T-plate fixation

Fractures of the metaphysis can be transverse, oblique, or comminuted. Reduction is achieved by traction and digital manipulation. When the fracture is stable, it can be treated nonoperatively.
If the fracture is irreducible, ORIF is indicated.
Other indications for ORIF are open fractures or soft-tissue lacerations.

For this procedure the following approaches may be used:

• Dorsal approach to the phalangeal metaphysis (after Pratt)
• Dorsal approach to the MCP joint

Reduction can be obtained by traction and flexion exerted by the surgeon.
Confirm reduction using image intensification.
Often, these fractures are stable after reduction, in which case nonoperative treatment is indicated.

Direct reduction is necessary when the fracture can not 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 interposition of parts of the extensor apparatus.
Use two pointed reduction forceps for direct reduction.

Insert a K-wire for provisional fixation.

At this stage, after provisional fixation, 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 the fingers in a degree of flexion, and never in full extension. Malrotation may manifest itself by overlap of the flexed finger over its neighbor. Subtle rotational malalignments can often be judged by tilting 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, 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 dorsal surface of the proximal phalanx is gently convex. If the straight T-plate is not adequately contoured to follow this convexity, tightening of the distal screw will open the fracture on its palmar aspect.
To overcome this, the plate is slightly overcontoured so that when the distal load screw is tightened, compression is generated evenly over the whole fracture surface.

The plate is placed 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.

Using a drill guide, carefully drill a first hole for a screw through the transverse part of the plate with a 1.0 mm drill bit.
Repeat for the second hole in the transverse part.

Pitfall
Be sure not to injure the flexor tendons and digital artery and nerve.

Use a depth gauge to determine screw length.

Insert the first screw. Ensure that it engages the far cortex but does not protrude into the fibro-osseous 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 after the same fashion, alternately tightening both screws.

Check for perfect adaptation of the plate to the diaphysis and metaphysis. If it is not perfectly adapted, take out the screws and recontour the plate to avoid fracture displacement, or malrotation.

Conflict of tips of the screws in the transverse part of the plate and joint penetration must be avoided.

Use a drill guide and 1.0 mm drill bit to prepare an eccentric hole for the distal plate screw.

Use a depth gauge to determine screw length.

Insert the distal, self-tapping screw eccentrically and tighten it, thereby compressing the fracture.
Prepare and insert another, more proximal diaphyseal screw in a neutral position.

Protect the digit with buddy strapping to the adjacent finger, to neutralize lateral forces on the finger.

The patient can begin active motion (flexion and extension) immediately after surgery.

See patient after 5 days 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’s restricting finger movement, tenolysis, or arthrolysis become necessary. In these circumstances, take the opportunity to remove the implants.