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Authors

Harry Hoyen, Simon Lambert, Joideep Phadnis

Executive Editor

Simon Lambert

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ORIF - Plate fixation

1. General considerations

Introduction

Plating with precontoured periarticular locking plates provides angular-stable fixation and is the most commonly used method of distal humeral fracture fixation.

Treatment principle

In this fracture, both columns are fractured with either a simple wedge or comminution on each side.

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

The fracture zone in relation to the olecranon fossa can be variable, ie, there are high and low variants.

If the size of the fragments and bone quality permit independent lag screw fixation, place these screws before plate application. This is typically the case when the fracture is above the olecranon fossa.

ORIF - Bicolumnar bridge plating

Triangle-of-stability concept

The mechanical properties of the distal humerus are based on a triangle of stability, comprising the medial and lateral columns and the articular block (see also the anatomical concepts).

In principle, for extraarticular fractures, the side of the triangle with the simplest fracture is fixed first.

The mechanical properties of the distal humerus are based on a triangle of stability, comprising the medial and lateral columns and the articular block.

Plating modes

In these fractures, two modes of plate application are used:

  • Bridge plating for the comminuted column(s)
  • Compression plating for the column with a simple wedge, intrinsically stable after reduction

Reduction and fixation principle for extensive comminution

There is no intrinsic guide to the length and rotational alignment of the distal humerus. In these cases, an external fixator or distractor to gain provisional alignment can be used.

For many comminuted fractures, it is preferable to bridge the comminution without reducing and securing 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 - Bicolumnar bridge plating of a fracture with extensive comminution

Plate selection

Precontoured anatomical plates have been designed. If these are not available, at least one column (usually the lateral column) should be fixed with a small-fragment LCP in bridging mode. The other column can also be fixed with a small-fragment LCP or a reconstruction plate in bridging mode.

Note: radial nerve at risk

For balanced fixation, it may be necessary to use a longer lateral plate, putting the radial nerve at risk.
Therefore, it may be necessary to expose the nerve and release it from the lateral intermuscular septum (see also neurological protection and handling).
Radial nerve at risk with longer lateral plate

Note: ulnar nerve at risk

On the medial side, if the fracture exits just above the medial condyle, the ulnar nerve is at risk and needs to be exposed, released, and protected (see also neurological protection and handling).
Ulnar nerve is at risk if the fracture exits just above the medial condyle.

2. Patient preparation and approaches

Patient positioning

This procedure is normally performed with the patient either in a prone position or lateral decubitus position.

Approaches

For this procedure, a posterior approach may be used:

For very low fractures, a triceps-elevating approach or an olecranon osteotomy may be preferable.

Skin incision of triceps-split, triceps-on, and triceps-elevating approach

3. Reduction

Preparing the fracture site

In principle, preserve all fracture fragments attached to soft tissue in situ if possible.

Preserve loose bone fragment for later use as bone graft. Keep removal of hematoma to the minimum necessary to facilitate the exposure of the fracture.

Note: The more distal the transcondylar fracture line and the more complex the articular fracture pattern, the greater the risk to fragmental perfusion. Soft-tissue attachments are vital to fracture healing and should be respected (see additional material on vascularization).
Vascularization around the distal humerus

Indirect reduction

Use an external fixator or distractor to facilitate and provisionally stabilize the angular and rotational alignment, although in most cases, manual traction is sufficient.

Distraction may be performed by transarticular or periarticular pin placement depending on the available bone stock of the articular segment.

Note: Plan the pin insertion to avoid interference of the distractor with later plate application.
Note: The radial nerve is at risk during proximal pin insertion.

Ensure an accurate alignment of the articular block to the shaft (see also the anatomical concepts).

Use of a distractor to facilitate and provisionally stabilize the angular and rotational alignment

4. Plate fixation

Basic techniques

The basic technique for application of anatomical plates is described in:

If precontoured anatomical plates are not available, see the basic technique for application of reconstruction plates.

Comminuted columns: bridging

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

Start fixation of the less complex fragmented column in bridge mode. No compression should be exerted.

Then bridge the other column accordingly.

ORIF - Bicolumnar bridge plating

Option: compression of the column with a simple wedge

If one column comprises a simple wedge fragment, which can be reduced and is then intrinsically stable, apply a plate in compression mode.

5. Final assessment

Visually inspect the fixation and manually check for fracture stability.

Repeat the manual check under image intensification.

Ensure the ulnar nerve is not unstable or tethered on implants throughout a full range of motion.

6. Aftercare

Introduction

The rehabilitation protocol consists usually of three phases:

  • Rehabilitation until wound healing
  • Rehabilitation until bone healing
  • Functional rehabilitation after bone healing

Immediate aftercare

The arm is bandaged to support and protect the surgical wound.

The arm is rested on pillows in slight flexion of the elbow so that the hand is positioned above the level of the heart.

Short-term splinting may be applied for soft-tissue support.

Neurovascular observations are made frequently.

Semireclining patient position, with the elbow elevated, preferably above the chest, on pillows

Hand pumping and forearm rotation exercises are started as soon as possible to reduce lymphedema and to improve venous return in the limb. This helps to reduce postoperative swelling.

Hand pumping

Mobilization until wound healing

Gravity-eliminated active assisted exercises of the elbow should be initiated as soon as possible, as the elbow is prone to stiffness:

  • The bandages are removed, and the arm rested on a side table
  • Flexion/extension of the arm at the elbow is encouraged in a gentle sweeping movement on the tabletop as far as comfort permits (as illustrated)
  • Full pronation and supination in protected arm position is encouraged
  • Exercises are performed hourly in repetitions, the number of which is governed by comfort
  • Between periods of exercise, the elbow is rested in the elevated position for at least the first 48 hours postoperatively
  • Keep the arm elevated between periods of exercise until the wound has healed
Flexion/extension of the arm at the elbow in a gentle sweeping movement on the tabletop

Rehabilitation until bone healing

Note: Close surveillance by the clinician during this rehabilitation period has a tremendous impact on the patient outcome.

Active patient-directed range-of -motion exercises should be encouraged without the routing use of splintage or immobilization.

Avoid forceful motion, repetitive loading, or weight-beating through the arm.

A simple compressive sleeve can provide proprioceptive feedback which can help regain motion and avoid cocontraction.

No load-bearing (ie, pushing, pulling, or carrying weights) or strengthening exercises are allowed until early fracture healing is established by x-ray and clinical examination.

This is usually a minimum of 8–12 weeks after injury. Weight-bearing on the arm should be avoided until bony union is assured.

The patient should avoid resisted extension activities, especially after a triceps-elevating approach or olecranon osteotomy.

Rehabilitation after bone healing

When the fracture has united, a combination of active functional motion and kinetic chain rehabilitation can be initiated.

Active assisted elbow motion exercises are continued. The patient bends the elbow as much as possible using his/her muscles while simultaneously using the opposite arm to gently push the arm into further flexion. This effort should be sustained for several minutes; the longer, the better.

Gravity-eliminated active-assisted elbow motion exercises

Next, a similar exercise is performed for extension.

Extension exercise

If the patient finds it difficult to accomplish these exercises when seated, then performing the same exercises when lying supine can be helpful.

Note: When a damaged joint is rehabilitated in this way, the risk of “co-contraction” is reduced, and the incidence of chronic regional pain syndrome is also reduced.
Over-head elbow motion exercises

Implant removal

Generally, the implants are not removed. If symptomatic, hardware removal may be considered after consolidated bony healing, usually 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.