Authors of section

Authors

Renato Fricker, Matej Kastelec, Fiesky Nuñez, Terry Axelrod

Executive Editor

Chris Colton

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Compression plate fixation

1. Principles

These fractures tend to be unstable, and bone healing is often prolonged. Internal fixation allows for anatomical reduction, early active motion and shorter rehabilitation.
In transverse fractures, an interfragmentary lag screw can not be used. Absolute stability is achieved using compression plate principles.

These fractures tend to be unstable, and bone healing is often prolonged. Internal fixation allows for anatomical reduction, ...

Teaching video

AO teaching video: Transverse Fracture of metacarpal II - fixation with 2.0/5-hole LC-DCP

2. Approaches

3. Reduction

Two pointed reduction forceps can be used for direct reduction.
As most of these fractures have a flexion deformity, indirect reduction can be performed by pressure on the metacarpal head from the palmar aspect.

Two pointed reduction forceps can be used for direct reduction. As most of these fractures have a flexion deformity ...

Pearl: flex finger

Alternatively, maximally flex the finger at the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints and use the proximal phalanx to push up the metacarpal head.
If all the fingers are flexed at the MCP joints, this automatically ensures correct rotational alignment.

Alternatively, maximally flex the finger at the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints and use ...

Preliminary fixation in unstable situations

In very unstable situations, insert a K-wire across the fracture plane for provisional stabilization.
Be aware that the cortical bone in the metacarpals is dense and thick, so the tip of the K-wire gets very hot. Irrigation during insertion of the K-wire is essential to avoid thermal necrosis of the bone around the wire track.

In very unstable situations, insert a K-wire across the fracture plane for provisional stabilization. Be aware that the ...

4. Fixation: Compression plate

Bending and contouring the plate

The plate is placed dorsally onto the metacarpal; usually 2 mm plates are used.
The plate has to be slightly overbent in order to compress the far cortex when axial compression is produced by tightening the screws.
If the plate is not overbent, tightening the screws will result in a gap in the opposite cortex.

The plate is placed dorsally onto the metacarpal; usually 2 mm plates are used. The plate has to be slightly overbent in order t

Plate application

Depending on the fracture configuration, a 4- or 5-hole plate is used. When using a 5-hole plate, the middle hole is centered over the fracture. When a 4-hole plate is used, ensure that the screw position will not interfere with the fracture line.

Depending on the fracture configuration, a 4- or 5-hole plate is used. When using a 5-hole plate, the middle hole is centered ..

Pitfall

If the plate is not properly centered on the dorsal surface of the metacarpal, the screws may not penetrate the medullary canal and may not have sufficient purchase. Secondary fractures may result.

If the plate is not properly centered on the dorsal surface of the metacarpal, the screws may not penetrate the medullary ...

Drilling

Using a drill guide, the first hole is drilled with a 1.5 mm drill bit close to the fracture line.
Make sure that the screw does not enter the fracture plane. When a 4-hole plate is positioned, take care that the corresponding plate hole on the other fragment is not too close to the fracture.

Using a drill guide, the first hole is drilled with a 1.5 mm drill bit close to the fracture line.

Measuring

Use a depth gauge to determine screw length.

Use a depth gauge to determine screw length.

Screw insertion

Insert the first screw but do not fully tighten. Ensure that it engages the far cortex. Failure to take accurate measurement of the required screw length risks not engaging the far cortex, thereby weakening the fixation and creating the risk of implant failure.

Insert the first screw but do not fully tighten. Ensure that it engages the far cortex. Failure to take accurate measurement ...

Insert second screw

Pull the plate towards the second fragment so that the first screw comes to occupy an eccentric load position. Ensure that the plate is lying in the long axis of the metacarpal shaft.
Insert the second screw as a load screw. Tighten the screws alternately to produce interfragmentary axial compression. Before final tightening, any provisional K-wire should be extracted.

Pull the plate towards the second fragment so that the first screw comes to occupy an eccentric load position.

Check rotational alignment

Before inserting the remaining screws, check rotational alignment.

Before inserting the remaining screws, check rotational alignment.

Complete fixation

The remaining screws are inserted in neutral positions.

The remaining screws are inserted in neutral positions.

5. Postoperative splint

A removable splint may be applied at the end of the operation, with the hand in an intrinsic plus (Edinburgh) position.
In compliant patients with stable internal fixation the splint can be removed after any swelling has receded. It may be worn at night for a longer period as this may increase patient comfort.

screw fixation

While the patient is in bed, use pillows to keep the hand elevated above the level of the heart, in order to reduce swelling.

screw fixation

For ambulant patients, put the arm in a sling and elevate to heart level.

Instruct the patient to lift his hand regularly above the head, in order to mobilize the shoulder and elbow joints.

screw fixation

Follow up

See the patient after 2 days for a dressing change. After 10-12 days, remove the sutures and confirm radiologically that no secondary displacement has occurred.
Additional x-rays are taken 4 weeks after internal fixation. Usually, the fracture line will still be visible.
X-rays are repeated after 8 weeks to assess union.
Strengthening exercises and manual work are allowed according to clinical and radiological evidence of bone healing.

Functional exercises

As pain and swelling recede, early, active, controlled digital range of motion exercises gently progress.
The importance of mobilization must be emphasized to the patient and rehabilitation should be supervised by a physical therapist.

nonoperative treatment