Authors of section

Authors

Mariusz Bonczar, Daniel Rikli, David Ring

Executive Editor

Chris Colton

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ORIF - Screw and protection plate

1. Introduction

Fracture assessment

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

orif plate fixation

Indication

Screw fixation alone will only provide adequate stability for immediate active exercises when the bone quality is excellent, and the fracture simple and non-fragmented.

In practice, screw fixation alone is used primarily in skeletally immature patients that 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 to allow more confident immediate active motion.

orif plate fixation

Plate position

The plate can be applied either directly lateral or posterior to neutralize a lag screw.

In this module, we demonstrate a posterior plate neutralizing a lag screw.

partial articular lateral sagittal

2. Patient preparation and approach

Patient preparation

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

orif plate fixation

Approach

For this procedure a lateral approach is normally used.

orif plate fixation

3. Open reduction

Mobilize the fragment

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

Open the fracture site by mobilizing the fragment.

orif plate fixation

Clean the fracture site

Clean out the fracture by removing blood clots, loose pieces of bone, and interposed tissue.

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

orif plate fixation

Reduction

Realign the fracture.

Monitor fracture reduction by realigning the metaphyseal fracture lines.

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

orif plate fixation

4. Plate preparation

Planning for plate placement

The posterior aspect of the lateral column is nonarticular. The plate is contoured to the back of the posterior aspect of the lateral column, including the lateral condyle.

A posterior plate is best used to protect one or two screws, inserted as described below.

The screws must avoid the olecranon fossa and the articular surface. In particular the distal screws should be unicortical so that they do not penetrate the articular cartilage of the capitellum anteriorly.

partial articular lateral sagittal

Radial nerve

The radial nerve is safer when a posterior plate is used, but should be identified if a very long plate is indicated, as in more complex fracture combinations.

orif screw and protection plate
orif screw and protection plate

5. Provisional fixation

Placement of K-wires

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

Through a plate screw hole or adjacent to the plate.

orif screw and protection plate

Screw insertion

One or two lag screws are inserted across the fracture plane, as described for noncannulated screw fixation.

orif screw and protection plate

6. Plate application

Distal plate screw insertion

The order of plate screw insertion may vary. In general, it is best to insert the most distal screw first, in order to ensure that the plate is not placed too distally.

The distal screws must be unicortical to avoid violating the anterior articular surface of the capitellum, or the coronoid fossa.

orif screw and protection plate

Remaining screws

Insert the screws first distally and then proximally.

orif screw and protection plate

7. Aftertreatment

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.

orif plate fixation

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.

orif plate fixation