Authors of section

Authors

Mariusz Bonczar, Daniel Rikli, David Ring

Executive Editor

Chris Colton

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ORIF - Plate and screw fixation

1. Principles

Fracture assessment

In this fracture, both columns are comminuted with a wedge on each side.

Therefore, each column should be stabilized with an individual plate.

orif plate and screw fixation

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:

orif parallel plating

4. Reduction

Clean the fracture site

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

orif plate and screw fixation

Reduction strategy

The situation is very unstable. A good way to build up stability stepwise is to reconstruct each column by anatomically reducing and fixing the respective wedge to the column: The radial wedge to the radial column (either to the proximal or to the distal fragment), and the ulnar wedge to the ulnar column (either to the proximal or to the distal fragment).

In this way, you create a two-fragment fracture.

Then the proximal and the distal fragment are reduced. This is only possible for a relatively simple multifragmented fracture.

orif plate and screw fixation

Alternative for extensive comminution

For many comminuted fractures it is preferable to bridge the comminution without attempting to reduce and secure each fragment individually.
This approach preserves the blood supply and healing capacity of the fragments while relying on the implants for relative stability until early healing is established.

orif plate and screw fixation

Reduce fracture lines with Weber clamps

First, the ulnar wedge (3) is reduced to the proximal shaft (1) and held with a Weber clamp. Then the radial wedge (4) is reduced to the proximal shaft (1) and similarly held with a Weber clamp.

The distal fragment (2) is reduced to the fixed wedges, and held with a Weber clamp.

orif plate and screw fixation

Replace Weber clamps with lag screws

The Weber clamps are stepwise replaced with lag screws:

The ulnar and the radial wedges (3,4) are fixed to the shaft (1). Then the shaft is fixed to the distal fragment with a lag screw between the radial wedge fragment (4) and the distal fragment (2).

Now the entire fracture is fixed with lag screws.

orif plate and screw fixation

Indirect reduction for complex comminution

When the comminution is so great that reduction and fixation of each fragment is not advisable, the comminution can be bridged by plates. The angular and rotational alignment can be facilitated and provisionally stabilized using an external fixator, although in most cases manual traction is sufficient.

orif plate and screw fixation

5. Plate selection and application

Preliminary consideration

Both the medial and lateral columns need protection with individual plates. The plates should have secure purchase in both the distal and the proximal main fragments. This allows bridging of the comminuted zone of the fracture.

Both plates need to be contoured before application. Perfect contouring with direct contact to the bone is not necessary.

One option is to place the lateral column plate dorsally and the medial column plate medially. In this position they form an angle of approximately 90 degrees to each other.

orif plate and screw fixation

Precontoured anatomic plates have been produced. If these are not available, a one-third tubular plate may be used on the crest of the medial supracondylar ridge, and a reconstruction plate on the posterior aspect of the lateral column. If a stronger plate is required, a small fragment dynamic condylar plate may be used, but this is more difficult to contour.

orif plate fixation

Alternative: parallel plates

Another option is to place one plate directly laterally and another plate directly medially. This is referred to as parallel plating. If a precontoured anatomic plate is not available for the lateral side of the distal humerus, a DCP must be contoured and applied. The advantages of this technique include longer screws in the distal fragments and the ability to capture articular fragments with small screws in the subchondral bone.

For long lateral plates it is advisable to find and protect the radial nerve.

orif plate and screw fixation

Contouring

To facilitate contouring, malleable templates are used.

orif plate and screw fixation

Plate application

Apply both plates. A minimum of two screws in each main fragment should be used. Be aware that the plates should not end at the same level proximally. One plate should be longer in order to avoid creating a stress riser.

orif plate and screw fixation

Alternative for complex comminution: Bridge plate

The fracture fragments are manipulated as little as possible, and their soft-tissue attachments preserved. Once length and alignment are restored, plates alone provide relative stability, and no screws are used in the intervening fracture fragments.

orif plate and screw fixation

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.

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