Authors of section

Editors

Peter Kloen, David Ring

Executive Editors

Peter Trafton, Michael Baumgaertner

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Lag screw with neutralization plate

1. Principles

Lag screw principles

In an oblique fracture, compression across the fracture is achieved with a lag screw.

The thread pulls the opposite bone fragment towards the head of the screw, creating compression across the fracture. The screw slides through the overdrilled near cortex.

Insert the lag screw as perpendicularly to the fracture plane as possible.

Simple olecranon – Plate with or without lag screw

Neutralization plate

As a lag screw osteosynthesis alone is not able to resist shearing and torsion forces, a neutralization plate has to be added to allow early mobilization.

Note: Whenever possible (considering soft-tissue condition, fracture configuration, associated radial head fracture etc.), insert the lag screw through the plate to achieve better stability.

Simple olecranon – Plate with or without lag screw – Neutralization plate

Plate selection

Plate length should be sufficient to place, usually, three screws in each fragment.

The plate may be a small fragment dynamic compression plate (3.5 DCP), or limited contact dynamic compression plate (LC-DCP), or locking plate (LCP) with conventional screws. More recently, use of 2.7 LCP has been reported.

Note: In osteoporotic bone, a LCP with locking head screws should be used, after insertion of a conventional lag screw through the plate.

Simple olecranon – Plate with or without lag screw – Plate selction

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

Cleaning the fracture site

Expose the fracture ends with minimal soft tissue dissection off the bone.

Remove hematoma and irrigate.

Check elbow stability.

Simple olecranon – Plate with or without lag screw – Cleaning fracture site

Direct reduction

Reduce the fracture with the help of small pointed reduction forceps and provisionally fix with forceps or K-wires.

Simple olecranon – Plate with or without lag screw – Direct reduction

4. Lag screw insertion

Plate contouring

Contour the plate according to the posterior surface anatomy of the proximal ulna.

Contouring of the plate is achieved with bending irons or bending press.

Simple olecranon – Plate with or without lag screw – Plate contouring

Plate application

Make a small transverse cut in the triceps tendon to slide the plate under.

Simple olecranon – Plate with or without lag screw – Plate application

Apply plate and hold it against the bone with a bone clamp or one or two fingers.

Simple olecranon – Plate with or without lag screw – Plate application

Drilling

Through the hole just proximal to the fracture drill a 3.5 mm gliding hole for the lag screw into the posterior cortical bone of the proximal fragment. The drill should be angled slightly ulnar to avoid impingement in the radio-ulnar joint.

Insert the 2.5 mm drill sleeve into the gliding hole until it reaches the far cortical bone.

Now drill the far cortex with the 2.5 mm drill bit.

Simple olecranon – Plate with or without lag screw - Drilling

Measuring

Measure the depth of the hole with the hook of the depth gauge pointing distally.

Simple olecranon – Plate with or without lag screw – Measuring screw length

Insertion of the lag screw

Closely observe the compression effect on the fracture line while tightening the lag screw.

The reduction forceps should be removed just before the final tightening of the screw.

Simple olecranon – Plate with or without lag screw – Insertion of lag screw

5. Finish plate fixation

Fix the plate to the bone with three screws proximal and three screws distal to the fracture in neutral position to protect the lag screw.

Simple olecranon – Plate with or without lag screw - Plate

Alternatively, a so called "home run screw" can be placed as an intramedullary screw. This screw is a non-locking screw that can place thru a small stab incision in the triceps tendon. To allow passage of this long screw you can use unicortical locking screws distally. By drilling this long screw using the oscillating drilling technique there is low risk of an early extramedullary exit and/or screw interference with the more distal screws.

Assess the range of motion in pronation, supination, flexion and extension. Screw tips should not touch the radius.

Check results with image intensifier or x-ray.

Repair the small incision in the triceps over the plate.

Simple olecranon – Plate with or without lag screw – Home run screw

6. 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.