Authors of section

Authors

Mariusz Bonczar, Daniel Rikli, David Ring

Executive Editor

Chris Colton

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ORIF - Plate fixation

1. Principles

Stabilization

In osteoporotic bone, the distal articular fragment may be very short, and varying degrees of metaphyseal comminution may be present in the ulnar or radial column.

The most difficult task is to stabilize a very short articular fragment when the bone quality is poor. This can be achieved with standard techniques, preferably with a precontoured angular-stable plate.

orif plate fixation

Plating principles

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

  • Compression plating for the non-comminuted column
  • Bridge plating for the comminuted column

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

Cleaning of the fracture site

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

Reduction of non-comminuted column

Reduction of the articular block to the shaft is easier on the side without metaphyseal comminution.

The reduction is held with an axial K-wire.

orif plate fixation

Reduction of comminuted column

With one column preliminarily stabilized, reduction of the other column can be achieved.

Insert a K-wire to secure the reduction preliminarily.

Correct reduction of the articular block in flexion / extension may be difficult.

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 reconstruction plate is used both on the medial and the lateral sides. 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. On the lateral side, the plate can be placed very distally onto the posterior aspect of the capitellum. On the medial side, the plate is bent around the epicondyle, as necessary.

To facilitate contouring, malleable templates are used.

If standard implants are used, the plates must be perfectly adapted to the bone.

orif plate fixation

6. Plate application

Non-comminuted column: compression

Start with the non-comminuted column.

The plate is fixed distally with two screws. Compression on the fracture site can be achieved with eccentrically placed screws in the proximal fragment.

When the plate is securely in place, the lateral K-wire is withdrawn.

orif plate fixation

Comminuted column: bridging

The metaphyseal comminution is bridged. No compression should be exerted. The plate is fixed with 2 screws in each main fragment.

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

extraarticular wedge intact or fragmentary

7. Pearls

Pearl I: Column screw

If the articular fragment on the medial side is very short, the plate can be bent around the epicondyle.

A long screw through the plate, up the medial column, into the opposite cortex of the shaft, provides additional stability.

orif plate fixation

Pearl II: Distal humeral plate

In this clinical case, the Locking Distal Humeral Plates were used. These plates allow insertion of three 2.4 locking screws, even in very short distal fragments. Moreover, the locking screws provide better purchase in poor quality bone.

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