What is the step-by-step procedure for Open Reduction Internal Fixation (ORIF) with plating for a patient with a fracture of the distal humerus?

Open Reduction Internal Fixation (ORIF) with Plating for Distal Humerus Fractures

Preoperative Planning

ORIF with dual plating is the gold standard for complex distal humerus fractures, requiring meticulous surgical technique to achieve anatomic reduction and rigid fixation that allows early mobilization. 1, 2

Patient Assessment

• Identify neurovascular status preoperatively, particularly ulnar nerve function 2
• Classify fracture using AO/OTA system (Type A, B, or C patterns) to guide surgical approach 3
• Assess for open fracture, comminution, bone loss, or osteoporotic bone that may require augmented fixation 4
• Review imaging to determine if fracture extends very distally or involves significant articular comminution 4

Implant Selection

• Use anatomically pre-contoured, locking distal humeral plates for all cases 1, 3
• Plan for dual-plate configuration (parallel or orthogonal) based on fracture pattern 3
• Consider temporary spanning plate across elbow for highly comminuted, very distal, osteoporotic, or revision cases with bone loss 4

Surgical Approach

Posterior Approach with Olecranon Osteotomy

• The posterior approach with olecranon osteotomy provides optimal exposure for complex intra-articular fractures 2
• This approach was used in 51% of cases in contemporary series 3
• Position patient prone or lateral decubitus with arm over bolster
• Make posterior midline incision centered over olecranon 2

Ulnar Nerve Management

• Identify and protect the ulnar nerve in all cases 2
• Perform ulnar nerve transposition as needed based on fracture pattern and plate positioning 3
• Tag nerve with vessel loop for continuous visualization throughout procedure 2

Olecranon Osteotomy Technique

• Create chevron or transverse osteotomy through bare area of olecranon 2
• Pre-drill holes for later fixation before completing osteotomy 2
• Reflect triceps and olecranon proximally to expose distal humerus and articular surface 2

Fracture Reduction

Articular Surface Reconstruction

• Achieve anatomic reduction of the articular surface as the critical first step 2
• Identify and reduce all intra-articular fragments under direct visualization 2
• Use pointed reduction forceps and provisional K-wires to hold articular block 2
• Verify articular congruity before proceeding to column fixation 2

Column Fixation Strategy

• Apply rigid fixation to both medial and lateral columns of the distal humerus 2
• Reduce articular block to humeral shaft, restoring anatomic alignment 2
• Use lag screws across articular fragments before plate application 1
• Ensure adequate screw purchase in distal fragments with locking screws 1

Plate Application

Dual-Plate Configuration

• Apply anatomically pre-contoured plates to medial and lateral columns 1, 3
• Parallel plate configuration (42% of cases) or orthogonal configuration based on fracture geometry 3
• Achieve bicortical fixation proximally and multiple locking screws distally 1
• Ensure plates do not impinge on olecranon fossa or coronoid fossa 2

Augmented Fixation for Complex Cases

• For comminuted, very distal, osteoporotic, or revision cases, add temporary spanning plate across elbow joint 4
• Apply spanning plate from humeral shaft to proximal ulna as internal fixator 4
• This protects primary fixation construct until bone union occurs 4
• Plan for spanning plate removal at 3-4 months once early radiographic union evident 4

Wound Closure

Olecranon Osteotomy Repair

• Reduce olecranon osteotomy anatomically 2
• Fix with tension band wiring, plate, or intramedullary screw based on osteotomy pattern 2
• Verify stable fixation allowing early motion 2

Final Steps

• Irrigate wound copiously 2
• Close fascia and subcutaneous layers 2
• Apply well-padded posterior splint with elbow at 90 degrees 2

Postoperative Management

Early Mobilization Protocol

• Initiate range of motion as soon as possible postoperatively to prevent stiffness 1, 2
• Begin gentle active-assisted motion at 3-7 days if fixation stable 1
• Progress to active motion and strengthening as tolerated 1
• For cases with spanning plate, delay full motion until plate removal at 3-4 months 4

Expected Outcomes

• Mean flexion of 121 degrees with extension deficit of 18 degrees achievable 1
• Flexion and extension strength recover to 70-75% of contralateral side 1
• Mayo Elbow Performance Score averages 80-91 points 1, 4

Common Pitfalls and Complications

High Complication Rates

• Despite modern pre-contoured implants, complication rates remain 61% with 49% requiring reoperation 3
• Elbow stiffness is most common complication (19% of cases) 3
• Nerve palsy occurs in 16% of cases 3
• Nonunion, infection, painful implants, post-traumatic arthritis, and heterotopic ossification each occur in 9% of cases 3

Specific Complications to Avoid

• Ulnar neuropathy from inadequate nerve protection or transposition 2
• Loss of fixation from inadequate screw purchase in osteoporotic bone 4
• Delayed union at olecranon osteotomy site 1
• Heterotopic ossification from delayed mobilization 2

Management of Open Fractures

• For open distal humerus fractures, consider external fixation as alternative to ORIF to reduce infection risk 5
• Mini-external fixator constructs achieve good to excellent results in 75% of open fracture cases 5