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.
Screw insertion through the tab
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.
Distal screw insertion
Insert the distal screws through the plate. This will engage the anterior capitellar shear fragments if present.
Final screw insertion
Insert the remaining screws as determined by the biomechanical requirements of the fracture.
6. Alternative: lateral plate
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:
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).
Note: ulnar nerve at risk
On the medial side, if the fracture exits just above the medial condyle, the ulnar nerve is at risk and needs to be exposed, released, and protected (see also neurological protection and handling).
8. Final assessment
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.
Mobilization until wound healing
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
Rehabilitation until bone healing
Note: Close surveillance by the clinician during this rehabilitation period has a tremendous impact on the patient outcome.
Active patient-directed range-of -motion exercises should be encouraged without the routing use of splintage or immobilization.
Avoid forceful motion, repetitive loading, or weight-beating 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.
Rehabilitation after bone healing
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.
Note: When a damaged joint is rehabilitated in this way, the risk of “co-contraction” is reduced, and the incidence of chronic regional pain syndrome is also reduced.
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.