Further proximal and distal screw insertion is now completed. It is advisable to formally expose the proximal end of the plate to ensure accurate screw positioning.
The number and position of the screws inserted depends on the specific fracture pattern. The goal is “balanced fixation”. This means roughly equivalent fixation strength in both proximal and distal segments. Usually, the metaphysis requires more screws (3-5) than the diaphysis (2-3). Cortical bone provides better screw purchase than cancellous bone.
In osteoporotic bone, the number of screws should be increased, particularly in the cancellous distal segment.
Note that a single conventional screw, with lag technique, passes through the wedge fragment, and into the distal lateral spike of diaphysis. This compresses a large wedge fragment between plate and diaphysis, improving fracture stability.
Bone grafting is almost never required, except in open extraarticular fractures with bone loss. In such cases, it should be delayed until the soft-tissue envelope is stable.