Authors of section

Authors

Mariusz Bonczar, Daniel Rikli, David Ring

Executive Editor

Chris Colton

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ORIF - Perpendicular plating

1. Principles

Triangle of stability

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.

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2. Patient preparation

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

3. Approaches

For this procedure a posterior approach is normally used:

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4. Identification of the bony fragments

Recognize fragments

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

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Mobilize the fragment

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.

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5. Reconstruction of the articular surface

Condylar reassembly

Reduce and hold the articular fragments using cannulated screw guide wires.

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Assemble all small fragments covered by cartilage, even if they have no soft tissue connection. A headless screw is often a good choice for fixing some of these fragments.

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Definitive fixation of articular fragments

Insert a cannulated screw over the guide wire after pre-drilling the pilot hole. Alternatively, insert a non-cannulated screw in the standard manner parallel to the wire, and then remove the wire.

Insert the screw from the lateral to the medial side, so that the screw head does not irritate the ulnar nerve and conflict with the planned position of the medial plate.

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If possible, insert a second screw to improve rotational stability.

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Bone stock quality

Use the lag screw technique only in good bone quality and when anatomical reconstruction of all articular fragments is possible.

In osteoporotic bone, or when bone graft has to be added to fill an articular gap, use a position screw to avoid deformation of the articular surface.

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Pitfall

In inferior bone quality, or when a fragment is missing, use of a lag screw, producing interfragmentary compression, will deform the articular surface.

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Missing bone

In case of missing bone, always use bone graft or fill the defect with the remaining small fragments.

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orif perpendicular plating

6. Condylar reattachment

Temporary fixation

Reduce the reconstituted articular mass to the metaphysis and use K-wires for preliminary fixation.

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orif perpendicular plating

Plate preparation

The plates must be carefully contoured using an appropriate malleable template.

Pace the lateral column plate dorsally and the medial column plate medially. In this position their planes form an angle of approximately 90 degrees to each other.

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Definitive fixation

First place a 3.5 mm reconstruction plate posterolaterally. It may curve around the capitellum which has no cartilage cover posteriorly.

The comminution is bridged if it cannot be precisely reduced and fixed with absolute stability. A slightly longer plate is used to provide additional stability.

In a more distal fracture, the reconstruction plate may be contoured to extend all the way to the edge of the capitellar articular surface. It will not interfere with the radial head during the extension of the joint. The more bone is covered by the plate, the greater is the stability achieved.

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Placement of the lateral plate

Insert a K-wire through the distal hole. As the plate is pulled proximally, stable contact with the bone is obtained.
Now insert the proximal screw.

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Remaining screws

Insert the remaining screws.

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Medial plate

Place another plate medially on the crest of the medial supracondylar ridge, its plane at right angles to the lateral plate to increase stability.

It is recommended to insert the distal screw into the trochlea below the medial epicondyle.

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7. Completed osteosynthesis

The x-rays show the completed osteosynthesis.

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8. Aftertreatment

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.

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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.

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9. Case

3D-CT demonstrating a C-type distal humeral fracture with much comminution.

3D-CT demonstrating a C-type distal humeral fracture with much comminution

This image shows the patient with the arm hanging over a bolster in the operating room which allows for the best surgical approach to this difficult fracture.

This image shows the patient with the arm hanging over a bolster in the operating room.

The surgical anatomy has been drawn on the patient's elbow and a small, lateral, grade 1 open wound is present.

The surgical anatomy has been drawn on the patient's elbow and a small, lateral, grade 1 open wound is present.

This is a complex, intraarticular fracture. Anatomic reduction is required to give the best functional outcome. This requires adequate exposure.

This is a complex, intraarticular fracture.

The ulnar nerve is carefully dissected and protected on the medial side.

The ulnar nerve is carefully dissected and protected on the medial side.

This image shows a carefully dissected and protected branch to the flexor carpi ulnaris.

This image shows a carefully dissected and protected branch to the flexor carpi ulnaris.

By dissecting medially from the cubital tunnel, the bare spot of the olecranon can be found. This is the best spot for the osteotomy of the olecranon.

By dissecting medially from the cubital tunnel, the bare spot of the olecranon can be found.

A Chevron osteotomy is carefully started with a saw, but not completed.

A Chevron osteotomy is carefully started with a saw, but not completed.

The olecranon osteotomy is completed with an osteotome.

The olecranon osteotomy is completed with an osteotome.

The olecranon osteotomy, when completed, reveals a badly comminuted C3 distal humeral fracture.

The olecranon osteotomy, when completed, reveals a badly comminuted C3 distal humeral fracture.

Often small cortical pieces are found without soft tissue attachment and are discarded.

Often small cortical pieces are found without soft tissue attachment and are discarded.

The surgical tactic is started by reducing the articular components, converting the C-type fracture into an A-type fracture.

The surgical tactic is started by reducing the articular components, converting the C-type fracture into an A-type fracture.

The joint is carefully reduced and held with a temporary K-wire. Note the ulnar nerve is carefully protected. K-wires are being used as joysticks.

The joint is carefully reduced and held with a temporary K-wire.

Sometimes the joint surface has missing fragments, which makes reconstruction difficult. However, the width, length, and depth of the condylar region must be maintained as it articulates with the olecranon and radial head.

Sometimes the joint surface has missing fragments, which makes reconstruction difficult.

This intraoperative video demonstrates the joint reduction and the significant metaphyseal comminution.

This intraoperative video demonstrates the joint reduction and the significant metaphyseal comminution.

The carefully reconstructed joint surface is held nicely with a transcondylar lag screw.

The carefully reconstructed joint surface is held nicely with a transcondylar lag screw.

The medial VA LCP must be carefully placed beneath the mobile ulnar nerve.

The medial VA LCP must be carefully placed beneath the mobile ulnar nerve.

The medial LCP may be used as a reduction plate with locking screws distally assisting with transcondylar fixation.

The medial LCP may be used as a reduction plate with locking screws distally assisting with transcondylar fixation.

With the medial plate applied, the metaphyseal comminution is bridged temporarily.

With the medial plate applied, the metaphyseal comminution is bridged temporarily.

Once the metaphyseal component is reduced, proximal fixation can be performed.

Once the metaphyseal component is reduced, proximal fixation can be performed.

A posterolateral LCP can then be applied as a reduction plate to supplement the medial fixation.

A posterolateral LCP can then be applied as a reduction plate to supplement the medial fixation.

Great care must be taken to ensure that the distal end of the lateral plate is clear of the olecranon fossa, so as not to compromise extension of the elbow.

Great care must be taken to ensure that the distal end of the lateral plate is clear of the olecranon fossa, so as not to compromise extension of the elbow.

The variable angle lateral plate should obtain at least 3 points of distal fixation. Care must be taken when placing these screws to avoid penetrating the radio capitellar joint.

The variable angle lateral plate should obtain at least 3 points of distal fixation.

Once the two plates are fixed proximally and distally, further screws may be inserted, but the principle of bridging the comminuted fracture is maintained.

Once the two plates are fixed proximally and distally, further screws may be inserted, but the principle of bridging the comminuted fracture is maintained.

AP X-ray demonstrates the lag screw reducing the articular fracture and nice, two-sided, stable fixation. Note the fixation is bridging the metaphyseal fragments.

AP X-ray demonstrates the lag screw reducing the articular fracture and nice, two-sided, stable fixation.

The Chevron osteotomy is closed and held with K-wires.

The Chevron osteotomy is closed and held with K-wires.

A hook plate is applied over the longitudinal K-wires to complete the fixation of the osteotomy.

A hook plate is applied over the longitudinal K-wires to complete the fixation of the osteotomy.

The osteotomy is nicely reduced with the hook plate.

The osteotomy is nicely reduced with the hook plate.

Lateral X-ray demonstrating the hook plate reduction of the Chevron osteotomy.

Lateral X-ray demonstrating the hook plate reduction of the Chevron osteotomy.

Final closure

Final closure

Final X-ray images

Final X-ray images