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 minimize morbidity and mortality, and improve quality of life. The procedure involves several critical steps, including positioning the patient 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 carefully protected throughout the procedure, as noted in studies on the treatment of pediatric supracondylar humerus fractures 1.

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. A pre-contoured distal humerus plate system is then applied, typically in a dual-plate orthogonal configuration (one plate on the medial column and one on the lateral column) to provide optimal stability.

• Key considerations in the procedure include:
  • Anatomical reduction of the fracture fragments
  • Restoration of the articular surface integrity
  • Protection of the ulnar nerve
  • Use of a pre-contoured distal humerus plate system for optimal stability
  • Intraoperative fluoroscopy to confirm proper reduction and hardware placement

Screws of appropriate length are inserted through the plate holes, ensuring they engage both cortices without penetrating the joint surface. Intraoperative fluoroscopy confirms proper reduction and hardware placement, as recommended by the AAOS guidelines 1. The surgical field is thoroughly irrigated, and the triceps is reattached if an olecranon osteotomy was performed. The wound is closed in layers, and a well-padded posterior splint is applied with the elbow at 90 degrees of flexion.

Postoperatively, early controlled range of motion exercises typically begin at 1-2 weeks to prevent stiffness, with progressive strengthening over 6-12 weeks as healing progresses. This procedure restores anatomical alignment and stability, allowing for early mobilization and reducing the risk of post-traumatic arthritis. The goal of the procedure is to minimize morbidity and mortality, and improve quality of life by restoring functional use of the affected arm.

From the Research

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

The management of fracture supracondyle humerus right sided using open reduction and internal fixation (ORIF) with plating involves several key steps:

• Preoperative preparation: The patient is prepared for surgery, and the affected limb is cleaned and draped in a sterile manner 2.
• Incision and exposure: An anterior median incision is made in the humerus to expose the fracture site 2.
• Reduction and fixation: The fracture is reduced, and an anatomical locking plate is applied to the anterior side of the distal humerus to restore and fix the structure of the distal humerus 2, 3.
• 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 3.
• Double plating: In some cases, double plating may be used to achieve greater stability and improve functional outcomes 4.
• Wound closure: The wound is closed, and the patient is taken to the recovery room for postoperative care.

Key Considerations

• The goal of ORIF with plating is to achieve stable fixation, allowing for early mobilization and rehabilitation 3, 4.
• The choice of plate and screw configuration depends on the specific fracture pattern and the surgeon's preference 3, 4.
• Neurovascular complications, such as nerve damage or vascular injury, must be carefully evaluated and managed during the surgical procedure 5.
• Cubitus varus deformity is a common complication of supracondylar fractures, and measures should be taken to prevent or correct this deformity during the surgical procedure 5.

Postoperative Care

• The patient is typically immobilized in a splint or cast for a period of time to allow for fracture healing 2, 4.
• Early mobilization and rehabilitation are crucial to achieve optimal functional outcomes and prevent stiffness and contractures 2, 3, 4.
• Regular follow-up appointments are necessary to monitor fracture healing, range of motion, and functional progress 2, 4.