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.