Authors of section

Authors

Mariusz Bonczar, Daniel Rikli, David Ring

Executive Editor

Chris Colton

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ORIF - Plate and screw fixation

1. Introduction

Most medial condyle fractures in adults feature complex articular comminution. Computed tomography—particularly 3D CT - can help define the fracture anatomy and facilitate planning of the surgery.

orif plate and screw fixation

The surgeon must be prepared to apply fixation specific to small osteochondral fracture fragments (eg headless screws and small threaded K-wires), in addition to standard plate and screw fixation.

Furthermore, autogenous bone grafting from the iliac crest may prove useful for supporting disimpacted articular fragments.

Extensive access to the articular surface is necessary, so an olecranon osteotomy is preferred.

orif plate and screw fixation

2. Patient preparation

Depending on the approach, the patient may be placed in the following positions:

3. Approaches

For this procedure either a medial approach or a transolecranon approach with osteotomy of the olecranon may be used.

As extensive access to the articular surface is necessary, the olecranon osteotomy is preferred.

orif screw fixation protection plate

4. Open reduction

Clean the fracture site

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

orif plate and screw fixation

Disimpact fracture fragments

Many of the displaced fracture fragments are stable, which may suggest that they are appropriately aligned; however, many are impacted into an incorrect alignment.

Using carefully controlled force, these fragments must be gently disimpacted and brought into alignment with intact parts of the bone.

orif plate and screw fixation

Reduction

Reduce the fracture.

Monitor fracture reduction by realigning the articular and metaphyseal fracture lines.

Small fragments that may need to be discarded can be used as “puzzle pieces” to ensure correct relationships of the major fragments.

orif plate and screw fixation

5. Plate preparation

Planning for plate placement

The plate should wrap around the entire medial epicondyle. The ulnar nerve must be mobilized and transposed.

Complex plate contouring, using a malleable template, is necessary. This is possible with a reconstruction type plate. Alternatively, a precontoured plate may be selected.

It is useful to be able to place a screw through the distal plate hole and across the trochlea below the medial epicondyle.

orif plate and screw fixation

6. Provisional fixation

The osteochondral fragments are realigned and secured provisionally with smooth K-wires.

orif plate and screw fixation

7. Definitive screw fixation

Subchondral fixation

In some cases provisional K-wire stabilization is not possible.

When there is no intact posterior distal humerus onto which to fix the fragment, or when the fragment is too small to accept a screw, small threaded K-wires, or absorbable pins can be used.

These fragments are stabilized to an adjacent fragment by drilling small threaded K-wires from one fragment to the next in the subchondral bone.

orif plate and screw fixation

Buried screws

The articular fragments are usually secured first—either to the intact lateral column or to other large fracture fragments on the medial column.

Large articular fragments can be secured with headless screws buried beneath the articular surface.

orif plate and screw fixation

8. Plate application

The major medial column fragment is then secured with a plate.

Start with a distal screw to ensure proper plate placement.

partial articular medial sagittal fragmentary transtrochlear

9. 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