Authors of section

Authors

Mariusz Bonczar, Daniel Rikli, David Ring

Executive Editor

Chris Colton

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ORIF - Plate fixation

1. Principles

This fracture may occur in a young patient with strong bone. Shear forces lead to an oblique separation of the metaphyseal / articular block from the shaft. Due to strong rotational forces at the level of the elbow, stabilization with plates on the ulnar and radial columns is preferred. The plates should be applied in a compression mode.

The obliquity of the fracture plane can be in two directions:

  • Obliquely downward and medially
orif plate fixation

  • Obliquely downward and laterally (radially)

orif plate fixation

2. Patient preparation

This procedure is normally performed with the patient in a prone position.

orif plate fixation

3. Approaches

For this procedure a posterior approach is normally used:

orif parallel plating

4. Reduction

In a simple fracture with strong bone stock, the main fragments can be reduced anatomically. Preliminary fixation with axial K-wires may be helpful.

orif plate fixation
orif plate fixation

5. Plate preparation

Plate selection and contouring

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

The plate length should allow for at least 2 screws in each fragment. If the fracture line exits low on the medial (ulnar) side, the plate is bent around the epicondyle.

To facilitate contouring, malleable templates are used.

orif plate fixation

If the fracture exits low on the lateral (radial) side, the plate can be placed distally onto the back of the lateral condyle.

orif plate fixation

6. Plate application (low fracture exit medially)

Medial: One-third tubular plate

The medial plate is applied first. It serves as an antiglide plate. The plate is contoured around the medial epicondyle and fixed distally. The proximal fragment is then pulled underneath the plate with a first eccentrically drilled screw in the proximal fragment.

orif plate fixation

Insert second proximal screw

A second bicortical screw in the proximal fragment completes fixation on the ulnar side.

orif plate fixation

Lateral plate

The radial plate is applied dorsally on the radial column. Drilling of an eccentric hole for a load screw in the proximal fixation creates compression of the fracture plane.

orif plate fixation

Option: additional lag screw

If the fracture configuration, bone quality and medial plate position permit, a lag screw through the plate, as illustrated, will enhance the rigidity of the fixation.

extraarticular simple oblique

7. Plate application (low fracture exit laterally)

See step 4. For fractures where the fracture line exits low on the lateral side, a posterior placement of the lateral plate is necessary. You may start with either the radial or the ulnar plate. Compression is exerted by eccentric drilling.

orif plate fixation

Option: additional lag screw

If the fracture configuration, bone quality and medial plate position permit, a lag screw through the plate, as illustrated, will enhance the rigidity of the fixation.

orif plate fixation

8. 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