ORIF - Bridge plate

Bridge plating (or biological plating) is a technique to achieve relative stability by splinting. This allows for indirect healing with preservation of blood supply and soft tissue attachments while bridging the fracture zone maintaining the correct length, rotation and alignment. Anatomical reduction of each fracture fragment is not necessary.

A precontoured plate is useful in situations when normal anatomical landmarks are distorted or there is significant bone fragmentation. We will here show the procedure with a precontoured clavicular plate which has both a bend and a twist built into it.

However, if a precontoured clavicular plate is not available, there are other options.

A straight plate may be used if it fits the clavicle (conventional or angle stable). If it does not, then it needs to be contoured.
This is best achieved with a slight twist at the midportion of the plate. This results in the lateral plate being applied superiorly and the medial portion anteriosuperiorly. A reconstruction plate which is easier contour may be used in smaller patients where the forces working on the plate are not as great.

When the fracture location is more lateral or more medial, the bone quality near the metaphysis may not offer sufficient screw purchase. In these instances, a plate offering additional screw fixation may be required (eg, longer plate, periarticular plate, locking head screws).

The goal when choosing the plate length is to reduce the concentration of bending forces. This typically requires a longer plate. Care must be taken not to insert a screw in each hole of the plate or rigidly fix fracture gaps.

This procedure is normally performed with the patient either in a beach chair or a supine position.

For this procedure an anterior approach is normally used.

Fracture fragments should not be devitalized or stripped from their soft tissue attachments. Achieve reduction by indirect means where possible.

The aim is to restore normal alignment and rotation as well as length. At times some sacrifice of length may be acceptable in order to improve bone contact and avoid excessive gapping.

The plate can often assist as a reduction tool to restore the length and rotation.

A properly contoured plate is usually fixed first to the medial side as medial side malalignment is less well tolerated. The lateral fragment is then reduced by manipulation involving traction and rotation and is aligned anatomically with the lateral side of the plate.

The superior surface of the lateral fragment is flat and readily identified. Reduction of the plate to the superior flat surface of the lateral segment will often restore the correct rotation.

A push-pull device is often helpful in obtaining the appropriate clavicular length when manual distraction is unsuccessful.

Once the fracture alignment, length, and rotation are satisfactory, the remaining screws can be inserted.

Two days post-surgery the main surgical dressing may be removed and showers are permitted and a light dry dressing may be applied. Soaking in baths, hot tubs and swimming pools are not permitted until minimum two weeks after surgery when the wound is completely healed and the sutures and staples have been removed.

Plate removal from the clavicle is not routinely required or recommended. Symptomatic prominence and impingement of the clavicle plate can occur. After the fracture has completely healed, removal of the implant may be a consideration.

Athletes who return to contact sports should only have the plate removed if absolutely necessary and if so, done at the end of the season to allow maximal healing prior to return to sport.

Many patients who request hardware removal from local symptomatology 6-12 months after implantation find that symptoms diminish significantly by 2 years postoperatively and defer hardware removal indefinitely.

The patient should sleep wearing the sling on his/her back or on the non-injured side.

When sleeping on the side, a pillow can be placed across the chest to support the injured side.

When sleeping on the back, the injured side should be supported by placing a pillow underneath the arm.

It may be more comfortable sleeping in a sitting or semi reclined position.

A non-slip mat in the shower/bath tub will improve safety. The arm can hang gently at the patient's side while bathing. Axillary hygiene is important. If assistance is not available, a long-handled sponge can be used to wash the back and legs.

Loose fitting clothing and button-up shirts are ideal. The affected arm may be used for buttoning and unbuttoning. The affected arm is dressed first, then the non-affected arm. When undressing, start with the non-affected arm, then the affected arm.

Sling support should be provided until the patient is sufficiently comfortable to begin shoulder use, and/or the fracture shows early evidence of healing radiographically.

Once these goals have been achieved, rehabilitative exercises can begin to restore range of motion, strength, and function.
The phases of nonoperative treatment are thus:

• Temporary immobilization
• Passive/assisted range of motion
• Active range of motion
• Progressive resistance exercises

Usually immobilization is maintained for 1-2 weeks for comfort and wound healing purposes. The use of the sling is gradually decreased at this point.

This is followed by gentle range of motion exercises.

Non-weight-bearing of the affected upper limb is continued for approximately for 6 weeks or until radiographic and clinical evidence of progressive healing.

Resistance exercises can generally be started at 6 weeks. Isometric exercises may begin earlier, depending on the injury and patient symptoms.

After clavicular surgery, it is important to maintain full mobility of the unaffected joints to reduce arm swelling and to preserve joint motion. The following exercises are recommended:

• Straightening and flexion of the elbow
• Open and closure of the hand
• Squeezing of a soft ball

• Bending of the wrist forward, backwards and in a circular motion
• Movement of an open hand from side to side

• Squeezing the shoulder blades together, while shoulders remain relaxed

Pendular exercises can be started when pain starts to subside.

Gradual progression to passive and assisted range of motion exercises are started as tolerated. Scapular stabilization must be observed to restore normal kinetics to shoulder motion.

Activated assisted range of motion exercises are started with:

• External rotation
• Internal rotation

• Flexion with arms on table
• Flexion with ball on wall

Sub-maximal isometric exercises with:

• Internal rotation
• External rotation (1)
• Abduction (2)
• Extension

Note: Timing and progression of exercises are ultimately directed by the operating surgeon as factors such as bone quality, type of fracture and fixation may vary in individuals.

Pending clinical and radiographic review by the operating surgeon, weight-bearing may now be permitted and gradual resisted/strengthening exercises can begin.

Return to full activities and/or contact sports is permitted once the fracture is united and the extremity has regained full strength. Typically this takes around 6 months post injury. It may be sooner or later depending on the patient factors, progress of fracture healing and response to rehabilitation.

If there has been no progress on serial radiographs of fracture healing, at 3 months, then delayed or impaired healing may be present. If the fracture has not united after 9 months surgical intervention should be considered.