ORIF - Lag screw with antiglide plate

Articular fractures that have proximal extension into the metadiaphysis require addition of a neutralization plate.

The lag screw may be placed independently or through the plate, depending on the fracture configuration and the chosen plate.

With a lateral plate, the lag screw would be placed through the plate. With a dorsolateral plate, an independent lag screw is placed.

There are two options for definitive fixation with compression across the articular fracture, which may be combined:

• Lag screw outside a plate
• Compression with forceps and holding it with a locking screw through a plate

Here the application of intrinsic compression held with a metaphyseal compression screw or a locking screw through the plate is described.

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 plate can be applied either directly laterally, or dorsolaterally to support a primary lag screw.

This procedure illustrates the direct lateral plate application as the primary option. The application of a dorsolateral plate is the alternative option.

The screws that cross the fracture site should normally only have thread purchase in the far fragment to apply interfragmentary compression.

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

The articular screws are 2.7 mm low-profile metaphyseal and VA-LCP locking screws. The type of screw used depends on the desired fixation when planning for a lag/position screw within the plate.

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.

The preferred approach is the direct lateral approach for a lateral plate or a paratricipital approach for a dorsolateral plate.

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

Open the fracture site by gently retracting the fragment anteriorly.

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.

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.

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.

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

• Lateral plate application

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

Apply a lateral plate.

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

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.

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.

The position of the lateral plate often depends on patient anatomy. If the plate fits better in a more proximal position, then compression is achieved with an independent lag screw placed first, outside and distal to the plate.

• Basic technique: cancellous lag screws

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

• Basic technique: cancellous lag screws

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

• Dorsolateral plate application

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.

Visually inspect the fixation and manually check for fracture stability.

Repeat the manual check under image intensification.

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.