ORIF - Conventional plating

Anatomical reduction of the metaphyseal component should be achieved with direct visualization and direct reduction techniques.

Provided the reduction is anatomic, this fracture can be successfully managed with either medial or lateral single-column plating. The choice of which column is plated depends on soft tissue and fracture variables. Wide displacements, poor bone quality, or extreme proximal fractures may require double plating.

The patient is placed in the Supine position.

• Supine position

For this procedure the following approaches may be used:

• Anterolateral/extended anterolateral approach
• Medial/posteromedial approach

The A2 fracture pattern is best treated with open reduction and direct visualization of the displaced fracture fragments. This ensures anatomic restoration of frontal and sagittal plane alignment.

In situations where both columns are not directly visualized, positioning of the knee is important for correct reduction and fixation. Frontal and sagittal plane alignment must be confirmed radiographically. The use of large fragment clamps and K-wires to directly maintain alignment is extremely helpful.

The positioning of the neutralization plate can be either medial or lateral. Important fixation considerations are to create an axilla to resist the direction of displacement and to enable screw fixation through the plate across the primary fracture line. In some situations, independent lag screws can be placed initially.

This illustration shows the final construct.

Close monitoring of the tibial compartments should be carried out, especially during the first 48 hours after injury and again after surgery to rule out compartment syndrome. More information is provided here:

• Compartment syndrome

The neurovascular status of the extremity must be carefully monitored. Impaired blood supply or developing neurological loss must be investigated as an emergency and dealt with expediently.

Oral or subcutaneous administration of DVT prophylaxis for six weeks should be strongly considered.

Optimal stability should be achieved at the time of surgery, in order to allow early range of motion exercises. Unless there are other injuries or complications, mobilization may be performed on post OP day 1. If available, continuous passive motion (CPM) splints can be very helpful in the early phase of rehabilitation. Static quadriceps exercises with passive range of motion of the knee should be encouraged. Afterwards special emphasis should be given to active knee and ankle movement.

The goal is to achieve as full range of motion as possible within the first 4–6 weeks.

Weight-of-leg weight bearing is initiated depending on patient comfort. Depending on the severity of the articular displacement, weight bearing can begin as early as 6 weeks postoperatively. In situations where articular displacement was significant weight bearing should be delayed for 10–12 weeks.

Wound healing should be assessed within the first two weeks. Subsequently, a 6- and 12-week follow-up with radiographic assessment is usually performed. If a delayed union is recognized, further surgical care may be necessary and should be carried out as soon as possible. Residual knee instability may require delayed reconstruction.

Implant removal is not mandatory and should be discussed with the patient.