ORIF - Plate fixation

The typical patient with this fracture is an elderly woman with osteoporotic bone.
This example shows a very distal transcondylar extraarticular distal humerus fracture.
Articular involvement may be present, but not obvious from initial x-rays. For this reason, a posterior approach is preferred.
Since the distal fragment is very short and the bone quality is poor, fixation with conventional implants is difficult.
The Distal Humeral Plate offers two major advantages:

• Three 2.4 mm screws can be inserted even in very small distal fragments of each column
• Angular stability enhances the purchase of the implant in the bone.

This procedure may be performed with the patient in either a prone position or lateral decubitus position.

For this procedure a posterior approach is normally used:

• Posterior triceps-on approach
• Triceps-elevating approach
• Transolecranon approach

The distal fragment is manually reduced to the radial and ulnar columns.

Preliminarily stabilize the reduction with two K-wires introduced from the distal fragment into each column.
It may be difficult to align the fracture correctly in flexion/extension.

A K-wire introduced into the trochlea can be used as a joystick to rotate the distal fragment and restore the angle of forward inclination of the lateral condylar mass in relation to the humeral shaft axis.

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.

Plate length should be determined so that the plates end at different levels on the humeral shaft to prevent a stress riser.

Screw length should be checked under image intensification, to avoid penetration into the joint.

At least three screws proximal to the fracture and as many distal screws as possible are preferred. Fixation using locking screws may give more stable fixation, particularly in osteoporotic bone, sufficient to allow for early functional rehabilitation.

Note
In fractures with very short distal segments, additional stability can be gained by inserting long, distal-to-proximal, 3.5 mm column screws.

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.

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.

This 3D-CT shows a low transcondylar/supracondylar distal humeral fracture. As there is no significant articular involvement, it is classified as an A-type fracture.

Anatomic landmarks are drawn for the surgical incision and the distal humerus is exposed via a direct posterior approach.

The first task is to carefully dissect medially to identify and protect the ulnar nerve.

The ulnar nerve has been identified and protected. This image also shows dissection of the olecranon for osteotomy placement.

The clamp is distracting the humeral ulnar joint and demonstrating the position for the ulnar osteotomy.

This image shows the oscillating saw, starting the osteotomy which will be completed with a small osteotome.

Here the osteotomy has been completed with the triceps still attached to the right-hand portion of the olecranon.

The main articular epiphyseal fragment is held with a clamp.

With the fracture reduced, the medial LCP is carefully applied beneath the protected ulnar nerve. The fracture can be seen in this image as it enters the olecranon fossa.

This image shows the careful protection of the ulnar nerve and the use of the variable angle drill guide and the VA- LCP.

Once medial stability has been achieved the posterior LCP is applied to the lateral column at 90° to the medial plate.

When drilling this back to front screw, the surgeon must be careful not to penetrate the capitellar joint surface but should be as deep as possible with the screw length, especially in osteoporotic bone.

In these fractures, the fixation is often tenuous. The LCP design should allow at least three points of screw fixation in each of the two plates, above and below the fracture.

This image shows the fracture reduced and good fixation proximal and distal to the fracture.

The ulnar nerve will lie in the cubital tunnel and run directly over the plate.

The olecranon osteotomy is then reduced and held with longitudinal K-wires.

A heavy gauge needle is passed behind the longitudinal K-wires and used as a wire passer for the tension band.

The posterior tension band wiring can be seen reducing the olecranon osteotomy with the ulnar nerve back in the cubital tunnel lying over the medial LCP.

The K-wires have been cut and the ends turned over, ready to be hammered into the bone under the triceps.

The incision has been closed.

Two-week X-rays.

Two-week clinical images showing restoration of all motion except elbow flexion.

Final X-ray images at 14 weeks showing satisfactory union.

Excellent final clinical result.