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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6. Condylar reattachment

Temporary fixation

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

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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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