1 Introduction topenlarge
Most medial condyle fractures in adults feature complex articular comminution. Computed tomography—particularly 3D CT - can help define the fracture anatomy and facilitate planning of the surgery.
The surgeon must be prepared to apply fixation specific to small osteochondral fracture fragments (eg headless screws and small threaded K-wires), in addition to standard plate and screw fixation.
Furthermore, autogenous bone grafting from the iliac crest may prove useful for supporting disimpacted articular fragments.
Extensive access to the articular surface is necessary, so an olecranon osteotomy is preferred.
2 Patient preparation top
Depending on the approach, the patient may be placed in the following positions:
3 Approaches topenlarge
For this procedure either a medial approach or a transolecranon approach with osteotomy of the olecranon may be used.
As extensive access to the articular surface is necessary, the olecranon osteotomy is preferred.
4 Open reduction topenlarge
Clean the fracture site
Clean out the fracture lines by removing blood clots unfixable, loose pieces of bone, and any interposed tissue.
Disimpact fracture fragments
Many of the displaced fracture fragments are stable, which may suggest that they are appropriately aligned; however, many are impacted into an incorrect alignment.
Using carefully controlled force, these fragments must be gently disimpacted and brought into alignment with intact parts of the bone.
Reduce the fracture.
Monitor fracture reduction by realigning the articular and metaphyseal fracture lines.
Small fragments that may need to be discarded can be used as “puzzle pieces” to ensure correct relationships of the major fragments.
5 Plate preparation topenlarge
Planning for plate placement
The plate should wrap around the entire medial epicondyle. The ulnar nerve must be mobilized and transposed.
Complex plate contouring, using a malleable template, is necessary. This is possible with a reconstruction type plate. Alternatively, a precontoured plate may be selected.
It is useful to be able to place a screw through the distal plate hole and across the trochlea below the medial epicondyle.
6 Provisional fixation topenlarge
The osteochondral fragments are realigned and secured provisionally with smooth K-wires.
7 Definitive screw fixation topenlarge
In some cases provisional K-wire stabilization is not possible.
When there is no intact posterior distal humerus onto which to fix the fragment, or when the fragment is too small to accept a screw, small threaded K-wires, or absorbable pins can be used.
These fragments are stabilized to an adjacent fragment by drilling small threaded K-wires from one fragment to the next in the subchondral bone.
The articular fragments are usually secured first—either to the intact lateral column or to other large fracture fragments on the medial column.
Large articular fragments can be secured with headless screws buried beneath the articular surface.