What is the step-by-step procedure for managing a right-sided supracondylar fracture of the humerus using Open Reduction Internal Fixation (ORIF) with plating?

From the Guidelines

The surgical management of a right-sided supracondylar humeral fracture using open reduction and internal fixation (ORIF) with plating is a complex procedure that requires careful attention to detail to ensure optimal outcomes in terms of morbidity, mortality, and quality of life.

Step-by-Step Procedure

The procedure involves several critical steps:

• The patient is positioned supine with the affected arm on a radiolucent table under general anesthesia.
• A posterior approach is typically used, with a longitudinal midline incision approximately 10-15 cm long, centered over the olecranon.
• The ulnar nerve is identified and protected by gentle retraction.
• The triceps muscle is split or reflected using an olecranon osteotomy to expose the fracture site.
• Once exposed, the fracture fragments are anatomically reduced under direct visualization, with special attention to restoring the articular surface integrity.
• Temporary K-wires may be used to hold the reduction while preparing for definitive fixation.
• Pre-contoured anatomical plates (typically 3.5mm distal humerus plates) are positioned, with one plate placed on the lateral column and another on the medial column in a perpendicular or parallel configuration, creating a stable construct.
• Multiple screws (typically 3.5mm cortical or 4.0mm cancellous) are inserted through the plate into both the distal fragment and proximal humeral shaft, ensuring bicortical purchase when possible.
• Fluoroscopic imaging confirms proper reduction and hardware placement.
• The wound is irrigated thoroughly, and if an olecranon osteotomy was performed, it is repaired with tension band wiring or plate fixation.
• The triceps is reattached, and the wound is closed in layers.
• A well-padded posterior splint with the elbow at 90 degrees is applied.

Postoperative Care

Postoperatively, antibiotics are continued for 24-48 hours, and appropriate pain management is provided.

• Early controlled range of motion exercises typically begin at 1-2 weeks post-surgery to prevent stiffness, with progressive strengthening as healing advances.
• This procedure restores anatomical alignment and stability, allowing for early mobilization and reducing the risk of post-traumatic arthritis that might occur with non-operative management of displaced intra-articular fractures, as supported by the findings of 1.

Considerations

It is essential to note that the choice of treatment for supracondylar humeral fractures depends on various factors, including the patient's age, fracture pattern, and overall health status.

• While the AAOS guidelines are unable to recommend for or against open reduction and stable fixation for adolescent patients with supracondylar fractures of the humerus, as stated in 1, the procedure can still be considered on a case-by-case basis, taking into account the potential benefits and risks.
• The decision to proceed with ORIF with plating should be made after careful consideration of the individual patient's needs and circumstances, with the goal of achieving optimal outcomes in terms of morbidity, mortality, and quality of life.

From the Research

Step-by-Step Procedure for Fracture Supracondyle Humerus Right Sided Managed by ORIF with Plating

• Preoperative preparation: The patient is prepared for surgery, and the affected limb is cleaned and draped in a sterile manner.
• Incision and approach: An anterior median incision is made in the humerus to access the fracture site, as described in the study by 2.
• Reduction and fixation: The fracture is reduced, and internal fixation is performed using an anatomical locking plate on the anterior distal humerus, as proposed in the study by 2.
• Plate placement: The plates are placed in a parallel configuration medially and laterally, and the screws passing through these plates in the distal fragments interdigitate and lock together, as outlined in the study by 3.
• Double plating: In some cases, double plating may be used to achieve greater stability, as described in the study by 4.
• Postoperative care: The patient is monitored for complications, and rehabilitation is started early to restore range of motion and functional scores, as reported in the study by 2.
• Follow-up: Regular follow-up is necessary to assess fracture union, range of motion, and functional outcomes, as described in the studies by 2, 3, and 4.

Key Considerations

• The choice of surgical approach and fixation method depends on the fracture pattern, patient age, and surgeon preference, as discussed in the studies by 2, 3, and 4.
• Neurovascular complications, such as nerve damage or blood vessel injury, must be carefully assessed and managed, as highlighted in the study by 5.
• Cubitus varus deformity is a common complication of supracondylar fractures, and careful attention must be paid to fracture reduction and fixation to minimize this risk, as noted in the study by 5.
• Postoperative rehabilitation plays a crucial role in achieving excellent functional and radiological outcomes, as reported in the studies by 2 and 4.

Fracture Classification and Management

• The modified Gartland classification is commonly used to classify supracondylar fractures, as mentioned in the study by 5.
• The classification system helps guide management decisions, including the need for surgical intervention, as discussed in the study by 5.
• Type III A, III B, and Type IV fractures are more likely to require surgical intervention due to the higher risk of neurovascular complications, as noted in the study by 5.