Compression plating

Short oblique shaft fractures may be treated with open reduction and compression plate fixation.

Usually, the plate may be applied laterally. In some cases, the plate may be applied dorsally.

This fixation follows the principles of compression plating of oblique fractures, ie, the plate should create an axilla (acute angle) with the oblique fracture line. If such an axilla cannot be created, lag-screw fixation with a neutralization plate should be considered.

Depending on the fracture morphology and surgeon’s preference, compression can be applied in one of the following modes:

• Compression with a plate
• Compression with a lag screw through a plate

Intrinsic compression can be achieved with a locking compression plate, shown in this procedure. With an anatomic plate, extrinsic compression is applied with forceps and maintained with locking head screws.

Obliquity of the fracture is possible either in the plane visible in the AP view or the lateral view. Always confirm the fracture configuration with views in both planes.

Select a plate (1.5–2.0 mm) according to the size of the bone, fracture geometry, and surgeon’s preference.

The plate length should allow for at least two screws in each main fragment.

The plate is available as a conventional compression plate or with variable-angle (VA) locking-head screws.

Place the patient supine with the arm on a radiolucent hand table.

For this procedure, the following approaches may be used:

• Midaxial approach to the proximal phalanx
• Dorsal approach to the proximal phalanx

Reduction can be achieved by axial traction with lateral pressure exerted at the site of maximal displacement.

Confirm reduction clinically and with an image intensifier. If there is shortening of the finger, then there is often malrotation of the fracture.

If the fracture appears stable after reduction, nonoperative treatment can be considered. Confirming reduction with an image intensifier is then essential.

Direct reduction is necessary when the fracture cannot be reduced by traction and flexion or is unstable.

When indirect reduction is not possible, this is usually due to interposing parts of the extensor apparatus.

Use two pointed reduction forceps for direct reduction.

Insert K-wires for provisional fixation.

At this stage, it is advisable to check the alignment and rotational correction by moving the finger through a range of motion.

Rotational alignment can only be judged with flexed metacarpophalangeal (MCP) joints. The fingertips should all point to the scaphoid.

Malrotation may manifest by an overlap of the flexed finger over its neighbor. Subtle rotational malalignments can often be judged by a tilt of the leading edge of the fingernail when the fingers are viewed end-on.

If the patient is conscious and the regional anesthesia still allows active movement, the patient can be asked to extend and flex the finger.

Any malrotation is corrected by direct manipulation and later fixed.

Under general anesthesia, the tenodesis effect is used, with the surgeon fully flexing the wrist to produce extension of the fingers and fully extending the wrist to cause flexion of the fingers.

Alternatively, the surgeon can exert pressure against the muscle bellies of the proximal forearm to cause passive flexion of the fingers.

Confirm fracture fixation and stability with an image intensifier.

If the plate is perfectly adapted to the concavity of the lateral phalangeal surface, tightening the screws may result in a gap in the opposite cortex.

The solution is the same as all diaphyseal long bone transverse and oblique fractures. The plate is not contoured, so that it is “overbent” relative to the bone surface. When screws are tightened, compression is then applied across the whole fracture plane including the opposite cortex.

Select a plate with at least 5 holes and center it over the fracture.

Ensure that the plate is centered on the long axis of the diaphysis in the lateral view.

The compression plate is applied according to standard techniques.

• Application of compression plate to an oblique fracture

Insert the first screw to create an axilla (acute angle) between the plate and one of the fragments. The apex of the second fragment can then be reduced into the axilla.

After inserting the second screw, check rotational alignment again.

Insert the remaining screws in neutral mode to provide improved resistance to rotational forces applied to the plate.

Cover the plate with periosteum to avoid adhesion between the tendon and the implant leading to limited finger movement.

A lag screw may, in some cases, be inserted to compress the fracture plane, and therefore increase interfragmental stability.

• Cortical lag-screw insertion

Confirm fracture reduction and stabilization and implant position with an image intensifier.

The aftercare can be divided into four phases of healing:

• Inflammatory phase (week 1–3)
• Early repair phase (week 4–6)
• Late repair and early tissue remodeling phase (week 7–12)
• Remodeling and reintegration phase (week 13 onwards)

Full details on each phase can be found here.

If there is swelling, the hand is supported with a dorsal splint for a week. This would allow for finger movement and help with pain and edema control. The arm should be actively elevated to help reduce the swelling.

The hand should be splinted in an intrinsic plus (Edinburgh) position:

• Neutral wrist position or up to 15° extension
• MCP joint in 90° flexion
• PIP joint in extension

The reason for splinting the MCP joint in flexion is to maintain its collateral ligament at maximal length, avoiding scar contraction.

PIP joint extension in this position also maintains the length of the volar plate.

After subsided swelling, protect the digit with buddy strapping to a neighboring finger to neutralize lateral forces on the finger.

To prevent joint stiffness, the patient should be instructed to begin active motion (flexion and extension) immediately after surgery.

See the patient after 5 and 10 days of surgery.

The implants may need to be removed in cases of soft-tissue irritation.

In case of joint stiffness or tendon adhesion restricting finger movement, arthrolysis or tenolysis may become necessary. In these circumstances, the implants can be removed at the same time.