Authors of section

Authors

Mariusz Bonczar, Daniel Rikli, David Ring

Executive Editor

Chris Colton

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ORIF - Screw fixation

1. Introduction

It is not uncommon for an elbow dislocation in a skeletally immature patient to be associated with a medial epicondylar fracture.

One or two screws will provide sufficient fixation.
It can be useful to incorporate the soft tissue attachments to the medial epicondyle by using a washer.

Screw fixation is straightforward, using cannulated screws, but can also be performed with non-cannulated screws.

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2. Patient preparation and approach

Patient preparation

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

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Approach

For this procedure a medial approach is normally used.

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3. Open reduction

Mobilize the fragment and clean the fracture site

Identify and protect the ulnar nerve.
Open the fracture site by gently retracting the fragment anteriorly.
Clean out the fracture by removing blood clots, loose pieces of bone or interposed tissue. Inspect the joint to ensure that no intraarticular fracture component was missed when examining the imaging.

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Reduction

Realign the fracture and hold reduced with a small hook.
Monitor fracture reduction by realigning the metaphyseal fracture lines.
Depending on the extent of exposure, you can check the anterior and posterior fracture lines, including the articular surface.

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4. Provisional fixation

Planning for screws

The screws must avoid the olecranon fossa and the articular surface. Generally there is room for one screw down the articular part, and one screw up the lateral column.

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Insertion of K-wires

Secure the fracture with 2 or more K-wires crossing the fracture site. Take care to avoid the planned screw track.

Use smooth K-wires at least 1.5 mm in diameter.

Check fracture alignment using an image intensifier.

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Alternative K-wire placement

Alternatively, use a K-wire the size of the drill and place the K-wires in the planned screw tracks.
Using this technique, each wire can be exchanged for its screw, skipping the drilling step.

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5. Drilling

Position screw technique

For a partially threaded screw, drill both fragments with a 2.5 mm drill.

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Alternative lag screw technique

For lag screw technique using a fully threaded screw, drill the near fragment with a 3.5 mm drill to create a gliding hole, and the far fragment with a 2.5 mm drill.

Be careful using lag screw technique in metaphyseal bone, particularly when osteoporotic. It may be preferable to obtain thread purchase in both the near and far fragments (a position screw).

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6. Definitive fixation

Insertion of screw

Self-tapping screws are generally recommended for their ease and speed of insertion.

When using a non-self-tapping screw, tap the screw track prior to screw insertion.

For poor bone quality it may be helpful to use a washer with the screw, and to avoid tapping the far condylar fragment.

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Insertion of further screws

Insert two or more screws. Complete the entire sequence for each screw before inserting the next screw.
Remove provisional K-wires.

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7. 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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