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 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. Reconstruction of the articular surface

Cleaning of the fracture site

Clean out the fracture by removing blood clots, loose pieces of bone, and any interposed tissue.

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Condylar reassembly

Reduce the articular fragments. In good bone stock, use pointed reduction forceps.

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In compromised bone stock, use temporary fixation with one or preferably 2 K-wires, inserted manually.

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Definitive fixation

Use a lag screw (a partially threaded screw, or a fully threaded screw with overdrilling the near cortex) to obtain compression.
In osteoporotic bone, use one or more position screws.
Try to use two screws to avoid rotational instability, if possible.

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Definitive fixation

In very distal fractures, generally only one screw can be inserted. An additional K-wire can be used to achieve rotational stability.

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5. 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.

Place 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 should curve around the capitellum which has no cartilage cover posteriorly.

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

In a more distal fracture, the reconstruction plate can be extended 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
Place a K-wire through the distal plate hole. As the plate is pulled gently proximally, stable contact with the bone is obtained.
Now insert the proximal screw without load.

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Screw insertion

Complete the plate fixation to the bone by inserting the remaining screws.

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Medial plate

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

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

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Bone graft

In case of great metaphyseal comminution, or missing bone, use a bone graft.

complete articular simple articular fragmentary metaphyseal

6. 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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