Open plating is less biologically favorable because soft-tissue and especially periosteal stripping will slow fracture healing. In addition, muscle dissection can contribute to discomfort and joint stiffness.
Soft-tissue dissection should be minimized during open plating.
Note on illustrations
Throughout this section generic fracture patterns are illustrated as:
Reduced and provisionally stabilized
Compression vs bridge plating
Transverse and short oblique fractures can be made more stable by compressing using gliding holes in the plate.
Bridge plating relies on indirect fracture reduction.
Most children’s fractures heal readily and compression is not mandatory.
The approach that involves the least dissection of the fracture site to obtain stable fixation is preferred.
2. Selection of implants
For younger children a small fragment set can be used (3.5 mm). For older children and adolescents, a large fragment plate, typically a narrow 4.5 mm plate, can be used.
Select a plate long enough to allow three bicortical screws in each main fragment.
If longer plates are used, a curved plate may provide a better fit and accommodate the sagittal anatomy of the femur.
An x-ray of the contralateral side is useful for templating.
3. Patient preparation and approach
Place the patient in a supine position on a traction table or a translucent table with a bump under the ipsilateral flank.
After extraperiosteal exposure of the lateral aspect of the femur, perform direct reduction using manual traction/traction table, and/or bone reduction forceps.
Anatomical fracture reduction can be observed directly.
With purely transverse fractures, it is rarely possible to achieve reduction by forceful longitudinal traction alone. It is usually necessary to increase the angulation (apex anteriorly) to reduce the posterior cortices, and then straighten the bone to reduce the whole fracture.
5. Plate contouring
Position the plate on the lateral aspect of the femur.
Fitting the plate to the bone
Depending on the planned location, proximal and distal contouring of the plate may be necessary.
Contouring is aided by a stable provisional reduction and a malleable template that can be shaped along the bone surface.
The malleable template is then used as a guide for shaping the plate to the bone.
Pearl: Undercontour a plate to be used in compression, to avoid gapping of the far cortex.
Application of the plate
Avoid periosteal stripping when exposing the bone for plate fixation.
Position the plate over the fracture so that at least three holes are available in the proximal and distal fragments.
Insert the first screw close to the fracture site.
Confirm plate position relative to the fragment before placing the second screw.
Insert the second screw through the plate in the same fragment and tighten both screws.
If unstable, fix the plate to one fragment and then reduce the other fragment onto the plate, using a bone holding forceps.
Assessment of rotational alignment
Confirm rotational alignment of the femur clinically and radiographically before fixing the second fragment. This can be done by:
Direct visualization of fracture site
Fluoroscopy of fracture site
Comparing internal and external rotation to the contralateral side
Fluoroscopy of proximal femur (lesser trochanter profile)