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Authors of section

Authors

Harry Hoyen, Simon Lambert, Joideep Phadnis

Executive Editor

Simon Lambert

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

1. General considerations

Treatment principle

The anterior 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.

ORIF - Headless screw and plate fixation of fracture with simple osteochondral fragments

Triangle-of-stability concept

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).

The mechanical properties of the distal humerus are based on a triangle of stability, comprising the medial and lateral columns and the articular block.

Screw selection

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

Locking-head and cortical screws

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

Articular screw dimensions

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.

Cannulated headless compression screws

Note: radial nerve at risk

For balanced fixation, it may be necessary to use a longer lateral plate, putting the radial nerve at risk.
Therefore, it may be necessary to expose the nerve and release it from the lateral intermuscular septum (see also neurological protection and handling).
Radial nerve at risk with longer lateral plate

2. Patient preparation and approaches

Patient positioning

If a lateral pate application is indicated, the patient is usually placed in a supine position.

If a dorsolateral plate is to be inserted, the lateral or prone position is preferred.

Supine patient position

Approaches

For less complex fractures, ie, simple articular fracture and simple column fracture, the preferred approach is the direct lateral approach for a lateral plate or a paratricipital approach for a dorsolateral plate.

Skin incision of direct lateral approach

3. Reduction (through lateral approach)

Mobilizing the fragment

Elevate the triceps and anconeus from the posterior aspect of the lateral column.

Open the fracture site by gently retracting the fragment anteriorly.

Mobilizing the fragment

Clearing the fracture site

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

Inspect the joint surfaces to ensure that there is no additional intraarticular fracture extension.

Clearing the fracture site

Reduction

Align the fracture and maintain reduction with a small hook or pick.

Monitor fracture reduction by realigning the metaphyseal fracture lines.

Depending on the extent of exposure, check the anterior and posterior fracture lines, including the articular surface.

Direct fracture reduction

Provisional fixation with K-wires

Maintain the reduction with smooth K-wires at least 1.6 mm in diameter. Insert the wires so they do not hinder plate placement.

Provisional wires may also be inserted through a plate screw hole or adjacent to the plate.

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

Provisional K-wire fixation

4. Fixation of articular fragments

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

This illustration shows the insertion of a headless double-pitch screw.

Securing the entirely articular fragments with a buried headless screw

Headless screw fixation

Principle

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

Drilling

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.

Drilling for headless screws
Screw insertion

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

Insert the subsequent screws in the same way.

Headless screw insertion

5. Fixation of lateral condyle

Repair of the lateral epicondyle

Small epicondylar fractures may benefit from fixation with a tension band wire that incorporates the soft-tissue attachments.

Basic techniques

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

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

Plate application

Apply a lateral plate.

Hold the plate with a cortical screw in the combihole proximal to the fracture.

Application of lateral plate

Distal screw insertion

The distal screws must avoid the olecranon fossa and the articular surface.

Use a 2.0 mm drill to drill a pilot hole across the fracture site in the condylar mass.

Insert the screw with the appropriate length.

Insert a second locking screw in the same way.

Insertion of distal screws into the articular segment

Final screw insertion

Insert proximal screws (3.5 mm) bicortically in neutral mode to anchor the plate in the humeral shaft.

Remove the K-wires.

Confirm fracture alignment and implant placement using image intensification.

Finalizing plate fixation

6. Alternative: dorsolateral plate with independent lag screw

If a dorsolateral plate has been chosen for neutralization, first apply compression with a lateral-to-medial lag screw.

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

The order of plate screw insertion may vary. In general, the basic technique is followed. A cortical screw is inserted in the gliding hole to place the plate provisionally. It is then best to insert the most distal screw to ensure that the plate is not placed too distally.

Check the plate position under image intensification before finalizing plate fixation.

Fixation with dorsolateral plate and independent lag screw

7. Final assessment

Visually inspect the fixation and manually check for fracture stability.

Repeat the manual check under image intensification.

8. Aftercare

Introduction

The rehabilitation protocol consists usually of three phases:

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

Immediate aftercare

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.

Semireclining patient position, with the elbow elevated, preferably above the chest, on pillows

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.

Hand pumping

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
Flexion/extension of the arm at the elbow in a gentle sweeping movement on the tabletop

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.

Gravity-eliminated active-assisted elbow motion exercises

Next, a similar exercise is performed for extension.

Extension exercise

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.
Over-head elbow motion exercises

Implant removal

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.