ORIF - Bridge plating (DCS)

Throughout this treatment option illustrations of generic fracture patterns are shown, as four different types:

A) Unreduced fracture

B) Reduced fracture

C) Fracture reduced and fixed provisionally

D) Fracture fixed definitively

Bridge plating uses the plate as an extramedullary splint, fixed to the two main fragments, leaving the intermediate fracture zone untouched. Anatomical reduction of intermediate fragments is not necessary. Furthermore, their direct manipulation would risk disturbing their blood supply. If the soft tissue attachments are preserved, and the fragments are relatively well aligned, healing is enhanced.

Alignment of the main shaft fragments can be achieved indirectly with the use of traction and the support of indirect reduction tools, cerclage wires, or indirectly via the implant.

Mechanical stability, provided by the bridging plate, is adequate for gentle functional rehabilitation and results in satisfactory indirect healing (callus formation). Occasionally, a larger wedge fragment might be approximated to the main fragments with a lag screw.

• Basic technique: insertion of cortical lag screws

It is important to restore axial alignment, length, and rotation.

Reduction can be performed with a single reduction tool (eg, large distractor), or by combining several steps (for example fracture table +/- external fixator, cerclage wires, +/- reduction via the implant, etc.) to achieve the final reduction.

The preferred method depends on the fracture and soft-tissue injury pattern, the chosen stabilization device, and the experience and skills of the surgeon.

If a large fragment has separated from the fracture zone and impaled the adjacent muscle, direct reduction may be required.

The patient may be placed in one of the following positions:

• Supine position with manual traction
• Supine knee flexed 30°
• Scissor position

For this procedure a lateral approach is used.

Sometimes, manual traction is not sufficient to achieve and control preliminary reduction.

Then the use of an external fixator facilitates the reduction procedure and provides alignment and temporary stability for the bridge plating procedure.

Proximal and distal pins should be inserted carefully in order not to conflict with the later plating procedure. For this purpose, anterolateral or anterior positions on the femur are safe.

If no traction table is used, folded linen bolsters under the fracture zone may facilitate the reduction maneuver.

AO teaching video: Application of the large distractor

As a first step, a guide wire for the condylar screw is inserted into the distal femur.

This is an extremely important step, because it determines the later plate positioning in two planes.

The guide wire for the cannulated condylar screw is inserted into the condylar mass from laterally. The entry point lies anterior to the midpoint between the anterior and posterior edges of the lateral femoral condyle, in line with the femoral shaft axis, and 2 cm proximal to the knee joint.

The guide wire must be parallel to the plane of the tibio-femoral joint (line A) and, at the same time, parallel to the plane of the patello-femoral joint (line B).

The correct positioning of the guide wire must be checked using image intensifier fluoroscopy. The depth of guide wire insertion is crucial. Remember that the cross-section of the distal femoral condylar mass is trapezoidal and slopes markedly on the medial side. The tip of the guide wire should just engage the medial cortex, and so will appear short of the medial condylar cortex on the AP intensifier image.

Next, the surgeon slides the direct measuring device over the guide wire and determines guide wire insertion depth and, thereby, the length of condylar screw required.

After assembling the DCS triple reamer and setting the reamer to the correct depth, the hole for the condylar screw is reamed over the guide wire.

First, the condylar screw is inserted to its final position. The T-handle is lined up parallel to the femoral shaft axis in order to ensure an adequate plate placement.

Now the T-handle is detached and the plate barrel is placed over the screw shank. Afterwards, the T-handle is reconnected to the screw.

The preliminary reduction is checked with respect to axial alignment and length, and to a degree rotation. Before fixation to the proximal fragment, it is often advisable to insert a cancellous screw into the most distal plate hole to prevent rotation of the plate about the axis of the condylar screw.

Two blunt Hohmann retractors placed ventrally and dorsally around the femoral shaft can be helpful to control the lateral position of the plate.

If the overall reduction is found to be adequate, the first cortical screw in the proximal fragment is inserted without being fully tightened. This still allows for the plate position to be fine tuned.

In case the lateral position prior to the placement of the second screw is inadequate, the use of sterile bolsters is recommended.

The lateral plate position can be confirmed by palpation.

Once the most proximal screw has been inserted, the first screw in the proximal fragment is fully tightened.

According to preoperative planning, additional screws are inserted into the distal and proximal main fragments.

Close monitoring of the femoral muscle compartments should be carried out especially during the first 48 hours, in order to rule out compartment syndrome.

In all cases in which radiological control has not been used during the procedure, a check x-ray to determine the correct placement of the implant and fracture reduction should be taken within 24 hours.

Unless there are other injuries or complications, mobilization may be started on postoperative day 1. Static quadriceps exercises with passive range of motion of the knee should be encouraged. If a continuous passive motion device is used, this must be discontinued at regular intervals for the essential static muscle exercises. Afterwards special emphasis should be placed on active knee and hip movement.

Full weight bearing may be performed with crutches or a walker.

Wound healing should be assessed regularly within the first two weeks. Subsequently a 6 and 12 week clinical and radiological follow-up is usually made. A longer period may be required if the fracture healing is delayed.

Implant removal is not mandatory and should be discussed with the patient, if there are implant-related symptoms after consolidated fracture healing.