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

ORIF with Plating for Distal Humerus Fractures: Detailed Surgical Procedure

Open reduction and internal fixation with double plating through a posterior approach is the standard surgical treatment for displaced intra-articular distal humerus fractures, with the goal of achieving anatomic articular reduction and rigid bicolumnar fixation to allow early range of motion. 1, 2

Preoperative Planning

• Fracture Classification: Assess fracture pattern using AO/OTA classification (Type B or C fractures), with particular attention to comminution, articular involvement, and bone quality 3, 4
• Patient Selection: Consider age and bone quality—elderly patients (>65 years) with extensive comminution may be better candidates for total elbow arthroplasty rather than ORIF 4
• Imaging: Obtain AP and lateral radiographs; CT scan with 3D reconstruction helps visualize fracture pattern and plan reduction strategy 1
• Timing: Surgery should be performed as soon as medically feasible, ideally within 12 hours of injury for open fractures 4

Patient Positioning and Anesthesia

• Anesthesia: General anesthesia with endotracheal intubation 2
• Position: Lateral decubitus or prone position with arm draped free over a padded bolster to allow elbow flexion 1, 2
• Tourniquet: Apply sterile tourniquet to upper arm (optional, based on surgeon preference) 2

Surgical Approach Options

The posterior approach with olecranon osteotomy provides the most extensile exposure for complex bicolumnar fractures, though triceps-sparing approaches are viable alternatives 1, 2

Olecranon Osteotomy Approach (Traditional)

• Make a posterior midline incision centered over the olecranon, extending 10-15 cm proximally and distally 2
• Identify and protect the ulnar nerve—mobilize it from the cubital tunnel and either transpose anteriorly or leave in situ with decompression 1, 2
• Perform chevron or transverse olecranon osteotomy at the bare area of the olecranon to expose the articular surface 2
• Elevate medial and lateral soft tissue flaps subperiosteally to expose both columns 2

Triceps-Reflecting Anconeus Pedicle (TRAP) Approach (Alternative)

• This approach combines modified Kocher and Bryan-Morrey techniques, reflecting the triceps medially while preserving the anconeus muscle laterally 5
• Provides adequate exposure without creating an olecranon fracture, avoiding potential complications of osteotomy nonunion 5
• Results in no significant triceps weakness compared to osteotomy approaches 5

Fracture Reduction Sequence

Articular surface reconstruction must be performed first, followed by restoration of the columns to the humeral shaft 2, 3

Step 1: Articular Surface Reconstruction

• Remove hematoma and debris from fracture site 2
• Provisionally reduce articular fragments using pointed reduction forceps 2
• Achieve anatomic reduction of the trochlea and capitellum under direct visualization 1, 2
• Temporarily stabilize with 0.045-inch or 0.062-inch Kirschner wires 2
• Confirm reduction with direct visualization and fluoroscopy 2
• Apply 3.5mm or 4.0mm lag screws perpendicular to fracture lines to compress articular fragments 2

Step 2: Column Reconstruction

• Reduce the medial and lateral columns to the reconstructed articular segment 2, 3
• Use bone reduction clamps to hold columns in position 2
• Verify alignment of both columns to the humeral shaft with fluoroscopy in AP and lateral planes 3

Plate Application and Fixation

Double plating with either parallel or orthogonal plate configuration provides rigid bicolumnar fixation 1, 2

Plate Configuration Options

• Parallel plating: Medial and lateral plates applied to respective columns in same plane 1
• Orthogonal plating: Medial plate applied posteriorly, lateral plate applied laterally at 90-degree angle 1
• Both configurations provide equivalent biomechanical stability; choice depends on fracture pattern and surgeon preference 1

Medial Column Fixation

• Apply anatomically pre-contoured locking compression plate (LCP) to medial column 3
• Position plate along medial supracondylar ridge extending to medial epicondyle 2
• Insert at least 3-4 locking screws distally into medial column and trochlea 3
• Insert 4-6 screws proximally into humeral shaft 3
• Ensure screws do not penetrate olecranon fossa anteriorly 2

Lateral Column Fixation

• Apply anatomically pre-contoured LCP to lateral column 3
• Position plate along lateral supracondylar ridge extending to lateral epicondyle 2
• Insert at least 3-4 locking screws distally into lateral column and capitellum 3
• Insert 4-6 screws proximally into humeral shaft 3
• Maximize screw purchase in distal fragments, with screws from opposite plates interdigitating but not conflicting 2

Angular Stable Fixation Advantages

• Locking screws provide angular stability particularly beneficial in osteoporotic bone 3
• Anatomically pre-shaped plates facilitate reduction and minimize soft tissue stripping 3
• Allow early postoperative mobilization due to rigid construct 3

Olecranon Osteotomy Repair (if performed)

• Reduce osteotomy site anatomically 2
• Fix with tension band wiring technique using two parallel 0.062-inch K-wires and 18-gauge wire in figure-of-eight pattern, or use plate and screws 2
• Confirm stable fixation by flexing and extending elbow intraoperatively 2

Ulnar Nerve Management

• If transposed anteriorly, create subcutaneous or submuscular pocket 1, 2
• If left in situ, ensure adequate decompression of cubital tunnel 1, 2
• Avoid excessive tension or kinking of nerve throughout range of motion 2

Wound Closure

• Irrigate wound copiously with normal saline 2
• Close fascia over ulnar nerve if transposed 2
• Close subcutaneous tissue in layers with absorbable suture 2
• Close skin with nylon suture or staples 2
• Apply sterile dressing and posterior splint with elbow at 90 degrees flexion 2

Postoperative Management

Early range of motion is critical to prevent elbow stiffness and should begin within the first week if fixation is stable 2, 3

• Remove splint at 48-72 hours postoperatively 3
• Begin active-assisted range of motion exercises immediately 3
• Avoid passive stretching for first 6 weeks 2
• Progressive strengthening begins at 6-8 weeks once fracture shows radiographic healing 3
• Serial radiographs at 2 weeks, 6 weeks, 12 weeks, and 6 months to assess healing and hardware position 3

Expected Outcomes

• Mean flexion-extension arc of 95-107 degrees can be expected 4
• Mayo Elbow Performance Scores typically range from 72-88 points at 2 years 4
• Complete radiographic union achieved in >95% of cases with proper technique 3

Common Complications and Prevention

• Ulnar neuropathy (transient in most cases): Careful identification and protection throughout procedure 5, 3
• Elbow stiffness: Prevented by rigid fixation allowing early mobilization 2, 3
• Heterotopic ossification: Minimize soft tissue trauma and consider prophylaxis in high-risk patients 5
• Nonunion: Ensure adequate fixation of both columns with compression at fracture sites 2
• Olecranon osteotomy delayed union: Occurs in <5% of cases, may require revision fixation 3

Note: In elderly patients (>65 years) with extensive comminution (AO Type C3), intraoperative conversion to total elbow arthroplasty should be considered if stable fixation cannot be achieved, as TEA provides superior functional outcomes in this population 4