Compression plating with a dorsal T-plate

In this procedure, compression plating of a transverse fracture of the proximal phalangeal base with a dorsal T-plate is shown.

Two plate types are available for treatment of this fracture:

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

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

The T-plate is available as a plate with variable-angle (VA) locking-head screws. This plate type has the advantage of allowing insertion of two or three screws at variable angles into the articular block. The rounded plate edges avoid soft-tissue irritation and adhesion.

The plate needs to be contoured to fit the anatomy of the phalangeal base.

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

For this procedure, the following approach may be used:

• Dorsal approach to the proximal phalanx (after Pratt)

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.

Direct reduction is necessary when the fracture cannot be reduced by traction and flexion or is unstable because of surrounding soft-tissue lesions.

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 a K-wire 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.

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 distal to the fracture available for fixation in the diaphysis. At least two screws need to be inserted into the diaphysis.

The dorsal surface of the proximal phalanx is gently convex. If the straight T-plate is not adequately contoured to follow this convexity, tightening the distal screw will open the fracture on its palmar aspect.

If the plate is perfectly adapted to the dorsal surface of the phalanx, 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 overbent so that when the screws are tightened, compression is applied across the whole fracture plane including the opposite cortex.

Check for perfect adaptation of the plate to the base of the phalanx before screw fixation.

If it is not perfectly adapted, fracture displacement or malrotation may occur.

Place the plate dorsally on the phalanx, as proximally as possible, without interfering with the joint.

Ensure that the plate is centered on the diaphysis in the coronal plane.

Keep the plate in place with the atraumatic forceps.

Insert two proximal screws:

• Screw insertion in neutral mode
• Locking head screw insertion

Carefully drill a first hole for a screw through the transverse plate part with a 1.0 mm drill bit. The drill bit should engage but not penetrate the far cortex.

Insert the first screw. Ensure it engages the far cortex but does not protrude into the fibroosseous flexor digital channel, where the flexor tendons run. The digital nerve and artery are also at risk of injury.

Insert a second screw into the opposite end of the transverse plate section in the same fashion, alternately tightening both screws.

Insert a cortical screw in compression mode in the oblong hole.

• Screw insertion in compression mode

Prepare and insert another, more distal diaphyseal locking screw.

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.