ORIF - Parallel plating

Stability of the distal humerus is based on 3 columns: Medial, lateral, and the articular surface.
In complete articular fractures, all 3 columns have to be restored.

This procedure may be performed with the patient in either a prone position or lateral decubitus position.

For this procedure a posterior approach is normally used:

• Posterior triceps-on approach
• Triceps-elevating approach
• Transolecranon approach

Take your time to identify all bony fragments, and compare them to the x-rays.

Some displaced fragments are not immediately seen after osteotomy. Be sure to account for all fragments. Mobilize the fragments and bring them into the surgical field.
Clean out the fracture by removing blood clots, loose pieces of bone, and interposed tissue. Inspect the joint to ensure that no intraarticular fracture component was missed when examining the imaging.

Assemble all small fragments covered by cartilage, even if they have no soft tissue connections. A headless screw, or buried threaded wire, or absorbable pin are options for fixing these fragments.

In parallel plating it is customary to reduce and provisional by secure all of the fracture fragments prior to plate application.

Contoured 3.5-millimeter reconstruction plates or precontoured plates are selected for direct lateral positioning on the lateral column and direct medial positioning on the medial column.

These are usually placed slightly posteriorly and are always placed on top of the soft tissues - do NOT strip the medial and lateral columns.

The plates should extend distally enough to engage all fracture fragments and proximally enough so that 2 or 3 screws in each plate engage the proximal (shaft) fragment.

As many screws as possible are placed in the distal fragments.
Each screw goes through a plate hole.
Smooth K-wires the same diameter as the appropriate drill (e.g. 2.0 mm wire for 2.7mm screw) can be inserted through the plate holes to ensure that the screws, once inserted, do not conflict: this allows the drilling stage to be skipped.

Each of the smooth K-wires is exchanged for a self-tapping screw.

When there is solid bony contact across the articular and proximal fragments, compression is applied with pointed reduction forceps and eccentrically placed load screws, one column at a time.

1. When a column is comminuted this should be bridged and if necessary, because of missing bone, bone grafted.
2. When the reassembled condylar mass is short, and non-locking plates are used, long, distal-to-proximal, 3.5 mm column screws will enhance the stability of the fixation. These need to be inserted with great care in the presence of comminution of a column.

Note that the plates rest on top of the muscle origins and these have NOT been stripped or removed.

The arm is immobilized in a splint for comfort with the elbow at 90° of flexion. Active exercises of the elbow should be initiated as soon as possible, as the elbow is prone to stiffness. For this reason, it is important that fixation is adequate to allow functional use of the arm for light tasks.

Avoidance of shoulder abduction will limit varus elbow stress. Shoulder mobility should be maintained by gravity-assisted pendulum exercises in the sling.

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

Next, a similar exercise is done for extension.

Load bearing
No load-bearing or strengthening exercises are allowed until early fracture healing is established, a minimum of 6-8 weeks after the fracture. Weight bearing on the arm should be avoided until bony union is assured.

Follow up
After suture removal, 2 weeks after surgery, the patient should be seen every 4-6 weeks for follow-up examination and x-rays, until union is secure and full functional range of motion and strength have returned.

Implant removal
Generally, the implants are not removed. If symptomatic, hardware removal may be considered after consolidated bony healing, certainly 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.