Compression plating with a lateral plate

In this procedure, compression of a transverse fracture of the proximal phalangeal head with a lateral anatomical plate is shown (phalangeal head plate).

Two plate types are available for treatment of this fracture:

• 1.5 mm phalangeal head plate; lateral
• 1.5 mm T-plate (adaption plate); dorsal

Select a plate according to fragment size, fracture geometry, and surgeon’s preference.

The plates are available as anatomical plates with variable-angle (VA) locking-head screws. This plate type has the advantage of sparing the soft tissue around the joints and allows insertion of two or three screws at variable angles into the articular block. The rounded plate edges avoid soft-tissue irritation and adhesion.

If an anatomical plate is not available, a conventional minicondylar plate may be used.

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

For this procedure, the following approach may be used:

• Midaxial (lateral) approach to the proximal phalanx

Reduction can be achieved by traction and flexion of the metacarpophalangeal (MCP) joint exerted by the surgeon.

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

Sometimes indirect reduction may be prevented by interposition of the lateral band.

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 interposition of parts of the extensor apparatus.

Use pointed reduction forceps for direct reduction.

Pointed reduction forceps, or a K-wire, may be used for preliminary fixation. However, the position of the forceps, or the K-wire may conflict with the planned plate or screw position.

For that reason, in many cases, the reduction is preliminarily held by an assistant holding the finger in flexion. If the extensor apparatus is intact, it will act as a tension band and hold the reduction.

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.

The fixation of a transverse fracture with a lateral plate follows the principles of compression plating of transverse fractures.

Adapt the plate length to fit the length of the proximal phalanx. Avoid sharp edges, which may be injurious to the tendons. There should be at least 3 plate holes proximal to the fracture available for fixation in the diaphysis. At least two screws need to be inserted into the diaphysis.

Place the plate slightly dorsal to the midaxial line of the bone, allowing at least two screws in the distal fragment.

To avoid conflict with the insertion of the collateral ligament, a K-wire may be placed in the isometric insertion of the collateral ligament and the notch of the plate aligned to it.

Keep the plate in place with the atraumatic forceps.

Insert at least two VA locking head screws in the articular block.

• Locking head screw insertion

Insert the next screw in compression mode in the oblong hole.

• Screw insertion in compression mode

Check the plate position with an image intensifier and adjust it if necessary.

Compression may also be achieved extrinsically with reduction forceps and then held with a locking screw.

Insert further screws in the shaft and distal end.

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

Confirm fracture reduction and stability 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.