ORIF Distal Humerus Fracture - Olecranon Osteotomy Approach

Patient Position: Lateral decubitus with arm over padded bolster (allows elbow extension), OR prone position on chest rolls. Arm draped free to allow full ROM assessment.

Surgical Approach: Posterior midline approach with olecranon osteotomy provides best visualization of articular surface.

Tourniquet: Sterile tourniquet on upper arm (avoid brachial plexus compression from non-sterile tourniquet).

Equipment: Pre-contoured anatomical distal humerus plates (medial and lateral), 2.7mm and 3.5mm screws, tension band wire set, fluoroscopy.

Step 1: Positioning and Incision

Position in lateral decubitus with arm over bolster allowing full elbow extension, or prone. Make posterior midline incision 15-20cm centered on olecranon tip, curving laterally around the olecranon to avoid direct pressure on skin over bony prominence. Identify and protect medial cutaneous nerve of forearm in subcutaneous tissue.

Step 2: Ulnar Nerve Identification and Management

Identify ulnar nerve behind medial epicondyle in cubital tunnel, proximal to its entry between the two heads of FCU. Trace from arcade of Struthers proximally to first motor branch distally. Protect with vessel loop. Decide: in-situ protection if hardware won't overlie nerve, or anterior subcutaneous transposition if plates will compress or if pre-operative symptoms present.

Step 3: Olecranon Osteotomy

Perform chevron (inverted V) osteotomy at bare area of sigmoid notch. Pre-drill olecranon for later screw or tension band fixation. Mark osteotomy line with electrocautery. Score cortices with oscillating saw to depth of 2-3mm, avoiding articular cartilage. Complete osteotomy with thin osteotome, applying controlled force. Reflect olecranon fragment with attached triceps proximally to expose distal humerus articular surface.

Step 4: Fracture Assessment and Articular Reduction

Assess fracture pattern with direct visualization. Irrigate and remove small loose fragments. Identify all articular fragments and their orientation. REDUCE ARTICULAR SURFACE FIRST - this is the key principle. Reconstruct trochlea by reducing condyles to each other. Use provisional K-wire fixation. Articular reduction must be anatomic, aiming for less than 2mm step-off. Consider bone graft or substitute for central comminution.

Step 5: Column Reconstruction and Plate Application

Attach reconstructed articular segment to metaphysis and diaphysis. Apply pre-contoured anatomical plates - medial plate on medial column ridge, lateral plate on posterolateral column. Use either 90-90 configuration or parallel plating based on fracture pattern and bone quality. Plates should be long enough to span metaphysis to diaphysis with at least 2-3 screws in each major fragment.

Step 6: Screw Placement and Interdigitation

Place screws through plates ensuring cortical purchase. Use long screws through distal holes to interdigitate through the articular block - one from medial plate into lateral condyle, one from lateral plate into medial condyle. This creates a stable construct. Check under fluoroscopy that no screws penetrate articular surface or olecranon fossa (blocks extension). Ensure screws avoid ulnar nerve course.

Step 7: Olecranon Osteotomy Fixation

Reduce olecranon osteotomy anatomically. Fix using tension band wire technique (converts extension force to compression), or plate fixation, or 6.5mm cannulated screw with washer. For tension band: two parallel K-wires from olecranon tip into anterior ulnar cortex, figure-of-8 wire through triceps insertion and around K-wires. Alternative: pre-contoured olecranon plate if comminuted or osteoporotic.

Step 8: Range of Motion Assessment

Take elbow through full ROM on table. Check: full extension (should reach 0° unless pre-existing contracture), flexion to 140°, full pronation and supination. Confirm no impingement from screws or plates. Assess stability of fixation through arc. Check ulnar nerve position - should not be compressed at any position. Ensure olecranon osteotomy stable through motion.

Step 9: Final Imaging and Wound Closure

Obtain final fluoroscopy: AP, lateral, and oblique views. Confirm anatomical articular reduction, adequate plate position and length, no intra-articular or olecranon fossa hardware. Irrigate copiously (minimum 3L). Release tourniquet and achieve meticulous hemostasis. Place drain deep to triceps. If ulnar nerve transposed, confirm it is in subcutaneous position without tension. Close triceps fascia, subcutaneous tissue, and skin. Apply well-padded splint in 45-90° flexion.

Step 10: Post-operative Protocol

Splint for comfort days 1-3, then remove for active-assisted ROM exercises. Early motion is CRITICAL - stiffness is the most common complication. Active elbow flexion/extension and forearm rotation. No passive stretching initially (increases HO risk). Hinged brace for protection if needed. No lifting more than 1kg for 6-8 weeks. Outpatient physiotherapy supervision. Serial radiographs at 2, 6, and 12 weeks.

Immediate (Days 1-3):

• Posterior splint in 45-90° flexion for comfort
• Elevation above heart level to reduce swelling
• Ice therapy
• Remove splint day 1-3 for gentle active-assisted ROM
• Wound check at 2 weeks, suture removal

Early (Weeks 1-6):

• Active-assisted ROM exercises 5-6 times daily
• NO passive stretching (increases HO risk)
• Hinged elbow brace for protection if needed
• Target: 30-130° ROM by 6 weeks
• No lifting more than 1kg
• Outpatient physiotherapy supervision

Intermediate (Weeks 6-12):

• Progressive strengthening
• Full ROM goal
• Increase lifting restrictions gradually
• Dynamic splinting if stiffness developing (less than 100° flexion)
• Radiographs at 6 and 12 weeks

Late (Months 3-6):

• Return to normal activities
• Full activity 4-6 months
• MUA consideration if less than 90° flexion at 3 months
• Hardware removal if symptomatic once healed (12-18 months)

HO Prophylaxis (if indicated):

• Indomethacin 75mg daily for 6 weeks (per eTG)
• OR single-dose radiation 700cGy within 72 hours
• Indications: brain injury, high-energy trauma, previous HO, burns

References

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