Authors of section

Authors

Mariusz Bonczar, Daniel Rikli, David Ring

Executive Editor

Chris Colton

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ORIF - Screw fixation

1. Principles

This is an avulsion fracture of the lateral epycondyle. By definition, there is no involvement of the joint (capitellum).
The fracture is an equivalent of an avulsion of the origin of the extensor tendons.
Typically, this injury occurs in young patients.
In order to avoid varus instability of the elbow, the fragment should be fixed.

orif screw fixation

2. Patient preparation and approach

Patient preparation

This procedure is normally performed with the patient in a supine position for lateral approach.

orif plate fixation

Approach

For this procedure a lateral approach is normally used.

orif plate fixation

3. Open reduction

Mobilize the fragment

Open the fracture site by mobilizing the fragment.

Clean out the fracture by removing blood clots and interposed tissue.

orif screw fixation

Reduction

Reduce the fragment. Hold it temporarily in place either with a dental hook or a K-wire.

orif screw fixation

4. Fixation

Drilling

The fragment is fixed with a lag screw. Usually the fragment is small and takes only 1 screw. If the fragment is large enough, you may use two screws.

Drill a 2.5 hole up to the opposite cortex. Measure for screw length. Self-tapping screws are generally recommended for their ease and speed of insertion. If these are not available, tap the opposite cortex.

In large fragments, overdrill with a 3.5 mm drill. However, caution must be exercised so as not to break the fragment.

orif screw fixation

Screw insertion

Insert the screw.

Occasionally, in smaller fragments, a spiked washer may be useful.

extraarticular avulsion of lateral epicondyle

5. 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.

orif plate fixation

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.

orif plate fixation