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Harry Hoyen, Simon Lambert, Joideep Phadnis

Executive Editor

Simon Lambert

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ORIF - Compression plating and lag screw fixation

1. General considerations


Plating with precontoured periarticular locking plates provides angular-stable fixation and is the most commonly used method of distal humeral fracture fixation.

Treatment principle

In this fracture, the articular block is fragmented, and both columns are fractured in a simple way.

This may be stabilized by interfragmentary compression of the articular fracture with a plate for each column.

ORIF - Compression plating and lag screw fixation

Triangle-of-stability concept

The mechanical properties of the distal humerus are based on a triangle of stability, comprising the medial and lateral columns and the articular block (see also the anatomical concepts).

In principle, the intraarticular fracture is fixed first. Thereby the fracture is converted to a transverse metaphyseal fracture and treated likewise.

The mechanical properties of the distal humerus are based on a triangle of stability, comprising the medial and lateral columns and the articular block.

Parallel vs perpendicular plating

There is little biomechanical evidence from in vitro studies to suggest that one has more advantages than the other. However, in clinical practice, a specific fracture pattern may indicate a specific plate construct.

In a very low transverse fracture, ie, exiting at or below the level of the olecranon fossa, the articular block does not provide enough hold for the application of a dorsolateral plate.

An alternative is a dorsolateral plate with lateral tab. This permits insertion of screws from lateral-to-medial into the articular block as well as posterior-to-anterior into the capitellum.

Plate selection

Precontoured anatomical plates have been designed. If these are not available, a reconstruction plate is used both on the medial and the lateral sides. If a stronger plate is required, a small-fragment compression plate may be used, but this is more difficult to contour.

Note: ulnar nerve at risk

On the medial side, the ulnar nerve is at risk and needs to be exposed, released, and protected before insertion of a medial column K-wire and/or if the fracture exits just above the medial condyle (see also neurological protection and handling).
Ulnar nerve at risk if the fracture exits just above the medial condyle.

Note: radial nerve at risk

For balanced fixation, it may be necessary to use a longer lateral plate, putting the radial nerve at risk.
Therefore, it may be necessary to expose the nerve and release it from the lateral intermuscular septum (see also neurological protection and handling).
Radial nerve at risk with longer lateral plate

2. Patient preparation and approaches

Patient positioning

This procedure is usually performed with the patient either in a prone position or lateral decubitus position.


A posterior triceps-elevating approach is preferred. However, triceps-on or olecranon osteotomy approaches may be used depending on surgeon’s preference.

The triceps-split approach does not allow for accurate control of the articular block and column fixation and is therefore not recommended.

Skin incision of triceps-split, triceps-on, or olecranon osteotomy approach

3. Preparing the fracture site

In principle, preserve all fracture fragments attached to soft tissue in situ if possible.

Keep removal of hematoma to the minimum necessary to facilitate the exposure of the fracture.

Note: The more distal the transcondylar fracture line and the more complex the articular fracture pattern, the greater the risk to fragmental perfusion. Soft-tissue attachments are vital to fracture healing and should be respected (see additional material on vascularization).
Vascularization around the distal humerus

4. Reduction and fixation of articular block

Articular reduction

Reduce the articular fragments manually, with K-wire joysticks or pointed reduction forceps.

Hold the reduced articular block with pointed reduction forceps. Thereby extrinsic interfragmentary compression is gained.

Holding the reduction of the articular block with forceps, gaining extrinsic interfragmentary compression

Temporarily fix the fragments with K-wires.

With a K-wire, interfragmentary positioning is achieved but no compression.

Temporary K-wire stabilization of the intraarticular fracture

Pitfall: overcompression

Avoid overcompressing the articular fragments. This may result in the collapse of the fragments and narrowing of the articular block, which can lead to maltracking of the joint with the ulna.
Priority should be given to reconstructing the medial trochlear ridge and lateral column.
Overcompression of the articular fragments

Option: position screw(s)

In poor-quality bone or multifragmentary fractures, interfragmentary compression is undesirable, and therefore interfragmentary alignment is gained with a position screw.

Positioning screws through a locking plate are preferred. If desired or locking plates are not available, these screws may be inserted outside a plate.

Pearl: Insert the lag screw from the side opposite to the condylar fragment with better bone quality to gain optimal screw purchase.
Position screw fixation of the intraarticular fracture

In very distal fractures, the positioning K-wire can be retained to maintain rotational stability.

Position screw fixation of the intraarticular fracture with additional K-wire

5. Supracondylar reduction and fixation

Basic techniques

The basic technique for application of anatomical plates is described in:

If precontoured anatomical plates are not available, see the basic technique for application of reconstruction plates.

Reduction and temporary fixation

Reduce the reconstituted articular (condylar) block to the metaphysis and use K-wire(s) for preliminary fixation.

To avoid risk to the ulnar nerve, parallel K-wires from laterally may be preferred.

It is recommended to check alignment under image intensification.

Temporary K-wire fixation of metaphyseal fracture reduction

Application of the first plate

Apply the first plate to the column, which is easier to fix. This is usually the lateral column.

Provisionally fix the plate to the bone with a cortical position screw through a slotted combihole proximal to the fracture.

Provisional fixation of the lateral plate to the bone with a cortical position screw through a slotted combihole proximal to the fracture

Place a locking screw through the plate into the articular block to hold the reduction. Make sure it is long enough to engage in the opposite articular fragment. If possible, use two long locking screws.

Insertion of locking screws into the articular block

Application of the second plate

Apply the second plate in the same fashion.

Insertion of locking screws into the articular block

Supracondylar compression

On the lateral side, release the positioning screw slightly and insert a bicortical cortical screw eccentrically in a more proximal plate hole for compression in the plane of the plate. Then tighten the positioning screw.

Pearl: In good-quality bone, two proximal screws may be sufficient. In this case, insert the load screw through the most proximal plate hole for near-far fixation (to resist torsional force in the fracture fixation).
Lateral supracondylar compression with eccentrical loading screw

Repeat this step on the other side.

Medial supracondylar compression with eccentrical loading screw

Insertion of remaining screws

Insert further screws.

In poor-quality bone, locking screws may be preferable in the diaphyseal segment.

The screw density should be similar on both columns.

Note: The screw density and cortical/bicortical screw depth should increase with decreasing bone quality.
Plate fixation in poor-quality bone with additional locking screws

6. Final assessment

Visually inspect the fixation and manually check for fracture stability.

Repeat the manual check under image intensification.

Ensure the ulnar nerve is not unstable or tethered on implants throughout a full range of motion.

7. Aftercare


The rehabilitation protocol consists usually of three phases:

  • Rehabilitation until wound healing
  • Rehabilitation until bone healing
  • Functional rehabilitation after bone healing

Immediate aftercare

The arm is bandaged to support and protect the surgical wound.

The arm is rested on pillows in slight flexion of the elbow so that the hand is positioned above the level of the heart.

Short-term splinting may be applied for soft-tissue support.

Neurovascular observations are made frequently.

Semireclining patient position, with the elbow elevated, preferably above the chest, on pillows

Hand pumping and forearm rotation exercises are started as soon as possible to reduce lymphedema and to improve venous return in the limb. This helps to reduce postoperative swelling.

Hand pumping

Mobilization until wound healing

Gravity-eliminated active assisted exercises of the elbow should be initiated as soon as possible, as the elbow is prone to stiffness:

  • The bandages are removed, and the arm rested on a side table
  • Flexion/extension of the arm at the elbow is encouraged in a gentle sweeping movement on the tabletop as far as comfort permits (as illustrated)
  • Full pronation and supination in protected arm position is encouraged
  • Exercises are performed hourly in repetitions, the number of which is governed by comfort
  • Between periods of exercise, the elbow is rested in the elevated position for at least the first 48 hours postoperatively
  • Keep the arm elevated between periods of exercise until the wound has healed
Flexion/extension of the arm at the elbow in a gentle sweeping movement on the tabletop

Rehabilitation until bone healing

Note: Close surveillance by the clinician during this rehabilitation period has a tremendous impact on the patient outcome.

Active patient-directed range-of -motion exercises should be encouraged without the routine use of splintage or immobilization.

Avoid forceful motion, repetitive loading, or weight-bearing through the arm.

A simple compressive sleeve can provide proprioceptive feedback which can help regain motion and avoid cocontraction.

No load-bearing (ie, pushing, pulling, or carrying weights) or strengthening exercises are allowed until early fracture healing is established by x-ray and clinical examination.

This is usually a minimum of 8–12 weeks after injury. Weight-bearing on the arm should be avoided until bony union is assured.

The patient should avoid resisted extension activities, especially after a triceps-elevating approach or olecranon osteotomy.

Rehabilitation after bone healing

When the fracture has united, a combination of active functional motion and kinetic chain rehabilitation can be initiated.

Active assisted elbow motion exercises are continued. The patient bends the elbow as much as possible using his/her muscles while simultaneously using the opposite arm to gently push the arm into further flexion. This effort should be sustained for several minutes; the longer, the better.

Gravity-eliminated active-assisted elbow motion exercises

Next, a similar exercise is performed for extension.

Extension exercise

If the patient finds it difficult to accomplish these exercises when seated, then performing the same exercises when lying supine can be helpful.

Note: When a damaged joint is rehabilitated in this way, the risk of “co-contraction” is reduced, and the incidence of chronic regional pain syndrome is also reduced.
Over-head elbow motion exercises

Implant removal

Generally, the implants are not removed. If symptomatic, hardware removal may be considered after consolidated bony healing, usually no less than 6 months for metaphyseal fractures and 12 months when the diaphysis is involved. The avoidance of the risk of refracture requires activity limitation for some months after implant removal.