Authors of section

Authors

Jonas Andermahr, Michael McKee, Diane Nam

Executive Editor

Joseph Schatzker

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ORIF - Plate fixation

1. Introduction

The complex articular fracture is often difficult to reduce. The best provisional reduction, if it cannot be achieved with screws, will now be maintained by the fixation of the plate to the articular block.

Preoperative assessment of these fractures is critical. If the CT and 3D reconstruction suggests that a satisfactory articular reduction of the articular fracture cannot be achieved, then closed treatment may be the best option.

In a patient for whom restoration of function is important, at least 70% of the glenoid should be reconstructable to achieve stability of the shoulder and congruency of the joint.

If the articular segment is reducible, then carry on as for simple articular neck multifragmentary fractures.

To illustrate the principles, we will here show the treatment of a fracture with but a multifragmentary articular block and multifragmentary neck.

orif plate fixation

Principle

In this procedure the angle subtended between the glenoid and the lateral border of the scapula must be restored.

Hardware selection

The object is to secure good fixation of the plate to the articular segment, restore the glenoid angle and achieve secure fixation to the lateral border of the scapula. The plate functions as a bridge plate. Its best fixation to the proximal segment is achieved through angular stability and the same applies for its fixation to the lateral border of the scapula.

The best implant is a reconstruction plate which has been appropriately contoured, or a pre-contoured plate. Its fixation to the bone is accomplished with locking screws.

orif plate fixation

2. Patient preparation

This procedure may be performed with the patient in either a prone position or lateral decubitus position.

3. Approach

Plating of the glenoid neck and the scapula are performed through a dorsal approach.

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4. Reduction and fixation

Reduction

If the fracture is considered reducible, insert a K-wire in a major segment of the glenoid fossa and use it as a joystick for reduction. If possible, it is advantageous to start the reconstruction from either the top, or alternatively a bottom segment.

Note: Careful attention must be made to the orientation of the first main segment as this will determine the angle of the glenoid fossa. Large deviations of the angle (> 20 °) will lead to a reduced function of the shoulder.

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When reduction is achieved, the segment is temporarily fixed to the scapular body by further insertion of the K-wire.

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The mid-segment is then reduced.

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The inferior segment is reduced and temporary fixed with a K-wire. The main goal is to re-establish an anatomical correct articular surface.

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Plate fixation

The plate is bent at the right spot to subtend the usual angle between the glenoid and the lateral border of the scapula (130 - 135 degrees).

When angularly stable fixation is used the plate does not have to fit the bone, but must fit the overall contour.

orif plate fixation

Begin the fixation by attaching the plate to the articular segment.

In the glenoid joint block there is usually space for 2 screws only. These should be placed in the main fragments.

Care must be taken regarding the direction of the locking head screws so that they do not enter the joint.

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A trans-glenoid X-ray is recorded to verify whether the anatomical angle is achieved.

Large deviations of the angle (>20 °) will reduce the functional outcome.

If need, the K-wires are removed and the plate used as a reduction aid.

When the correct reduction and the correct angle between the glenoid fossa and the lateral border of the scapula have been achieved, screws are inserted along the lateral border of the scapula.

If indicated, use locking screws and in the articular block beware that they do not enter the joint.

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Ideally, three bicortical screws are inserted in the lateral scapular border.

glenoid fossa complete articular articular multifragmentary

Correct reduction and fixation is verified by image intensification.

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5. Aftercare

Introduction

For postoperative treatment of surgically operated scapular fractures and nonoperative treatment of fractures of the scapula which are treated conservatively is basically the same.

The decision to operate or not to operate is made on the basis on the fracture type, the degree of fragment displacement and the intrinsic fracture stability. The stability of a fracture can be further determined with the aid of an image intensifier.

Phase I: Day one

It is important to maintain full mobility of the unaffected joints to reduce arm swelling and to preserve joint motion. The following exercises are recommended.

  • Straightening and flexion of the elbow


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  • Open and closure of the hand
  • Squeezing of a soft ball


Aftercare/Nonoperative Scapula

  • Bending of the wrist forward, backwards and in a circular motion.
  • Movement of an open hand from side to side.


nonoperative treatment

  • Squeezing the shoulder blades together, while shoulders remain relaxed


Aftercare/Nonoperative Scapula

Phase II: Two to six weeks

Pendular exercises can be started when pain starts to subside after the first few days.


nonoperative treatment

One progresses gradually from passive to assisted active range of motion exercises making sure that assisted active abduction is done without elevation of the shoulder.


Aftercare/Nonoperative Scapula

Active assisted range of motion exercises are started with:

  • External rotation
  • Internal rotation
  • Forward flexion with the arms on the table
  • Forward flexion and elevation of the arm with a ball on the wall


Aftercare/Nonoperative Scapula

Sub-maximal isometric exercises with:

  • Internal rotation
  • External rotation
  • Abduction
  • Extension

Note: Timing and progression of exercises is ultimately directed and determined by the operating surgeon since such factors as bone quality, type of fracture and fixation may vary from case to case.


Aftercare/Nonoperative Scapula

Sling and swath

Optimal shoulder immobilization is achieved when the upper arm and forearm are secured to the chest. Traditionally, this has been done with a sling that supports the elbow and forearm and counteracts the weight of the arm. The simplest sling is a triangular bandage tied behind the neck.

Additional support is provided by a swath which wraps around the humerus and the chest to restrict further shoulder motion, and keep the arm securely in the sling.
Commercially available devices provide similar immobilization, with or without the circumferential support of a swath.


glenoid fossa extraarticular simple

Shoulder immobilization

Sling and swath (A), shoulder immobilizer (B), Gilchrist bandage (C), and other such devices all provide essentially similar support for the shoulder joint.


Activities of daily living

Sleeping
The patient should sleep wearing the sling and lie either on his back or on the non-injured side.

When sleeping on the back, the injured side should be supported by placing a pillow underneath the arm and shoulder.

Some patients may find it more comfortable to sleep in a sitting or semi reclined position.


Sleeping

When sleeping on the side, a pillow can be placed across the chest to support the injured side.


Sleeping

Hygiene

A non-slip mat in the shower/bath tub will improve safety. The arm can hang gently at the patient's side while showering. Axillary hygiene is important. If assistance is not available, a long-handled sponge can be used to wash the back and legs.


Hygiene

Dressing

Loose fitting clothing and button-up shirts are ideal. The unaffected arm may be used for buttoning and unbuttoning. The affected arm is dressed first, then the non-affected arm. When undressing, start with the non-affected arm, then the affected arm.


Dressing

Shoulder abduction cushion

In the case of coracoid fractures or acromial fractures and rotator cuff surgery, one attempts to relieve tension by elevation and abduction of the extremity. This can be achieved with the aid of a so-called airplane splint or an abduction cushion as shown in this diagram.


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Mobilization: 2-3 weeks posttrauma

Nonoperative management of scapular fractures usually begins with maximal support - a sling and swath equivalent worn continuously. If the patient finds lying down uncomfortable, then a sitting position may be preferred for sleeping.

A patient who is very comfortable, at the beginning of treatment or after some recovery, may need less immobilization, and even begin gentle use of the injured arm.

The degree of required immobilization and the rate progression may be speeded up as comfort permits.


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When pain permits, begin with pendulum exercises (as illustrated).


nonoperative treatment

At the same time active hand and forearm use should also be encouraged.


Aftercare/Nonoperative Scapula

Isometric exercises can begin as soon as tolerated for the shoulder girdle including scapular stabilizers, and the upper extremity.
X-rays should be checked to rule out secondary fracture displacement.


Aftercare/Nonoperative Scapula

Active assisted exercises: 3-6 weeks postoperative

As comfort and mobility permit, and fracture consolidation is likely, the patient should begin active assisted motion. Physical therapy instructions and/or supervision are provided as desired and available.

If passive range of motion exercises are progressing satisfactory, one can then cautiously progress to active assisted.

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Shoulder therapy set: 3-6 weeks postoperative

A “shoulder therapy set” might be helpful. Typically included devices are:

  • An exercise bar, which lets the patient use the uninjured left shoulder to passively move the affected right side.
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  • A rope and pulley assembly. With the pulley placed above the patient, the unaffected left arm can be used to provide full passive forward flexion of the injured right shoulder.

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Strengthening: from week 6 on

As passive motion improves, and active assisted exercises progress satisfactory, and the fracture becomes fully consolidated one can begin strengthening. First one strengthens by active motion against gravity. To increase muscle strength, one must increase the resistance against which the muscles are working. Endurance training follows.

Beware of premature forward flexion which is done passively but puts a significant strain on the supraspinatus and its repaired tendon.

Elastic devices are useful in providing varying degrees of resistance. Ultimately the athletic patient can progress to resistance machines and free weights.

Physical therapy instruction and supervision may be helpful for optimal rehabilitation or if the patient is not progressing satisfactorily.
Remember to monitor rotator cuff strength. Significant weakness may indicate an unidentified rotator tendon cuff rupture which is in need of surgical repair.


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Pitfall: shoulder stiffness

To reduce the risk of stiffness, immobilization should be discarded as soon as possible. This can be done progressively, beginning with elimination of the swath (circumferential bandage) during the daytime and encouraging pendulum exercises.
The sling may be used on a part-time basis as soon as appropriate.
If formal physical therapy has not been prescribed, it should be considered for any patient whose range of motion is not improving as expected.

nonoperative treatment