What is the step by step procedure for treating a fracture of the supracondylar humerus using open reduction and internal fixation (ORIF) with plating?

Step-by-Step Procedure for Open Reduction and Internal Fixation of Supracondylar Humerus Fracture Using Plating

The surgical treatment of supracondylar humerus fractures in adults should utilize anatomical locking plates through an anterior approach to achieve optimal stability and functional outcomes. 1 While the American Academy of Orthopaedic Surgeons (AAOS) guidelines primarily address pediatric supracondylar fractures, the principles of anatomic reduction, rigid fixation, and early surgery provide the best results for adult patients with these fractures. 2

Pre-operative Assessment and Planning

1. Imaging studies:

   • Obtain a minimum of 3 radiographic views: posteroanterior (PA), lateral, and 45° semipronated oblique
   • Consider CT scan without IV contrast for complex fractures to evaluate:
     • Intra-articular extension
     • Fracture pattern
     • Degree of comminution
     • Pre-operative planning for complex articular injuries

2. Neurovascular assessment:

   • Document pre-operative neurovascular status
   • Check for vascular compromise (absent pulses, decreased perfusion)
   • Assess for nerve injuries (median, radial, ulnar)

Surgical Procedure

1. Patient Positioning and Anesthesia

• Position patient supine with arm on radiolucent table
• General anesthesia or regional block (axillary/supraclavicular)
• Apply tourniquet to upper arm (optional)
• Prep and drape the entire upper extremity

2. Surgical Approach

• Anterior approach (recommended for adult supracondylar fractures) 1
  • Make an anterior midline longitudinal incision centered over the distal humerus
  • Develop the interval between the brachialis muscle and the lateral neurovascular structures
  • Protect the median nerve and brachial artery medially
  • Protect the radial nerve laterally

3. Fracture Exposure and Reduction

• Identify and protect neurovascular structures
• Clear fracture hematoma and debris
• Identify fracture fragments
• Perform anatomic reduction of articular surface first (if involved)
• Use temporary K-wires to hold reduction if needed
• Restore the overall geometry of the distal humerus

4. Plate Application and Fixation

• Key principles for optimal stability: 3

  1. Every screw in distal fragments should pass through a plate
  2. Screws should engage fragments on the opposite side also fixed to a plate
  3. Place as many screws as possible in distal fragments
  4. Each screw should be as long as possible
  5. Each screw should engage as many articular fragments as possible
  6. Screws should interdigitate to create a fixed-angle structure
  7. Apply plates to achieve compression at supracondylar level
  8. Use plates strong enough to resist breaking or bending

• Plating technique:

  • Use anatomical locking plate designed for anterior distal humerus 1
  • For complex fractures, consider parallel plating technique:
    • Place two plates in parallel configuration (medial and lateral columns)
    • Ensure plates are strong enough and properly contoured
    • Interdigitate screws through both plates when possible

5. Verification of Reduction and Fixation

• Confirm anatomic reduction of articular surface
• Verify restoration of distal humeral geometry
• Check stability of fixation through range of motion
• Obtain intraoperative fluoroscopic images in multiple planes
• Ensure no hardware impingement during elbow motion

6. Wound Closure

• Irrigate wound thoroughly
• Close deep fascial layers with absorbable sutures
• Close subcutaneous tissue and skin appropriately
• Apply sterile dressing and well-padded posterior splint in slight flexion

Post-operative Management

1. Immediate post-operative care:

   • Elevate extremity to reduce swelling
   • Monitor neurovascular status
   • Provide adequate pain control
   • Obtain post-operative radiographs

2. Early rehabilitation:

   • Begin finger motion immediately to prevent stiffness
   • Convert to hinged brace when wound healing permits (typically 10-14 days)
   • Start progressive active-assisted range of motion exercises
   • Avoid resistance exercises until radiographic evidence of healing

3. Follow-up schedule:

   • 2 weeks: Wound check, suture removal, begin active motion
   • 6 weeks: Radiographic assessment of healing
   • 12 weeks: Progress to strengthening if healing adequate
   • 6 months: Final functional assessment

Potential Complications and Prevention

• Stiffness: Encourage early finger and elbow motion
• Malunion: Ensure anatomic reduction and stable fixation
• Nonunion: Consider bone grafting for comminuted fractures
• Hardware failure: Use proper plate selection and fixation techniques
• Neurovascular injury: Careful dissection and protection of structures
• Infection: Meticulous surgical technique and appropriate antibiotics

Special Considerations

• Osteoporotic bone: Consider longer plates with more points of fixation
• Comminution: Address severe metaphyseal comminution with supracondylar shortening if needed
• Intra-articular extension: Prioritize anatomic reduction of articular surface

By following these systematic steps and principles, surgeons can achieve optimal outcomes in the management of supracondylar humerus fractures using plate fixation, with the goal of restoring pain-free, functional elbow motion.