ORIF - Plate fixation

Take care when approaching an apparently non-articular lateral condylar fracture, as these are unusual. Preoperative imaging including computed tomography, can be used to identify associated articular fractures.

Only when bone quality is excellent will screw fixation alone provide adequate stability for early active exercises, and when the fracture is simple and non-fragmented.

In practice, screw fixation alone is used primarily in skeletally immature patients, who can be immobilized for 3-4 weeks in a cast without getting too stiff.

Most lateral condylar fractures in adults are fixed with a plate and screws, in order to allow more confident early active motion.

The plate can be applied either directly laterally, or posteriorly in order to protect and buttress a primary lag screw.

In this module, we demonstrate a direct lateral plate.

This procedure is normally performed with the patient in a supine position for lateral approach.

For this procedure a lateral approach is normally used.

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

Open the fracture site by gently retracting the fragment anteriorly.

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

Inspect the joint to ensure that no intraarticular fracture component was missed when examining the imaging.

Realign the fracture.

Monitor fracture reduction by realigning the metaphyseal fracture lines.

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

The distal aspect of a direct lateral plate must be contoured to bend anteriorly following the anterior bend of the lateral column. It should also be contoured to fit the lateral surface, although it does not have to fit precisely. A direct lateral plate will sit on the point of the supracondylar ridge. The muscle origins need not be disturbed.

A direct lateral plate acts in some respects like a buttress plate. Furthermore, all of the screws go through the plate.

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

A straight plate that is properly applied distally will come off the bone proximally.

A direct lateral plate sits on the apex of the supracondylar ridge.

Provided there is good screw purchase, it is not necessary for the plate to sit on a flat part of the bone.

Lateral plates extending fewer than 10 cm from the joint surface are unlikely to place the radial nerve at risk, but care should be taken in smaller patients.

The fracture is stabilized with smooth K-wires at least 1.5 mm in diameter. The wires should be inserted carefully so that they do not hinder plate placement.

Provisional wires can be inserted through a plate screw hole, or adjacent to the plate.

The order of screw insertion may vary. In general, it is best to insert the most distal screw first.

A 2.5 mm drill is used to drill a pilot hole across the fracture site in the condylar mass.

The screw length is measured, and the screw inserted. If a fully threaded screw is used, a 3.5 mm gliding hole should be drilled in the near fragment. For non-self-tapping screws, remember to tap prior to screw insertion.

The screws that cross the fracture site should normally only have thread purchase in the low fragment so as to apply interfragmentary compression. Only when there is marked comminution of the trochlea, when compression may crush the multifragmentary zone, should a fully threaded, position screw be used.

Next, insert one of the proximal screws to anchor the plate. This screw is a 3.5 mm cortical screw, so a 2.5 mm drill is used.

After initial proximal and distal screw fixation, fracture alignment and implant placement are confirmed, using image intensification.

The remaining screws are placed.

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.

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.