ORIF - Headless screw and plate fixation (complex osteochondral fragments)

The coronal articular segments are stabilized with headless compression screws.

The articular reconstruction is then supported with a lateral plate or dorsolateral plate with a lateral tab.

The extent of the articular fragmentation towards the medial side will dictate the choice of plate and surgical exposure. An additional medial plate may be necessary.

The mechanical properties of the distal humerus are based on a triangle of stability, comprising the medial and lateral columns and the articular block (see also the anatomical concepts).

In the shaft, 2.7 and 3.5 mm screws are most commonly used.

The articular screws are 2.7 mm metaphyseal and VA-LCP locking screws.

Headless compression screws are available as 2.4 and 3.0 mm screws. The size and number of headless compression screws used will depend on the complexity of the fracture to be fixed.

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

• Prone position
• Lateral decubitus position

If the articular fragment extends medially or is more complex, a triceps-elevating approach or olecranon osteotomy may be indicated.

Disimpact the posterior trochlea using a fine elevator. Take care to preserve smaller articular fragments.

Clear the fracture of any hematoma, loose pieces of bone, or interposed tissue.

Inspect the joint surfaces to ensure complete identification of additional intraarticular fracture extensions.

If the fracture morphology allows, stabilize small fragments with a threaded or smooth K-wire. Cut the K-wire so as not to interfere with the other fragment reduction.

Provisionally stabilize the reduced fragments with smooth K-wires.

If necessary, check the reduction and provisional fixation with image intensification.

Secure the coronal articular fragments with buried headless screws, small threaded K-wires, or absorbable pins.

The screw stabilization may be needed in several planes.

Complete the entire sequence of drilling and screw insertion for each screw before inserting the next screw.

Insert the guide wire.

Drill the pilot hole for the screw to the appropriate depth, using the cannulated drill bit placed over the guide wire.

Take care when removing the drill not to dislodge or remove the K-wire.

Insert the chosen screw over the wire, then remove the guide wire.

Insert the subsequent screws in the same way.

The basic technique for application of anatomical plates is described in:

• Dorsolateral plate application

If precontoured anatomical plates are not available, see the basic technique for application of reconstruction plates.

Apply a dorsolateral plate with a lateral tab.

The order of screw insertion may vary. In general, it is best to insert the most proximal cortical screw (3.5 mm) in the combihole first, to hold the plate in an orientation close to the final desired position. It is important to check accuracy of the orientation of the distal part of the plate with the lateral column and articular segment and that the plate lies accurately along the lateral aspect of the distal humerus before provisional fixation through the combihole of the plate.

If indicated, insert the screws through the lateral tab. This will link the lateral column with the central articular segment.

They should completely engage in the medial side of the articular segment.

Insert the distal screws through the plate. This will engage the anterior capitellar shear fragments if present.

Insert the remaining screws as determined by the biomechanical requirements of the fracture.

A lateral plate may be used alternatively if there is no anterior capitellar fracture extension.

The basic technique for application of anatomical plates is described in:

• Lateral plate application

Plating the medial column may be necessary for additional stability, especially if the central articular segment is involved.

Apply a medial plate in either compression or neutral mode (antiglide).

Visually inspect the fixation and manually check for fracture stability.

Repeat the manual check under image intensification.

Ensure the ulnar nerve is not unstable or tethered on implants throughout a full range of motion.

The rehabilitation protocol consists usually of three phases:

• Rehabilitation until wound healing
• Rehabilitation until bone healing
• Functional rehabilitation after bone healing

The arm is bandaged to support and protect the surgical wound.

The arm is rested on pillows in slight flexion of the elbow so that the hand is positioned above the level of the heart.

Short-term splinting may be applied for soft-tissue support.

Neurovascular observations are made frequently.

Hand pumping and forearm rotation exercises are started as soon as possible to reduce lymphedema and to improve venous return in the limb. This helps to reduce postoperative swelling.

Gravity-eliminated active assisted exercises of the elbow should be initiated as soon as possible, as the elbow is prone to stiffness:

• The bandages are removed, and the arm rested on a side table
• Flexion/extension of the arm at the elbow is encouraged in a gentle sweeping movement on the tabletop as far as comfort permits (as illustrated)
• Full pronation and supination in protected arm position is encouraged
• Exercises are performed hourly in repetitions, the number of which is governed by comfort
• Between periods of exercise, the elbow is rested in the elevated position for at least the first 48 hours postoperatively
• Keep the arm elevated between periods of exercise until the wound has healed

Active patient-directed range-of -motion exercises should be encouraged without the routine use of splintage or immobilization.

Avoid forceful motion, repetitive loading, or weight-bearing through the arm.

A simple compressive sleeve can provide proprioceptive feedback which can help regain motion and avoid cocontraction.

No load-bearing (ie, pushing, pulling, or carrying weights) or strengthening exercises are allowed until early fracture healing is established by x-ray and clinical examination.

This is usually a minimum of 8–12 weeks after injury. Weight-bearing on the arm should be avoided until bony union is assured.

The patient should avoid resisted extension activities, especially after a triceps-elevating approach or olecranon osteotomy.

When the fracture has united, a combination of active functional motion and kinetic chain rehabilitation can be initiated.

Active assisted elbow motion exercises are continued. The patient bends the elbow as much as possible using his/her muscles while simultaneously using the opposite arm to gently push the arm into further flexion. This effort should be sustained for several minutes; the longer, the better.

Next, a similar exercise is performed for extension.

If the patient finds it difficult to accomplish these exercises when seated, then performing the same exercises when lying supine can be helpful.

Generally, the implants are not removed. If symptomatic, hardware removal may be considered after consolidated bony healing, usually 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.