Overview
Fixation strategy: In general, reconstruct the articular surface first, followed by reduction and fixation of one column and then the other. Fixing the column with a reliable, simple fracture read first is useful when the articular surface is comminuted.
Pitfall: If there is bone loss, do not narrow the trochlea with a lag screw, because this reduces congruency with the greater sigmoid notch of the olecranon.
Implants: Locking plates with variable-angle screws are now standard and have improved fixation in poor bone.
About one in eight patients with operatively fixed distal humeral fractures eventually needs another procedure.
Complications of ORIF
Stiffness if the elbow is immobilized for more than 2–3 weeks. Early motion, supervised therapy and daily home exercises are needed to prevent it. If early motion goals are not met, dynamic flexion/extension splinting or even surgery may be required.
Arthrofibrosis: The risk increases with fracture severity and with delay to surgery.
Loss of strength
Ulnar neuropathy
Posttraumatic arthritis
Osteonecrosis
Symptomatic implants
Wound complications: More frequent with open fractures and with plate fixation of the olecranon.
Surgical Technique (Technique 62.9)
Positioning
Place the patient in the lateral decubitus position. Prone or supine positions can also be used. In the supine position, a sterile arm holder helps. Each position has its own technical nuances for overcoming common deformities, and the surgeon must be familiar with them.
Prep and drape the whole forequarter so that a sterile tourniquet can be placed on the proximal arm.
Approach and Ulnar Nerve
Make a midline incision, curving slightly radially around the tip of the olecranon, and raise full-thickness medial and lateral flaps.
Ulnar nerve:
Dissect it free from the medial border of the triceps up to the medial epicondyle, and expose it distal to the cubital tunnel as well.
Preserve its accompanying blood supply.
Perform a subperiosteal release through the cubital tunnel, so the nerve can be retracted medially with a periosteal sleeve.
Laterally, elevate the triceps from the lateral intermuscular septum. Open the interval between the triceps and anconeus to expose the joint, continuing the release 5 cm distal to the tip of the olecranon.
Perform a capsulectomy so that both the medial and lateral olecranon articular surfaces can be seen. Do not disrupt the MCL fibers on the sublime tubercle or the LCL fibers on the crista supinatoris.
Olecranon Osteotomy
If desired, predrill for the later olecranon fixation before making the osteotomy.
Make a distally pointing chevron osteotomy with an oscillating saw, aimed at the bare area of the olecranon articular surface. Complete it carefully with an osteotome. Forcefully levering the osteotomy open with the osteotome can create a large cartilage flap.
Reflect the triceps with the proximal olecranon fragment, elevating the triceps from the humerus while preserving the periosteum.
Reduction and Fixation
Debride the fracture edges to clean surfaces.
Control the medial and lateral condyles with joysticks: threaded K-wires, pointed reduction clamps, or both.
Simple articular fracture: Reduce it with the joysticks and a Weber clamp, and hold it with provisional K-wires.
Plate first whichever column reads most reliably against the shaft, then the other column.
Complex articular fracture, when one condyle keys well to the shaft:
Reduce that condyle to the shaft first.
Hold it provisionally with a countersunk minifragment (2.0 or 2.4 mm) lag screw, whose low profile does not block plate placement. Alternatively, apply a plate to that column with provisional unicortical screws.
Reconstruct the articular surface "around the clock" and fix the fragments provisionally. Then reduce the remaining condyle to the shaft and plate it.
Fix articular comminution with headless screws, minifragment screws, or absorbable screws.
Both 90-90 (orthogonal) and medial-lateral (parallel) plating are acceptable.
Confirm with fluoroscopy, and direct vision where possible, that all screws stay within the articular block. Interdigitating screws are desirable, but a screw deflected off its drilled path can cause problems, so take care.
Repair the olecranon osteotomy, consider ulnar nerve transposition, and close in layers.
Postoperative Care
Splint the elbow in extension, and start gentle range-of-motion exercises on the first postoperative day.
A removable posterior slab or sling can be used for comfort between therapy sessions.
First 4 weeks: Ideally, do the exercises supine, with the shoulder flexed to 90°, adducted, and in neutral rotation (arm over the face, a protected position).
Progress to full weight bearing around 10 weeks if radiographs show healing.
Reference
Cosgrove CT. Fractures of the shoulder, arm, and forearm. In: Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Philadelphia: Elsevier; 2026. Chapter 62, Technique 62.9.