1 Introduction topenlarge
Take care when approaching an apparently non-articular medial condylar fracture as these are unusual. Preoperative imaging, including computed tomography, can be used to identify associated articular fractures.
Screw fixation alone will only provide adequate stability for immediate active exercises when the bone quality is excellent, and the fracture is simple and non-fragmented.
In practice, screw fixation alone is used primarily in skeletally immature patients, who can be immobilized for 3-4 weeks in a cast without getting too stiff.
Most medial condylar fractures in adults are fixed with a plate and screws to allow immediate active motion.
2 Open reduction topenlarge
Mobilize the fragment and clean the fracture site
Isolate and protect the ulnar nerve.
Open the fracture site by gentle retraction of the fragment.
Clean out the fracture by removing blood clots, loose pieces of bone, and any interposed tissue. Inspect the joint to ensure that no additional intraarticular fracture component was missed when examining the imaging.
Reduce the fracture.
Monitor fracture reduction by realigning the metaphyseal fracture lines.
You should check the anterior and posterior fracture lines, including the articular surface.
3 Plate preparation topenlarge
Plate selection and preparation
Anatomic plates may be used, and do not require contouring. If these are not available, a one-third tubular plate may be used on the crest of the medial supracondylar ridge. If a stronger plate is required, a small fragment dynamic condylar plate may be used, but this is more difficult to contour.
If the plate does not go below the medial epicondyle, it is not necessary to transpose the ulnar nerve.
A screw can be placed separately from the plate or all the screws can pass through the plate.
4 Provisional fixation topenlarge
The fracture is preliminarily stabilized with smooth K-wires at least 1.5 mm in diameter. The wires should be inserted carefully so that they do not hinder plate placement.
Provisional wires can be inserted through a plate screw hole, or adjacent to the plate to prevent their conflicting with plate placement.
5 Lag screw insertion topenlarge
Drill the near fragment with a 3.5 mm drill to create a gliding hole.
Then drill the far fragment with a 2.5 mm drill.
Insert the screw and tighten to compress the fragments.
6 Plate application topenlarge
The order of screw insertion through the plate may vary. In general, it is best to insert the most distal screw first.
A 2.5 mm drill is used to drill a pilot hole into the trochlea across the fracture site.
Distal plate screw insertion
The screw length is measured, the pilot hole tapped if necessary, and the screw inserted.
Any screws that cross the fracture site can be placed as lag screws, partially threaded screws, or position screws.
Proximal plate screw insertion
Next, insert one of the proximal screws to anchor the plate. This screw is a 3.5 mm cortical screw, so a 2.5 mm drill is used.
After initial proximal and distal screw fixation, fracture alignment and implant placement are confirmed using image intensification.
Final screw insertion
The remaining screws are inserted.