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  5. Treatment

Authors of section


Harry Hoyen, Simon Lambert, Joideep Phadnis

Executive Editor

Simon Lambert

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ORIF - Lag screw with antiglide plate

1. General considerations

Treatment principle

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

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 with an independent lag screw outside the plate is described.

ORIF - Lag screw fixation with antiglide plate

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.

Plate selection

Precontoured anatomical plates have been designed. If these are not available, a reconstruction plate may be used. If a stronger plate is required for either column, a small-fragment compression plate may be used, but this is more difficult to contour.

The medial plate with extension is designed to wrap around the medial epicondyle. This allows a higher variation of screw trajectories, especially an ascending screw insertion.

ORIF Lag screw with antiglide plate

Screw selection

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.

Drill and screw dimensions for lag screw fixation

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.

VA-LCP locking screw and low-profile metaphyseal compression screw

Note: ulnar nerve exposure and protection

If the fracture exits just above the medial condyle, the ulnar nerve needs to be exposed, released, and protected (see also neurological protection and handling).
Ulnar nerve exposure and protection

2. Patient preparation and approach

Patient positioning

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

Supine patient position


The preferred approach is the direct medial approach. This provides access to the ulnar nerve, the medial fracture fragment, and the ulnohumeral joint.

Skin incision of medial approach

3. Reduction and temporary fixation

Mobilizing the fragment

Identify and protect the ulnar nerve (see also neurological protection and handling).

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 surface to ensure that there is no additional intraarticular fracture extension.

Clearing the fracture site


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

Before inserting K-wires, hold the reduction with forceps.

Holding reduction with forceps

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.

Maintaining the reduction with smooth K-wires

4. Lag screw insertion

Considerations for screw placement

The lag screw should be placed as distally as possible to ensure good compression of the articular surface fragments and minimal interference of the intended plate position. The screw should be as long as possible.


For a fully threaded lag screw, drill the near fragment with a 2.7/3.5 mm drill to create a gliding hole.

Then drill the far fragment with a 2.0/2.5 mm drill.

Drilling for lag screw fixation with a fully threaded screw, overdrilling the near fragment

Screw insertion

Insert the screw and tighten it to compress the fragments.

Depending on the stability provided by the lag screw, the K-wires can then be removed.

Lag screw insertion

5. Plate application

Basic technique

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.

Considerations for plate positioning

The plate should be positioned on the medial ridge, slightly dorsal to the intermuscular septum.

Due to the anatomy and/or the prominence of the screw head, it may be necessary to bend the plate. This ensures an optimal plate fit and positioning of long screws through the articular block.

Plate application

Apply the medial plate in neutral or compression mode.

Application of medial plate

6. Alternative: lag screw through the plate

When the medial plate is applied to the inferior edge of the epicondyle, the compression is applied in either way:

  • Compression with forceps and holding it with a VA locking screw through the plate
  • Insertion of a low-profile metaphyseal compression screw through the plate (shown in illustration)
Lag screw insertion through medial plate

7. Alternative: medial plate with extension

An ascending column screw can be placed through the plate in a distal-to-proximal direction.

It is recommended that this ascending screw is inserted first and the further distal screws at variable angles to avoid screw interference.

Fracture fixation using a medial plate with extension and ascending column screw

8. Final assessment

Visually inspect the fixation and manually check for fracture stability.

Repeat the manual check under image intensification.

Ensure the ulnar nerve is not unstable or tethered on implants throughout a full range of motion.

9. Aftercare


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 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.

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.