Can you describe the step-by-step procedure for open reduction and internal fixation (ORIF) with plating of a left olecranon fracture in an adult patient without significant comorbidities?

ORIF with Plating for Left Olecranon Fracture: Step-by-Step Procedure

Plate fixation is the preferred technique for displaced olecranon fractures requiring ORIF, offering superior reduction maintenance and functional outcomes compared to tension band wiring, particularly for comminuted fractures. 1, 2

Pre-operative Planning

• Obtain standard AP and lateral radiographs to assess fracture pattern, displacement, and comminution 3
• Consider CT without contrast for complex or comminuted fractures to evaluate fragment size, displacement, and surgical planning 3
• Assess for associated injuries including coronoid fractures, radial head fractures, and ligamentous disruption 3
• Evaluate triceps tendon integrity, as avulsion injuries may accompany olecranon fractures 3

Patient Positioning and Anesthesia

• General or regional anesthesia
• Position patient lateral decubitus (right side down for left elbow) or prone
• Affected arm across chest or over bolster with elbow flexed 90 degrees
• Apply tourniquet to upper arm (optional)

Surgical Technique

Step 1: Dorsal Incision 1

• Make a posterior midline longitudinal incision centered over the olecranon
• Extend incision 6-8 cm proximally and distally from the fracture site
• Avoid placing incision directly over the subcutaneous border where plate will sit

Step 2: Exposure Using Full-Thickness Flaps 1

• Develop full-thickness fasciocutaneous flaps medially and laterally
• Identify and protect the ulnar nerve - palpate medially, consider formal decompression if nerve is tethered or symptoms present
• Elevate flaps to expose fracture site while preserving triceps insertion

Step 3: Fracture Site Preparation 1

• Remove hematoma and debris from fracture site
• Irrigate thoroughly
• Identify all fracture fragments, particularly small medial/lateral cortical pieces in comminuted fractures 4
• Preserve soft tissue attachments to fragments when possible

Step 4: Fracture Reduction 1

• Reduce main fracture fragments anatomically
• Restore articular surface congruity - any step-off >2mm significantly impacts outcomes 2
• Use pointed reduction forceps to hold reduction
• Verify reduction with direct visualization and fluoroscopy

Step 5: Provisional Fixation 1

• Place 1-2 K-wires or small lag screws perpendicular to fracture line
• Maintain reduction while preparing for plate application
• Confirm articular reduction with fluoroscopy

Step 6: Plate Selection and Application 1

• Use a pre-contoured locking plate or 3.5mm reconstruction plate
• For standard fractures: position plate on dorsal surface of proximal ulna
• For proximal/comminuted fractures: consider omega plate technique - pass mini-fragment plate under triceps insertion to maximize contact with small proximal fragments 4
• Plate should span entire fracture with minimum 3 screws proximal and distal to fracture

Step 7: Proximal Fixation 1

• Place most proximal screw first in locking or compression mode
• For very proximal fractures, use multiple screws in different trajectories to capture small fragments
• Consider supplemental wire fixation through plate holes for osteoporotic bone 5
• Verify screws do not penetrate anterior cortex into joint

Step 8: Distal Fixation 1

• Apply compression across fracture if possible with compression screw technique
• Place remaining distal screws (minimum 3 bicortical screws)
• Ensure adequate screw purchase in distal fragment
• In elderly/osteoporotic bone, use locking screws to prevent screw pullout 6

Step 9: Final Assessment

• Remove provisional fixation
• Confirm stable fixation by gently ranging elbow through flexion/extension
• Obtain intraoperative fluoroscopy: AP, lateral, and oblique views
• Verify articular congruity, hardware position, and no intra-articular screw penetration
• Check ulnar nerve - ensure not tethered by hardware

Step 10: Layered Wound Closure 1

• Irrigate wound thoroughly
• Close fascia over plate if possible to minimize hardware prominence
• Close subcutaneous tissue in layers
• Skin closure with interrupted sutures or staples
• Apply sterile dressing and posterior splint with elbow at 90 degrees

Post-operative Management

• Splint for 5-7 days for soft tissue healing
• Begin early active range of motion at 7-10 days (plate fixation allows earlier mobilization than tension band) 2
• Avoid resisted extension for 6 weeks
• Radiographs at 2 weeks, 6 weeks, 12 weeks to assess healing
• Average fracture union occurs at 9-12 weeks 5

Critical Technical Points

Plate positioning is crucial: Placing plate too dorsally causes symptomatic hardware prominence (occurs in 42% with tension band, less with proper plate placement) 2. For thin patients, consider low-profile locking plates 6.

Comminuted fractures require plate fixation: Tension band wiring shows 53% loss of reduction versus 5% with plates 2. Use longer plates with multiple screws to bridge comminution 7.

Elderly/osteoporotic bone: Locking plates provide superior fixation 6. Consider nonoperative management for low-demand elderly patients with stable fracture patterns, as hardware complications are common 8.

Expected Outcomes and Complications

• Expect some loss of terminal extension (average ROM 123 degrees) 5
• Surgical site infection rate: 1.8% 9
• Overall complication rate: 7.2% 9
• Risk factors for complications: smoking (OR 1.66), increased age, prolonged operative time 9
• Hardware removal may be needed for symptomatic prominence
• Plate fixation results in 63% good clinical outcomes versus 37% with tension band 2