Authors of section

Authors

Mariusz Bonczar, Daniel Rikli, David Ring

Executive Editor

Chris Colton

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ORIF - Headless screw fixation

1. Introduction

Trochlear fractures are difficult to see on radiographs. Computed tomography - with 3D reconstruction in particular - is especially useful for understanding the fracture anatomy.

orif headless screw fixation

There is often complex articular comminution.

orif headless screw fixation

2. Patient preparation

Depending on the approach, the patient may be placed in the following positions:

3. Choice of approach

The best approach to the distal humerus depends on the main fracture morphology. In very complex fracture situations the posterior approach, using an osteotomy of the olecranon, provides an excellent access.

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For less complex fractures, a lateral, anterior, or medial approach can be chosen to access the articular segment of the distal humerus.

orif headless screw fixation

The following describes the use of a posterior approach with an olecranon osteotomy.

orif headless screw fixation

4. Open reduction

Clean the fracture site

Remove blood clots, small, unfixable loose pieces of bone, and any interposed tissue. Inspect the joint to ensure that no additional intraarticular fracture component is missed.

orif headless screw fixation

Disimpact fracture fragments

Many of the displaced fracture fragments are stable, which may suggest that they are appropriately aligned; however, these are often impacted into incorrect alignment. Using controlled force, these fragments must be disimpacted gently and brought into alignment with intact parts of the bone.

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Reduce the fracture

Monitor fracture reduction by realigning the articular fracture lines.

Provisionally fix the fragments with small, smooth K-wires.

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5. Internal fixation

Headless screws

Headless screws, cannulated or non-cannulated, can be used to secure articular fragments that are large enough and have adequate bone quality.

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Fixation of small fragments

Smaller articular fragments are secured with resorbable pins or headless compression screws.

partial articular frontal coronal trochlea

6. Osteosynthesis of the olecranon osteotomy

The olecranon osteotomy is typically repaired using plate osteosynthesis (hook plate or olecranon plate).

If plates are not available tension band wiring may also be used.

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7. 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.

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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