Bridging plate

Proper alignment of the femur must be obtained with special attention to angulation and torsion. Comparison with the contralateral unaffected bone can be useful.

The normal curve of the distal femur makes it difficult to achieve optimal screw purchase with standard straight plates. Contouring these plates is challenging.

This procedure is performed with the patient placed in either of the two positions:

• Lateral recumbency
• Dorsal recumbency

One of the following approaches is utilized:

• Lateral parapatellar approach
• Medial parapatellar approach
• Bilateral approach

Indirect reduction is achieved by distracting and aligning the major bone segments using bone clamps, or traction on the femoral condyles.

Once the bone length has been restored, it is necessary to check for correct alignment and rotation. Rotational alignment can be judged by palpation or by direct visualization of the greater trochanter and femoral trochlea. The distal part of the femur is held in a true lateral position. The position of the greater trochanter and alignment of the adductor magnus muscle are then inspected.
If the femur is correctly aligned in the axial plane the adductor magnus muscle should be aligned and the greater trochanter should be slightly caudal to the long axis of the bone.

Numerous plate types can be used. Specially designed plates for the distal femur are available.

Ideally the plate should be long enough to place at least three screws in either side of the fracture. In the distal femur the use of only two screws in the distal fragment is acceptable.

The plate is contoured to the lateral aspect of the distal femur. The plate position and contouring to the bone is checked thoroughly and adjusted, if required.

Note: Care should be taken to avoid placement of the plate high on the lateral trochlear ridge, where it can impinge on patellar tracking and result in pain and discomfort.

A detailed description of "Plate preparation" can be found here.

Screws are placed in a near-near far-far pattern. Limb alignment is reassessed.

The remaining screw holes are filled. If a screw holes lays over the fracture plane it should be left open.

Note: Care should be taken to avoid penetrating the articular surface with the screws. Where possible at least one screw should traverse both condyles.

If a locking plate is used, only 2-3 locking bicortical screws are needed per main fragment. One advantage of using a locking plate is that precise contouring is not necessary. Great care must be taken when contouring the distal part of the locking plate to avoid directing screws into the joint.

Note: If a combination of cortex and locking screws is used, the plate must be anatomically contoured at the sites of non-locking screw insertion. The non-locking screws must be inserted and tightened before any locking screws are placed.

Postoperative radiographs should be taken to assess the repair.

Activity restriction and controlled walking is indicated until evidence of bone healing is detected by radiographic examinations.

The aim is to reduce the edema, inflammation and pain using anti-inflammatory and analgesic medications.

Passive range of motion of the hip and stifle joint can be initiated to promote mobility and joint health.

The aim is to resolve the hematoma, edema and control pain, and prevent muscle contracture.

Anti-inflammatory and analgesic medications are still needed. Rehabilitation and integrative medical therapies can be used.

Special attention should be given to patients less than 1 year of age with a femoral fracture, as they are at risk for developing quadriceps contracture. Early controlled activity and passive range of motion is strongly recommended to help prevent this complication.

If the patient is not starting to use the limb within few days after surgery, a careful evaluation is recommended.

Rehabilitation therapy is continued.

10-14 days after surgery the sutures are removed.

Radiographic assessment is performed every 4-8 weeks until bone healing is confirmed.

Implants may be removed if there is irritation or infection present, however if they are not causing problems for the patient, there is no need for implant removal.