Authors of section

Editors

Peter Kloen, David Ring

Executive Editors

Peter Trafton, Michael Baumgaertner

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Bridge plate

1. Principles of bridge plating

Preliminary remark

Absolute stability is desirable for articular fractures. However, this may not be possible in multifragmentary fractures of the proximal ulna. Every effort should still be directed at anatomical reduction and absolutely stable fixation of the major articular surface fragments, particularly the coronoid process. Compression will deform the articular surface, so it no longer fits the trochlea. In this situation, the fracture must be bridged without compression to preserve size and shape of the olecranon fossa. Small interfragmentary screws, K-wires, medial, or lateral miniplate may improve stability.

Bridge plating

A bridge plate is analogous to locked intramedullary nail fixation of a comminuted shaft fracture. In multifragmentary fractures of the olecranon, anatomical reconstruction of the articular surface itself is the primary goal. Intermediate, nonarticular fragments do not need to be reduced anatomically. Cancellous bone graft can be used to support the articular fragments and fill defects.

Directly manipulate only the articular fragments. Excessive manipulation of intermediate fragments risks disturbing their blood supply. If the soft tissue attachments are preserved, and the fragments are relatively well aligned, healing is predictable. Alignment of the main fragments can usually be achieved indirectly utilizing traction and soft tissue tension.

Mechanical stability, provided by the bridging plate, is adequate for indirect healing (callus formation).

Multifragmentary olecranon - Bridge plate

2. Positioning and approach

Positioning

This procedure is normally performed with the patient either in a lateral position or in a supine position for posterior access.

Approach

For this procedure a posterolateral approach is normally used.

open reduction internal fixation

3. Reduction

Through a posterior incision, release the joint capsule medially and laterally at the fracture site. With direct visualization, manipulate and anatomically reduce the articular fragments. Use the distal humerus as a template for reduction. Provisionally fix the fragments with 1.0 mm K-wires.

Multifragmentary olecranon - Bridge plate - Reduction

Reduce the proximal part of the olecranon with pointed reduction forceps and temporarily hold the reduction with one or two K-wires.

Insert all K-wires in a position where they do not interfere with the planned plate and screws.

Control reduction with direct visualization of the sigmoid notch and the posterior cortex of the olecranon, and confirm with C-arm fluoroscopic control.

Multifragmentary olecranon - Bridge plate -Temporary fixation

4. Plate preparation

Implant choice

Use a 3.5 dynamic compression plate (DCP), reconstruction plate, limited contact dynamic compression plate (LC-DCP), or locking plate (LCP). The reconstruction plate is the least durable, and should be used cautiously as a bridged plate.

Choose the length of the plate so that at least three screws can be inserted in the most proximal fragment and three in the diaphysis.

If the fracture is very proximal or in osteoporotic bone, a pre-shaped olecranon LCP with locking head screws can be used to allow better fixation.

Multifragmentary olecranon - Bridge plate – Plate selection

Plate contouring

If an anatomic plate is not used, contour the plate to fit the proximal ulna, bending around the tip of the olecranon. Make sure to follow the curvature of the olecranon.

Contouring is done with bending irons and bending press.

Multifragmentary olecranon - Bridge plate – Plate contouring

5. Proximal plate fixation

Split the triceps attachment

To achieve close bone plate contact, split the triceps attachment before positioning the plate.

Multifragmentary olecranon - Bridge plate – Split of triceps attachment

Anchor the plate with three screws to the proximal olecranon. Make sure that the screws do not protrude into the joint.

Whenever possible, insert the screws bicortically, aiming the drill to the lateral or to the medial cortex.

Multifragmentary olecranon - Bridge plate – Proximal plate fixation

6. Distal plate fixation

Insert three bicortical screws in the distal fragment and in a divergent pattern.

Make sure to maintain contour and size of the olecranon’s articulation.

K-wires are then removed.

Multifragmentary olecranon - Bridge plate – Distal plate fixation

Bone graft

Large defects may be filled with bone graft.

Multifragmentary olecranon - Bridge plate – Bone graft

7. Possible fixation of a large coronoid fragment

Reduction of a large coronoid component of multifragmentary proximal ulna fractures can often be done through the fracture site. Provisional or definitive fixation can be placed at that time, but sometimes it helps to use a screw through a posterior plate for its fixation, as shown here. Insert this as a lag screw, as perpendicularly as possible to the fracture plane at the base of the coronoid. Smaller diameter screws may be better.

For further information on the fixation of coronoid fractures, see “Repair of coronoid fracture”.

Multifragmentary olecranon - Bridge plate – Fixation of large coronoid fragment

8. Tension band

In elderly patients, low demand patients, and/or severe osteoporotic bone, it may be possible to excise intermediate bone fragments. The elbow joint must be stable. Collateral ligaments, coronoid process, and distal olecranon surface must be intact.

Multifragmentary olecranon - Bridge plate – Osteoporotic bone

The proximal olecranon should be rotated so its articular surface fits the trochlea, recreating an olecranon fossa. Fix with a tension band wire or a re-contoured plate.

Multifragmentary olecranon - Bridge plate – Osteoporotic bone

9. Postoperative treatment following ORIF

Postoperatively, the elbow may be placed for a few days in a posterior splint for pain relief and to allow early soft tissue healing, but this is not essential. To help avoid a flexion contracture, some surgeons prefer to splint the elbow in extension.

If drains are used, they are removed after 12 - 24 hours.

open reduction internal fixation

Mobilization

Active assisted motion is encouraged within the first few days including gravity-assisted elbow flexion and extension. Encourage the patient to move the elbow actively in flexion, extension, pronation and supination as soon as possible. Delay exercises against resistance until healing is secure.

Use of the elbow for low intensity activities is encouraged, but should not be painful.

open reduction internal fixation

Range of motion must be monitored to prevent soft tissue contracture.

Prevent loading of the elbow for 6-8 weeks.

Monitor the patient to assess and encourage range of motion, and return of strength, endurance, and function, once healing is secure.

open reduction internal fixation

Follow up

The patient is seen at regular intervals (every 10-20 days at first) until the fracture has healed and rehabilitation is complete.

Implant removal

As the proximal ulna is subcutaneous, bulky plates and other hardware may cause discomfort and irritation. If so, they may be removed once the bone is well healed, 12-18 months after surgery, but this is not essential.