Authors of section

Authors

Mariusz Bonczar, Daniel Rikli, David Ring

Executive Editor

Chris Colton

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ORIF - Parallel plating

1. Principles

Triangle of stability

Stability of the distal humerus is based on a triangle of stability, comprising the medial and lateral columns, and the transverse condylar mass. 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. Reduction and provisional fixation

Fixation of small articular fragments

Although by definition, this is a simple articular fracture, in many instances, small articular fragments may be found.

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K-wire fixation

In parallel plating it is customary to reduce and provisionally secure all of the fracture fragments, prior to plate application, using smooth K-wires.

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5. Definitive plate and screw fixation

Plate selection and contouring

Contoured 3.5 mm 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 from each plate engage the proximal (shaft) fragment.

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Drilling for distal screws

As many screws as possible are placed in each distal fragment.
Each screw goes through a plate hole.
Smooth K-wires the same size as the appropriate drill (e.g. 2.0 mm wire for 2.7 mm screw) can be manually inserted through the plate holes to ensure that the screws, once inserted, do not conflict: this also allows the drilling stage to be skipped.
The length of each of these K-wires must be known so that the appropriate screw length can be measured off the protruding wire, or the wire removed and the length of the pilot hole that it created measured using a standard depth gauge.

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Distal screw application

Each of the smooth pilot K-wires is exchanged for its appropriate screw.

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6. Proximal plate fixation

Compression technique

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.

Once the fixation is complete, all remaining K-wires are removed.

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Alternatives

  1. When a column is comminuted it should be bridged and if necessary, because of missing bone fragments, 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.

7. Completed osteosynthesis

Final fixation

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

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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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