondingAuthor":true,"prefix":"","firstName":"Jinlei","middleName":"","lastName":"Dong","suffix":""}],"badges":[],"createdAt":"2025-03-26 17:08:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6314432/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6314432/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82119671,"identity":"b8e1c8b2-2593-4b1a-9644-01f20b33d8e9","added_by":"auto","created_at":"2025-05-07 03:10:46","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1951299,"visible":true,"origin":"","legend":"\u003cp\u003eThe flowchart shows the exclusion criteria.\u003c/p\u003e\n\u003cp\u003eEADHF, extra-articular distal humeral fracture\u003c/p\u003e","description":"","filename":"Fig.1.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6314432/v1/3c093b5b9e926f94856b59ee.jpg"},{"id":82119675,"identity":"db4b4058-c16e-432c-9217-e3e1a5ceec1b","added_by":"auto","created_at":"2025-05-07 03:10:47","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":992484,"visible":true,"origin":"","legend":"\u003cp\u003eThe new anatomical plate is available in three different lengths. (A) Front view, (B) right-side view, and (C) left-side view of the plates. (D) The short plate aligning with the humerus. (E) The medium plate aligning with the humerus. (F) The long plate aligning with the humerus, featuring an arch structure designed to protect the deltoid insertion point.\u003c/p\u003e","description":"","filename":"Fig.2.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6314432/v1/b8293266b58ed82502674f22.jpg"},{"id":82120723,"identity":"47e22f9e-c4c0-495e-ac20-4a23817c136a","added_by":"auto","created_at":"2025-05-07 03:18:46","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1715066,"visible":true,"origin":"","legend":"\u003cp\u003eKey findings during the surgical procedure. (A) Lateral incision on the upper arm. (B) Anterior view of the lateral incision. (C) Identification of the radial nerve positioned between the brachialis and brachioradialis muscles. (D) Proximal window: Proximal section of the plate secured to the proximal humerus. (E) Mid-window: The plate’s middle section secured between the brachialis and brachioradialis muscles. (F) Distal window: Distal section of the plate secured to the distal humerus.\u003c/p\u003e","description":"","filename":"Fig.3.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6314432/v1/d47b9d0507a3840affe8a323.jpg"},{"id":82119672,"identity":"3395e8fc-bf0c-4362-9540-deb333a67338","added_by":"auto","created_at":"2025-05-07 03:10:46","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":175968,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of clinical outcomes between new plate group and dual-plate group. (A) Interval between injury and surgery. (B) Hospital stays. (C) Operative time. (D) Blood loss. (E) Hospitalization cost. (F) Fracture union time. (G) UCLA score. (H) MEPS.\u003c/p\u003e\n\u003cp\u003e*\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05, **\u003cem\u003ep\u003c/em\u003e\u0026lt; 0.01.\u003c/p\u003e\n\u003cp\u003eUCLA, University of California at Los Angeles; MEPS, Mayo Elbow Performance Score.\u003c/p\u003e","description":"","filename":"Fig.4.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6314432/v1/3a380b438809e28414ba9368.jpg"},{"id":82119678,"identity":"027d0e2d-ce3b-4a3d-83b2-0d074cc21fb2","added_by":"auto","created_at":"2025-05-07 03:10:47","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":1724231,"visible":true,"origin":"","legend":"\u003cp\u003eCase 1. (A) An 18-year-old man sustained an extra-articular distal humeral fracture in a fall. (B) Postoperative radiograph after fixation with a new anatomical plate. Postoperative anteroposterior and lateral radiographs after (C) 3 months and (D) 6 months. (E) This patient requested implant removal for personal reasons after 14 months. Postoperative anteroposterior and lateral radiographs showed complete bony union with satisfactory alignment. (F) Anteroposterior and lateral radiographs after plate removal. (G) Clinical photograph showing healed incision. (H, I) The patient had excellent elbow functionality. (J, K) The patient had excellent shoulder function.\u003c/p\u003e","description":"","filename":"Fig.5.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6314432/v1/6a436af83c20e758b9080130.jpg"},{"id":82119679,"identity":"840b95ce-cc5d-4a3c-af53-428fbeb529d3","added_by":"auto","created_at":"2025-05-07 03:10:47","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":1558821,"visible":true,"origin":"","legend":"\u003cp\u003eCase 2. (A) A 20-year-old man sustained an extra-articular distal humeral fracture in a traffic accident. (B) Postoperative radiograph after fixation with dual plates. (C) Postoperative anteroposterior and lateral radiographs after 3 months. Anteroposterior and lateral radiographs (D) 6 months and (E) 15 months postoperatively showing complete bony union with satisfactory alignment. (F) Clinical photograph showing healed incision. (G, H) The patient had excellent elbow function. (I, J) The patient had excellent shoulder function.\u003c/p\u003e","description":"","filename":"Fig.6.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6314432/v1/053486382f4e5712f8d2e25f.jpg"},{"id":83661759,"identity":"97b93c22-a4be-4b88-9e6e-9f7be2bf5e12","added_by":"auto","created_at":"2025-05-30 10:08:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":8922100,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6314432/v1/99c0672a-bd1a-4524-9bef-911193c101f5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A new anatomical plate fixation verse dual plates fixation in the treatment of extra-articular distal humeral fractures: a retrospective study of 30 cases","fulltext":[{"header":"Background","content":"\u003cp\u003eHumeral shaft fractures are relatively common, accounting for 3\u0026ndash;5% of all fractures[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Among these, extra-articular distal humeral fractures (EADHFs) constitute approximately 16% of humeral fractures[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. These fractures occur between the humeral shaft and the supracondylar region, often presenting with displacement, comminution, and relatively small fracture fragments[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Treatment outcomes are frequently associated with elbow stiffness, weakness, and pain. A pain-free, stable, and mobile elbow joint is essential for performing daily activities[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Additionally, these fractures carry a high risk of complications such as nonunion and radial nerve injury following treatment. Given the limited treatment options, managing these fractures remains a significant challenge for orthopedic surgeons.\u003c/p\u003e \u003cp\u003eThe goal of EADHF treatment is to achieve stable fixation and proper alignment, allowing for early mobilization of the elbow and shoulder joints[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Because of the unique morphology of the distal humerus and the muscular forces acting on the fracture site, conservative treatment often fails to achieve therapeutic objectives and may lead to elbow joint stiffness and an increased incidence of nonunion[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. A randomized controlled trial demonstrated that surgical treatment for EADHF results in better outcomes than conservative management[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSurgical options for EADHFs include internal and external fixation techniques. External fixation is primarily used for temporary stabilization or in emergency situations. However, it carries risks such as fracture loosening and pin-track infections[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Open reduction and internal fixation (ORIF) is widely regarded as the gold standard for treating these fractures and including plate fixation and intramedullary nailing (IMN) [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, IMN requires sufficient bone stock at the distal fracture site and an adequate area for effective fixation. The small size of the distal humeral fragments and the narrow medullary canal make securing intramedullary devices challenging[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Therefore, most surgeons opt for plate fixation in patients with EADHFs. However, the failure rate for traditional single-plate fixation in distal humeral fractures is approximately 5%, with a reported nonunion rate of 2\u0026ndash;6%[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Dual-plate fixation is commonly employed to provide multiple fixation points to the distal fragments[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], offering greater resistance to torsional forces and improved stability under lateral stress[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. However, this technique presents challenges, such as difficulty in prebending the steel plate, a relatively complex surgical procedure, and extensive soft tissue stripping around the fracture, which can affect blood supply and prolong the surgery duration[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. To address these issues, various plating techniques have been proposed, including the lambda plate, metaphyseal plates, and extra-articular locking plates for the distal humerus[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, their reliability and effectiveness have yet to be conclusively proven. Research into EADHF treatment continues, and a new type of plate has been developed specifically for these fractures.\u003c/p\u003e \u003cp\u003eThe new plate is a pre-contoured, anatomically shaped locking plate specifically designed for EADHF. We refer to it as the Distal Humeral Subcondylar Locking Plate (Double Medical, Xiamen, China). This retrospective study was performed to compare the clinical and functional outcomes of EADHF treatment using the new anatomical plate versus dual-plate fixation. Additionally, we sought to evaluate the safety, efficacy, and potential benefits of the new plate for patients.\u003c/p\u003e"},{"header":"Methods and materials","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eEthics and patients\u003c/h2\u003e \u003cp\u003e This study was approved by the Ethics Committee of our institution. All patients provided written informed consent, and the patient representing the typical case in this study also gave consent for their image to be published.\u003c/p\u003e \u003cp\u003eData from patients treated with either the new anatomical plate or dual plates for EADHF at our trauma center between January 2018 and June 2023 were retrospectively collected. Initially, 56 patients were identified. After applying the inclusion and exclusion criteria, 30 patients were included in the study.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eInclusion and exclusion criteria\u003c/h3\u003e\n\u003cp\u003eThe inclusion criteria in this retrospective study were as follows: (1) age\u0026thinsp;\u0026ge;\u0026thinsp;18 years; (2) a diagnosis of EADHF based on medical history, physical examination, and imaging, such as radiography or CT; (3) treatment by ORIF with either dual plates or the new anatomical plate; and (4) a follow-up period of more than 12 months.\u003c/p\u003e \u003cp\u003eThe exclusion criteria were as follows: (1) age\u0026thinsp;\u0026lt;\u0026thinsp;18 years; (2) any additional injuries around the elbow besides EADHF; (3) pathological fractures, open fractures, or fractures with neurovascular injury; (4) a history of shoulder disease or shoulder surgery; (5) a history of elbow disease or shoulder surgery; and (6) a history of mental illness. Patients were then categorized into two groups: those treated with the new anatomical plate (the new plate group) and those treated with dual plates (the dual-plate group) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eThe new anatomical plate\u003c/h3\u003e\n\u003cp\u003eThe new plate is a specially designed locking plate with a pre-contoured anatomical shape specifically for EADHF. Its design aligns with the natural shape of the humerus, eliminating the need for bending, ensuring excellent conformity, and reducing soft tissue irritation. The plate features a dual-row, multi-hole, multi-angle configuration of distal screw holes, allowing for multiple locking screws. This design enhances angular stability and provides strong shear resistance. The distal end of the plate includes a low-profile notch, enabling it to extend up to the area above the capitellum of the humerus. It is positioned above the joint capsule of the lateral epicondyle, preserving the joint capsule and maintaining elbow mobility. Additionally, the arched design of new plate allows for preservation of the deltoid muscle insertion point during surgery, minimizing damage to the deltoid muscle. This design helps address the issue of internal fixation failure caused by the influence of the deltoid muscle insertion position[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e](Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eSurgical method\u003c/h3\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eNew anatomical plate group\u003c/h2\u003e \u003cp\u003eThe surgery was performed by the same group of surgeons with the patient under general anesthesia and in the supine position on the operating table. The upper limb was abducted to a neutral position. Surgical incisions were made using an anterolateral approach, with the appropriate length determined based on the location of the fracture along the line connecting the deltoid muscle insertion point and the lateral humeral condyle. The skin and subcutaneous tissue were incised, followed by fascial flap dissection. At the elbow plane, blunt dissection was performed to expose the brachialis, brachioradialis, and biceps brachii muscles. The lateral cutaneous nerve of the forearm was identified in the interval between the biceps brachii and brachialis and was protected with a rubber band. The interval between the brachioradialis and brachialis was then explored to locate the radial nerve, which was retracted and protected using a rubber band. The interval between the brachioradialis and biceps brachii was sharply incised, and the biceps were retracted to expose the lateral and anterolateral aspects of the distal humeral shaft. The dissection was extended proximally to further expose the humerus. Once exposure was complete, the hematoma and soft tissue around the fracture site were removed, and the fracture ends were meticulously debrided under the periosteum. During fracture reduction, a simple spiral fracture was held in place using reduction clamps and stabilized with K-wires. In cases of comminuted fractures, the main fragments were reduced first, with the smaller fragments addressed afterward while preserving soft tissue attachments to promote healing. C-arm fluoroscopy was then used to confirm the adequacy of the reduction. The appropriate length of the new anatomical plate was selected, with the proximal end positioned on the lateral aspect of the middle to upper humerus and the distal end placed anterolaterally over the lateral epicondyle of the humerus. Screws were used for fixation, with at least three securing the proximal end and at least four securing the distal end. Compression screws were also utilized at the fracture site if necessary. Alignment and plate fixation were verified using C-arm X-ray fluoroscopy to ensure satisfactory fracture reduction and internal fixation. After extensive irrigation, a single negative-pressure drainage tube was placed inside the incision. The incision was then closed in layers, followed by the application of sterile dressings and a pressure bandage (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eDual-plate group\u003c/h2\u003e \u003cp\u003eThe fractures were exposed either through an anterolateral surgical incision using the previously described technique or, alternatively, through a posterior incision. For the posterior approach, the incision was made along a line connecting the posterolateral aspect of the acromion and the olecranon, with the length tailored to the specific location of the fracture. After making the incision, the skin, subcutaneous tissue, and fascia were divided to locate the distal tendon of the triceps brachii. Proximally, blunt dissection was performed to separate the interval between the long head and lateral head of the triceps brachii. The radial nerve was identified at the proximal portion of the medial head of the triceps brachii and was then retracted and protected with a rubber band. Distally, a sharp longitudinal split was made in the triceps tendon. The muscle tissue was retracted to either side, allowing exposure of the distal humeral fracture site. After fracture reduction, double plates of appropriate length were selected. One pre-bent plate was used for fixation on the lateral or posterolateral side, supported by a pre-bent plate on the anterolateral side.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePostoperative management\u003c/h3\u003e\n\u003cp\u003eBoth groups followed the same postoperative management plan. The condition of the distal nerves and blood vessels was evaluated and documented, and signs of infection at the surgical site were monitored. Routine antibiotic treatment was administered within the first 24 hours postoperatively to prevent wound infection, after which antibiotics were gradually discontinued based on the individual condition of patients. All patients had their wounds covered with bandages postoperatively and their arms secured in slings for 4 to 6 weeks. Additionally, nonsteroidal anti-inflammatory drugs (NSAIDs) were prescribed to alleviate acute pain. Closed negative-pressure drainage was maintained until the drainage volume fell below 20 mL within a 24-hour period.\u003c/p\u003e \u003cp\u003eOn the first day postoperatively, once the pain had subsided, the patients were encouraged to begin passive range-of-motion exercises for the shoulder and elbow joints of the injured limb, while movement of the unaffected limbs remained unrestricted. During the first week, active and assisted arm movements were performed while in the sling. Following radiographic evidence of bone healing, further weight-bearing and resistance activities were permitted.\u003c/p\u003e\n\u003ch3\u003eEvaluation criteria for clinical effectiveness\u003c/h3\u003e\n\u003cp\u003eThe interval between injury and surgery, surgical duration, blood loss, hospitalization duration, total cost, fracture healing time, complications, and functional assessments were collected and reviewed. Complications included surgical site infections, nonunion of fractures, and iatrogenic radial nerve palsy. All patients underwent regular follow-up examinations, including clinical and radiological assessments, to evaluate their healing progress and the occurrence of complications. At the final follow-up, the same surgeon assessed shoulder and elbow function using the University of California at Los Angeles (UCLA) shoulder score and the Mayo Elbow Performance Score (MEPS).\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eAll results were analyzed using SPSS 26.0 for Windows (IBM, Armonk, NY, USA) and are expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation. Fisher\u0026rsquo;s exact test was used to compare differences in patient characteristics between the two groups, including sex, mechanism of injury, and fracture classification, as well as clinical and radiological outcomes. Student\u0026rsquo;s t-test was employed to compare age, surgical duration, blood loss, total costs, length of hospital stay, healing time, and functional scores between the two groups. Fisher\u0026rsquo;s exact test was also used to assess the incidence of complications, including nerve injuries, elbow stiffness, and nonunion of fractures. A \u003cem\u003ep\u003c/em\u003e-value of \u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eGeneral information\u003c/h2\u003e \u003cp\u003eA total of 30 patients who underwent orthopedic surgery for EADHF from January 2018 to June 2023 were included in the study cohort. Based on the matching method, the patients were divided into the new plate group and the dual-plate group. The new plate group comprised 12 patients with a mean age of 37.00\u0026thinsp;\u0026plusmn;\u0026thinsp;18.18 years (range, 18\u0026ndash;68 years). The dual-plate group comprised 18 patients with a mean age of 32.56\u0026thinsp;\u0026plusmn;\u0026thinsp;11.92 years (range, 18\u0026ndash;57 years). The initial injuries were caused by traffic accidents in 7 patients, falls in 16, and arm wrestling in 7. According to the AO/OTA classification[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], the new plate group included 3 patients with type A fractures, 6 with type B fractures, and 3 with type C fractures. The dual-plate group included 3 patients with type A fractures, 10 with type B fractures, and 5 with type C fractures. All patients were followed up for at least 1 year, with no cases of death or loss to follow-up. There were no significant differences between the two groups in terms of mean age, sex composition, or fracture type. The baseline characteristics are listed in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of baseline characteristics and demographic data between the two groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNew plate\u003c/p\u003e \u003cp\u003egroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDual-plate group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of cases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender (male/female)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9/3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12/6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.704\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37.00\u0026thinsp;\u0026plusmn;\u0026thinsp;18.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.56\u0026thinsp;\u0026plusmn;\u0026thinsp;11.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.424\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExtremity side (right/left)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8/4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9/9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.465\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInjury mechanism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.887\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFall\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArm wrestling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTraffic accident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFracture type (AO/ OTA Classification)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.889\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow-up (months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.42\u0026thinsp;\u0026plusmn;\u0026thinsp;1.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.56\u0026thinsp;\u0026plusmn;\u0026thinsp;1.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.735\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eData are presented as n or mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eOperative records\u003c/h2\u003e \u003cp\u003eThe mean operative time was significantly lower in the new plate group than in the dual-plate group (137.58\u0026thinsp;\u0026plusmn;\u0026thinsp;13.04 vs. 152.67\u0026thinsp;\u0026plusmn;\u0026thinsp;10.64 minutes in the new plate and dual-plate group, respectively, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002). However, there was no significant difference in blood loss between the two groups (168.33\u0026thinsp;\u0026plusmn;\u0026thinsp;32.78 vs. 181.39\u0026thinsp;\u0026plusmn;\u0026thinsp;29.35 mL in the new plate and dual-plate group, respectively; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.264). These results are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003e and presented graphically in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of results of different treatment methods\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNew plate\u003c/p\u003e \u003cp\u003egroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDual-plate group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterval between injury and surgery (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e3.08\u0026thinsp;\u0026plusmn;\u0026thinsp;1.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e3.61\u0026thinsp;\u0026plusmn;\u0026thinsp;1.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.475\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperation time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e137.58\u0026thinsp;\u0026plusmn;\u0026thinsp;13.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e152.67\u0026thinsp;\u0026plusmn;\u0026thinsp;10.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood loss (ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e168.33\u0026thinsp;\u0026plusmn;\u0026thinsp;32.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e181.39\u0026thinsp;\u0026plusmn;\u0026thinsp;29.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.264\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospital stays\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e7.92\u0026thinsp;\u0026plusmn;\u0026thinsp;1.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e8.22\u0026thinsp;\u0026plusmn;\u0026thinsp;2.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.693\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospitalization cost (yuan)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e28,729.66\u0026plusmn;\u003c/p\u003e \u003cp\u003e4,051.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e36,953.69\u0026plusmn;\u003c/p\u003e \u003cp\u003e3,269.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnion time (weeks)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e19.42\u0026thinsp;\u0026plusmn;\u0026thinsp;1.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e21.17\u0026thinsp;\u0026plusmn;\u0026thinsp;1.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.031\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUCLA score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e33.17\u0026thinsp;\u0026plusmn;\u0026thinsp;0.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e34.17\u0026thinsp;\u0026plusmn;\u0026thinsp;0.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.632\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMEPS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e95.83\u0026thinsp;\u0026plusmn;\u0026thinsp;1.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e95.56\u0026thinsp;\u0026plusmn;\u0026thinsp;1.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.983\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eData are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eUCLA, University of California at Los Angeles; MEPS, Mayo Elbow Performance Score.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eHospitalization costs\u003c/h2\u003e \u003cp\u003eThe difference in hospitalization costs between the two treatment groups was statistically significant (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The mean hospitalization cost was lower in the new plate group than in the dual-plate group (28,729.66\u0026thinsp;\u0026plusmn;\u0026thinsp;4,051.13 vs. 36,953.69\u0026thinsp;\u0026plusmn;\u0026thinsp;3,269.30 yuan in the new plate and dual-plate group, respectively; Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eFracture union\u003c/h2\u003e \u003cp\u003eThe difference in the fracture union time between the two treatment groups was statistically significant (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.031). Patients in the new plate group experienced a shorter union time than those in the dual-plate group (19.42\u0026thinsp;\u0026plusmn;\u0026thinsp;1.88 vs. 21.17\u0026thinsp;\u0026plusmn;\u0026thinsp;1.65 months in the new plate and dual-plate group, respectively; Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eFunctional outcomes\u003c/h2\u003e \u003cp\u003eAll patients in both groups were able to return to their previous jobs. There was no significant difference in the mean UCLA shoulder score between the new plate group and the dual-plate group (33.17\u0026thinsp;\u0026plusmn;\u0026thinsp;0.87 vs. 34.17\u0026thinsp;\u0026plusmn;\u0026thinsp;0.38 in the new plate and dual-plate group, respectively; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.632) at the last follow-up. Similarly, the mean MEPS showed no significant difference between the new plate group and the dual-plate group (95.83\u0026thinsp;\u0026plusmn;\u0026thinsp;1.35 vs. 95.56\u0026thinsp;\u0026plusmn;\u0026thinsp;1.21 in the new plate and dual-plate group, respectively; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.938) at the last follow-up. These results are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003e and presented graphically in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eComplications\u003c/h2\u003e \u003cp\u003eAll patients achieved good clinical and radiological outcomes, with no complications requiring a second surgery at the last follow-up, such as wound infections, implant fractures, nonunion, or neurovascular compromise. In the new plate group, one patient underwent removal of the internal fixation for personal reasons 14 months postoperatively. In the dual-plate group, one patient experienced postoperative radial nerve symptoms, which resolved spontaneously after 11 weeks of conservative treatment.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eCase presentation\u003c/h2\u003e \u003cdiv id=\"Sec20\" class=\"Section3\"\u003e \u003ch2\u003eCase 1\u003c/h2\u003e \u003cp\u003eAn 18-year-old man sustained an EADHF from a fall and was treated with the new plate 3 days later. Postoperatively, regular follow-ups were conducted. The fracture fully healed 18 weeks after the injury, and the patient underwent removal of the internal fixation after 14 months for personal reasons. At the last follow-up, the elbow and shoulder joints had returned to normal function (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eCase 2\u003c/h2\u003e \u003cp\u003eA 20-year-old man sustained an EADHF in a traffic accident and was treated with dual plating 3 days later. Postoperatively, regular follow-ups were conducted. The fracture fully healed 20 weeks after the injury, and the patient did not require a second surgery. At the last follow-up, the elbow and shoulder joints had returned to normal function (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study demonstrates that both the anatomical plate and dual plates are effective in treating EADHF, with patients achieving favorable outcomes. All patients tolerated the internal fixation well, and no complications required reoperation. Compared with traditional dual-plate fixation, the new anatomical plate resulted in a shorter surgery duration, lower overall costs, and faster fracture healing, offering significant advantages in the management of these fractures.\u003c/p\u003e \u003cp\u003eThe distal humerus transitions from a cylindrical shape in the diaphysis to a wider triangular prism at the distal end, where the cortex is thinner and the bone structure is weaker. EADHFs occur at the junction of these shapes, making it the mechanically weakest point of the humerus. The proximity of the fracture site to the joint, along with the presence of comminuted small bone fragments, complicates treatment. EADHF treatment failure is primarily due to instability of the initial fixation, accounting for 75% of cases[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Although conservative treatment methods can avoid the risks associated with surgery and reduce costs, they may lead to rotational and angular deformities, as well as instability of fixation, ultimately impairing shoulder and elbow function[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Additionally, Jawa et al. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] compared functional bracing with plate and screw fixation, concluding that surgical treatment provides better fracture alignment and improved functional outcomes. Furthermore, with improvements in living standards, surgical treatment has become increasingly popular because it effectively shortens the recovery time, which is particularly important for younger patients[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the surgical treatment of EADHF, rigid fixation and early mobilization of the elbow joint are essential to minimize the risk of nonunion during fracture healing. However, because of the strong torsional forces exerted by surrounding muscles and the difficulty in securing small distal fragments, there is no clear consensus on the optimal choice of implants for this type of fracture. Most practitioners prefer using plates to stabilize fractures in this region, requiring proximal and distal extension for effective fixation. Distal extension necessitates the plate reaching the posterior non-articular portion of the lateral column, making traditional straight plates challenging to use. Additionally, with traditional single-plate fixation, inserting three screws (engaging six cortices) in the distal fragment is often difficult. The most distal screw may only achieve single-cortex fixation, increasing the risk of pull-out, particularly in patients with osteoporosis. This inadequate fixation can lead to delayed union or nonunion of the fracture. As a result, dual-plate fixation is often required to stabilize the distal fragment by ensuring the placement of a sufficient number of screws[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Dual-plate fixation allows at least four screws with eight cortical fixation points to secure the distal fracture, providing greater resistance to stress[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. A biomechanical study[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] has demonstrated that the fixation strength of dual plates combined with multiple screws surpasses that of single-plate fixation. However, dual-plate fixation requires extensive soft tissue dissection, which can prolong the surgical duration and disrupt the blood supply, increasing the risks of infection, nonunion, and nerve injury [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. In a study by El Mahboub [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] involving 30 patients with EADHF treated with dual-plate fixation, 2 patients experienced delayed healing, necessitating bone grafting. Additionally, dual-plate fixation requires manual bending to match the bone structure, which can lead to excessive deformation of the screw holes, reducing resistance of the plate and potentially resulting in fatigue failure[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo address these challenges, experts have explored various methods, including the use of plates designed for different anatomical locations. Parmaksizoglu[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] utilized titanium cobra head plates, originally designed for the distal tibia, to treat distal humeral fractures, achieving complete healing in all 23 patients. However, these plates require customization to match pre-measured angles of inclination, ensuring proper conformity to the distal humeral anatomy. Li et al.[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] creatively repurposed the proximal humeral interal locking system (PHILOS) plate, originally designed for the proximal humerus, by inverting it for use in treating EADHFs. The authors reported favorable outcomes in all 20 patients, none of whom required reoperation for complications. Some researchers have also recommended altering the angle of plate placement to enhance stabilization. Moran[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] employed an oblique posterior plate set at an angle of 5 to 8 degrees relative to the longitudinal axis of the humerus, improving distal fragment fixation but compromising the stabilization of proximal fragments. Following a similar principle, Yang et al.[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] used an oblique metaphyseal end locking compression plate to stabilize fractures, achieving a healing success rate of 84.4%; however, because of medial deviation of the proximal plate end, fixation in long oblique and spiral fractures extending toward the diaphysis was less than ideal. Other single-plate designs have also emerged. Saragaglia et al.[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] developed a \u0026ldquo;Lambda\u0026rdquo; plate for EADHF, featuring an inverted Y-shaped design with a stem and two branching arms that can be reshaped to match fracture specifics. However, as a compression plate without locking holes, it carries a risk of inadequate fixation in comminuted and osteoporotic bones. Spitzer et al.[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] reported encouraging results using a \u0026ldquo;hybrid\u0026rdquo; metaphyseal plate for distal humeral fractures, featuring 4.5-mm locking holes on one end and 3.5-mm locking holes on the other; all 21 fractures healed within an average of 4.5 months without infection or implant failure. Trikha et al.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] used an Extra-Articular Distal Humeral Locking Plate (EADHP), a \u0026ldquo;J\u0026rdquo;-shaped titanium plate designed for the posterolateral surface of the distal humerus. They reported successful healing in 34 patients within 3 months, restoration of elbow range of motion, and a mean MEPS of 90.8\u0026thinsp;\u0026plusmn;\u0026thinsp;9.9. However, most patients experienced susceptibility to hardware prominence on the lateral aspect of the elbow, particularly in slender individuals, with nearly all reporting lateral elbow pain when struck by an object. Collectively, these studies suggest that specialized single-plate designs can provide effective fixation for rehabilitation, offering advantages such as reduced periosteal stripping and faster fracture healing.\u003c/p\u003e \u003cp\u003eWith the emergence of anatomically pre-contoured locking plates, the fixation of distal humeral extra-articular fractures has improved, reducing the need for dual plating,[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] including in this study. The main advantage of our study is the introduction of a strong fixation technique using a new plate, improving the shortcomings of conventional single-plate and dual-plate fixation for EADHF. The new plate is a single-plate system that allows for the placement of a higher number of screws in the distal segment, combining the advantages of single-plate use with enhanced postoperative stability through increased distal screw density. Additionally, as a locking plate system, it provides greater rigidity, helping to resist bending and torsional stresses[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The placement of the plate on the anterolateral aspect of the distal humerus offers higher torsional strength than does posterolateral plate placement[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Designed with evenly distributed screws, the new anatomical plate provides sufficient spacing between screws to disperse stress, preventing proximal screw failure by utilizing a longer plate with a uniform screw distribution[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. In our study, no instances of internal fixation device or screw failure were observed.\u003c/p\u003e \u003cp\u003eIt has been reported that single-plate fixation is more time-efficient than dual-plate fixation [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e], which aligns with the findings of this study. Our results showed that using the new plate significantly reduced the surgery duration (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002). This can be attributed to the fact that the new plate requires fewer screws than dual-plate fixation. The increased number of screws in dual plating is unavoidable, leading to a prolonged surgical time. Additionally, the new anatomical plate features a pre-contoured structure that conforms to the regional anatomy, eliminating the need for bending and adjustments, further contributing to a shorter operative time. A reduced surgical duration also minimizes the exposure of the surgical site to the operating room environment, thereby lowering the risk of postoperative infection[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eScolaro et al.[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] demonstrated that a single anatomical plate can achieve rigid fixation and reliable healing, with a 95% success rate for treating EADHF without the need for bone grafting. In our study, the new anatomical plate achieved complete healing, with a significantly faster healing rate than dual plating (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.031). Dual-plate fixation typically requires more extensive dissection of the soft tissues around the fracture site, whereas the placement of the new plate involves less soft tissue disruption. This reduced dissection minimizes periosteal detachment from the bone, helping to preserve the blood supply at the fracture ends. By maintaining better vascularity, the biological healing potential of the fracture is maximized, leading to an accelerated healing process and allowing patients to begin early mobilization and return to work sooner.\u003c/p\u003e \u003cp\u003eWith advancements in the medical field, commercialization and consumerism have contributed to growing dissatisfaction among patient populations, particularly in response to rising healthcare costs. Patients have increasingly begun to question the motivations of their physicians, which can exacerbate tensions in the doctor\u0026ndash;patient relationship[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. In our study, the use of the new anatomical plate was associated with a significant reduction in total hospitalization costs (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This decrease in overall expenses may help alleviate conflicts between doctors and patients, ultimately enhancing patient satisfaction.\u003c/p\u003e \u003cp\u003eIn our study, all patients who received the new anatomical plate achieved complete recovery, with no postoperative complications observed. However, special attention must be given to the risk of intraoperative radial nerve injury when treating EADHF. The radial nerve is located close to the distal humeral shaft, making it particularly vulnerable to iatrogenic injury during surgical procedures in this area[\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Studies indicate that radial nerve palsy occurs in up to 29% of humeral fractures, and because of the nerve\u0026rsquo;s proximity to the distal humerus, the risk of iatrogenic injury may increase during plate fixation treatments[\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. In our study, there were no instances of radial nerve injury in the new anatomical plate group, whereas one patient in the dual-plate group experienced postoperative radial nerve palsy. However, this condition resolved by the 11th week of follow-up and did not result in significant functional limitations. We believe this difference may be related to surgical techniques. Yang et al.[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] reported an incidence of iatrogenic radial nerve palsy of 5.3% with single-plate fixation, which is slightly lower than the 10.1% reported by Vazquez et al [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. A possible explanation for this discrepancy is that dual-plate techniques require extensive soft tissue dissection. Because the radial nerve is located distally and laterally to the humerus, it faces a heightened risk of injury due to the greater degree of soft tissue manipulation and handling of the fracture during dual-plate fixation.\u003c/p\u003e \u003cp\u003eThe limitations of this study include its small sample size and relatively short follow-up period, necessitating further follow-up to evaluate long-term outcomes. Additionally, the retrospective nature of our study introduces inherent limitations compared with prospective designs. Future research should focus on multicenter, large-sample, and sufficiently powered randomized controlled trials to comprehensively assess the effectiveness of the new plate in the treatment of EADHF.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eBoth the new single-plate and dual-plate fixation methods effectively stabilize EADHF, leading to successful fracture healing. The new anatomical plate has demonstrated promising results, significantly reducing the surgery time, shortening the healing duration, and lowering treatment costs. It presents a viable alternative treatment option for these fractures. However, larger-scale studies and longer-term follow-ups are necessary to fully confirm its efficacy and long-term benefits.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eEADHFs \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Extra-articular distal humeral fractures\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUCLA \u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;University of California Los Angeles\u003c/p\u003e\n\u003cp\u003eMEPS \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Mayo Elbow Performance Scale\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eORIF \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Open reduction and internal fixation\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIMN \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Intramedullary nailing\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNSAIDs \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Nonsteroidal anti-inflammatory drugs \u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePHILOS \u0026nbsp; \u0026nbsp; \u0026nbsp;Proximal humeral interal locking system\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDJL contributed to the idea of this study; WWB wrote the manuscript; LLX and DJL performed surgeries; XJJ and YCH collected the follow-up data; XLP , YXC and LS performed statistical analysis and data management; LLX and XWC supervised the study; DJL, LFX and XLP were major contributor in the revision of this manuscript. All authors revised the manuscript and approved the final version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by funds from the Shandong Province Major Scientific and Technical Innovation Project (No. 2021SFGC0502), Shandong Provincial Natural Science Foundation (No. ZR2022MH056), Shandong Provincial Natural Science Foundation (No. ZR2021QH307) and the Shandong Provincial Natural Science Foundation (No. ZR2023QH498).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData can be provided upon reasonable request from the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll experimental procedures were approved by the Human Ethics Committee of Shandong Provincial Hospital Affiliated to Shandong First Medical University (SWYX: NO.2022-590). All aspects of this study were conducted with adherence to the current version of the Declaration of Helsinki, the guidelines established by the International Conference on Harmonization of Good Clinical Practice, and the laws of China. All participants signed informed consent forms before enrollment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and any accompanying images.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclaimer\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSingh AK, Narsaria N, Seth RR, Garg S. 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Orthop Traumatol Surg Res. 2013;99:707\u0026ndash;12.\u003c/li\u003e\n\u003cli\u003eSpitzer AB, Davidovitch RI, Egol KA. Use of a \u0026ldquo;hybrid\u0026rdquo; locking plate for complex metaphyseal fractures and nonunions about the humerus. Injury. 2009;40:240\u0026ndash;4.\u003c/li\u003e\n\u003cli\u003eMills WJ, Hanel DP, Smith DG. Lateral approach to the humeral shaft: an alternative approach for fracture treatment. J Orthop Trauma. 1996;10:81\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eMeinberg EG, Agel J, Roberts CS, Karam MD, Kellam JF. Fracture and Dislocation Classification Compendium-2018. J Orthop Trauma. 2018;32 Suppl 1:S1\u0026ndash;170.\u003c/li\u003e\n\u003cli\u003eOliver WM, Searle HKC, Ng ZH, Molyneux SG, White TO, Clement ND, et al. Factors associated with humeral shaft nonunion. J Shoulder Elbow Surg. 2021;30:2283\u0026ndash;95.\u003c/li\u003e\n\u003cli\u003eRing D, Jawa A, Cannada L. Clinical Faceoff: Are Distal-third Diaphyseal Humerus Fractures Best Treated Nonoperatively? Clin Orthop Relat Res. 2016;474:310\u0026ndash;4.\u003c/li\u003e\n\u003cli\u003ePapasoulis E, Drosos GI, Ververidis AN, Verettas D-A. Functional bracing of humeral shaft fractures. A review of clinical studies. Injury. 2010;41:e21\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eGottschalk MB, Carpenter W, Hiza E, Reisman W, Roberson J. Humeral Shaft Fracture Fixation: Incidence Rates and Complications as Reported by American Board of Orthopaedic Surgery Part II Candidates. J Bone Joint Surg Am. 2016;98:e71.\u003c/li\u003e\n\u003cli\u003eKharbanda Y, Tanwar YS, Srivastava V, Birla V, Rajput A, Pandit R. Retrospective analysis of extra-articular distal humerus shaft fractures treated with the use of pre-contoured lateral column metaphyseal LCP by triceps-sparing posterolateral approach. Strategies Trauma Limb Reconstr. 2017;12:1\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eKosmopoulos V, Nana AD. Dual Plating of Humeral Shaft Fractures: Orthogonal Plates Biomechanically Outperform Side-by-Side Plates. Clin Orthop Relat Res. 2014;472:1310\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eWatts A, Weinhold P, Kesler W, Dahners L. A biomechanical comparison of short segment long bone fracture fixation techniques: single large fragment plate versus 2 small fragment plates. J Orthop Trauma. 2012;26:528\u0026ndash;32.\u003c/li\u003e\n\u003cli\u003eScolaro JA, Voleti P, Makani A, Namdari S, Mirza A, Mehta S. Surgical fixation of extra-articular distal humerus fractures with a posterolateral plate through a triceps-reflecting technique. J Shoulder Elbow Surg. 2014;23:251\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eMahboub NE, Arafat W. Open reduction and internal fixation of extra-articular comminuted distal humerus fractures by double-plating osteosynthesis. The Egyptian Orthopaedic Journal. 2012;47:393\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eKrishna KR, Sridhar I, Ghista DN. Analysis of the helical plate for bone fracture fixation. Injury. 2008;39:1421\u0026ndash;36.\u003c/li\u003e\n\u003cli\u003eParmaksizoglu A, \u0026Ouml;zkaya U, Bilgili F, Mutlu H, \u0026Ccedil;etin \u0026Uuml;. Fixation of extra-articular distal humeral fractures with a lateral approach and a locked plate: an alternative method. Acta Orthop Traumatol Turc. 2015;50:132\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eLi G, Cui Y, Hua X, Liu F, Li D, Lu J, et al. Management of extra-articular fracture of the distal humerus with the upside-down use of PHILOS plates in front of the humerus: a retrospective study of 20 patients after 28.3 months. BMC Musculoskelet Disord. 2024;25:952.\u003c/li\u003e\n\u003cli\u003eMoran MC. Modified Lateral Approach to the Distal Humerus for Internal Fixation. Clin Orthop Relat Res. 1997;340:190\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eYang Q, Wang F, Wang Q, Gao W, Huang J, Wu X, et al. Surgical Treatment of Adult Extra-Articular Distal Humeral Diaphyseal Fractures Using an Oblique Metaphyseal Locking Compression Plate via a Posterior Approach. Med Princ Pract. 2012;21:40\u0026ndash;5.\u003c/li\u003e\n\u003cli\u003eG\u0026ouml;sling T, Schandelmaier P, Marti A, Hufner T, Partenheimer A, Krettek C. Less Invasive Stabilization of Complex Tibial Plateau Fractures: A Biomechanical Evaluation of a Unilateral Locked Screw Plate and Double Plating. J Orthop Trauma. 2004;18:546\u0026ndash;51.\u003c/li\u003e\n\u003cli\u003eMutlu H, Polat A, \u0026Ccedil;etin M\u0026Uuml;, Mutlu S, Demir T, Parmaksizoğlu AS. A NEW ANATOMICAL PLATE FOR EXTRA-ARTICULAR DISTAL HUMERAL FRACTURES: BIOMECHANICAL STUDY. Acta Ortop Bras. 2022;30:e248473.\u003c/li\u003e\n\u003cli\u003eJain D, Goyal GS, Garg R, Mahindra P, Yamin M, Selhi HS. Outcome of anatomic locking plate in extraarticular. Indian J Orthop. 2017;51.\u003c/li\u003e\n\u003cli\u003eAggarwal S, Kumar V, Bhagwat KR, Behera P. AO extra-articular distal humerus locking plate: extended spectrum of usage in intra-articular distal fractures with metaphyseal extension\u0026mdash;our experience with 20 cases. Eur J Orthop Surg Traumatol. 2014;24:505\u0026ndash;11.\u003c/li\u003e\n\u003cli\u003eCheng H, Chen BP-H, Soleas IM, Ferko NC, Cameron CG, Hinoul P. Prolonged Operative Duration Increases Risk of Surgical Site Infections: A Systematic Review. Surg Infect (Larchmt). 2017;18:722\u0026ndash;35.\u003c/li\u003e\n\u003cli\u003eHarbishettar V, Krishna K, Srinivasa P, Gowda M. The enigma of doctor-patient relationship. Indian J Psychiatry. 2019;61:776.\u003c/li\u003e\n\u003cli\u003eWalker M, Palumbo B, Badman B, Brooks J, Van Gelderen J, Mighell M. Humeral shaft fractures: a review. J Shoulder Elbow Surg. 2011;20:833\u0026ndash;44.\u003c/li\u003e\n\u003cli\u003eShao YC, Harwood P, Grotz MRW, Limb D, Giannoudis PV. Radial nerve palsy associated with fractures of the shaft of the humerus: a systematic review. J Bone Joint Surg Br. 2005;87-B:1647\u0026ndash;52.\u003c/li\u003e\n\u003cli\u003eVazquez O, Rutgers M, Ring DC, Walsh M, Egol KA. Fate of the ulnar nerve after operative fixation of distal humerus fractures. J Orthop Trauma. 2010;24:395\u0026ndash;9.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"extra-articular distal humeral fracture, new anatomical plate, dual plates","lastPublishedDoi":"10.21203/rs.3.rs-6314432/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6314432/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe study aims to evaluate the clinical and functional outcomes of extra-articular distal humeral fractures (EADHFs) treated with a new anatomical plate compared with dual plates-plate fixation.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eFrom January 2018 to June 2023, patients with EADHFs who underwent internal fixation with either the new anatomical plate or dual plates were recruited, and divided into two groups (new plate \u003cem\u003evs\u003c/em\u003e dual-plate group). Data were recorded and analyzed, including operation time, blood loss, and hospitalization costs. Clinical outcomes were assessed using the indictors of interests, such as healing time and the complications, including wound infection, vascular and nerve damage, and nonunion. The shoulder and elbow function was evaluated using the University of California Los Angeles (UCLA) shoulder score and Mayo Elbow Performance Score (MEPS) respectively.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 30 patients (21males, 9 females) with a mean age of 32.97 years were included, with 12 patients in the new plate group, and 18 patients in the dual-plate group. The mean postoperative follow-up duration was 14.50\u0026thinsp;\u0026plusmn;\u0026thinsp;1.07 months (range, 13\u0026ndash;17 months). Preoperative data showed no significant difference in age, sex, or cause of EADHF between the groups. Interestingly, patients treated with the new anatomical plate have shorter operation times, lower hospitalization costs, and faster healing process than those treated with dual plates. However, no significant differences were found between the two groups in clinical and functional outcomes assessed using the MEPS and UCLA shoulder score.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe new anatomical plate for EADHF treatment demonstrates advantages such as reduced surgical time, lower costs, and shorter healing duration, making it a viable alternative treatment option. However, larger-scale studies with longer follow-up periods are necessary to fully confirm its efficacy and long-term benefits.\u003c/p\u003e","manuscriptTitle":"A new anatomical plate fixation verse dual plates fixation in the treatment of extra-articular distal humeral fractures: a retrospective study of 30 cases","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-07 03:10:42","doi":"10.21203/rs.3.rs-6314432/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"68948f4d-f0c7-4026-b0f0-627eadd436cc","owner":[],"postedDate":"May 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-05-30T10:08:27+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-07 03:10:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6314432","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6314432","identity":"rs-6314432","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}