Lag screw and bridging plate fixation

The goal of 23-C2 fracture treatment is anatomical reduction of the articular fracture line.

Bridging plates are used for complex, nonreconstructable metaphyseal fractures. The main fragments are realigned and stabilized in the correct spatial position achieving interfragmentary compression of the articular fracture, and the plate provides relative stability to the fracture.

The patient can be in dorsal or lateral recumbency.

In lateral recumbency, the affected leg should be in contact with the table.

Preparing the entire leg, including the foot in the surgical field helps in assessing the alignment.

A craniomedial approach to the distal radius is performed. The proximal extent of the approach varies according to the length of the selected plate.

The T-shape configuration of this fracture includes one fracture line involving the articular surface and the second comminuted fracture line in the metaphysis.

Therefore, this fracture is addressed in two steps.

The goal is to achieve anatomical reduction of the articular fracture line. The main fragments are then stabilized in the correct spatial position, and the bridging plate provides relative stability to the fracture.

Anatomical reduction of the articular fracture line is obtained first with the help of pointed reduction forceps placed from medial to lateral in the epiphyseal fragments.

Once the fracture has been reduced, the appropriately sized screw is selected. The correct drill bit for the glide hole is used to drill a hole from the styloid process of the radius to the fracture line in medial to lateral direction.

An appropriately sized drill guide is inserted into the glide hole and the correct drill bit for the threaded hole is used to drill a hole into the lateral cortex of the epiphysis.

The hole depth is measured with a depth gauge, and the appropriate self-tapping screw is inserted and tightened, countersinking the screw head.

An indirect reduction is achieved by distracting and aligning the major bone segments using bone-holding forceps or other distraction techniques.

It is necessary to check for correct alignment (length and rotation) once the bone length has been restored. Rotational alignment can be judged by palpation or direct visualization of the carpal and elbow joints. Flexing and extending the carpus and elbow will help check the repair's alignment. Preparing the entire leg, including the foot in the surgical field helps in assessing the alignment.

Alternatively, the plate can be fixed in the distal fragment first and then used to achieve reduction on the proximal fragment. In this case, the plate should be contoured before application.

According to the size of the distal fragment, a straight plate or a T-plate should be used in order to have a minimum of two screws in the distal fragment and three screws in the proximal fragment.

Since the bone will not share the load, the plate must withstand all the weight-bearing forces alone. Therefore, a large plate must be selected. A lengthening plate (ie, a plate without holes in the central part) can be used.

The plate should bridge at least 75% of the length of the radius.

A plate of appropriate size is contoured to fit the shape of the distal radius, taking into consideration the procurvatum. The degree of procurvatum can vary according to the breed, and should be checked in the unaffected leg, if possible.

Given the location of the fracture, the majority of cases will require a T-plate rather than a straight plate. The T-plate needs to be positioned on the cranial surface of the radius.

The contoured plate is applied to the surface of the radius and stabilized with plate-holding forceps.

The alignment is carefully checked. If required, the alignment is corrected and the plate-holding forceps are repositioned.

Usually, the plate is secured to the distal fragment first.

A push-pull device can be inserted instead of plate-holding forceps in the proximal and distal fragment to temporarily stabilize the plate if a locking compression plate is used.

With the temporary fixation in place, plate position and anatomical reduction are checked thoroughly and, if necessary, adjusted.

The first two screws are inserted in neutral position in the distal fragment after drilling with a neutral guide through the plate. The screws are fully tightened.

All the screws are inserted in a neutral mode.

It is not necessary to fill all the available plate holes.

Sometimes, it is not possible to insert three screws in the distal fragment, but a minimum of two screws is required.

A locking plate can be used instead of a traditional bone plate. Using a combination of nonlocking and locking screws or locking screws alone can provide adequate fixation.

The aim is to reduce edema, inflammation, and pain.

Following appropriate internal fixation, there should be no absolute need for external coaptation for a 23-C2 fracture. If bandaging is used to decrease edema and protect the surgical wound, it should be removed after 24–48 hours to reduce the risk of complications.

Integrative medical therapies, anti-inflammatory medications, and analgesics are recommended.

10–20 minutes of ice therapy is recommended every 8 hours in most cases.

The patient can immediately bear weight, but with strict control of activities.

The aim is to resolve hematoma and edema, control pain, and prevent muscle contracture. Anti-inflammatory and analgesic medications may still be needed.

Rehabilitation and integrative medical therapies can be used.

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

The sutures are removed 10–14 days after surgery.

Immature patients should be radiographed every 4 weeks.

A radiographic assessment is performed every 4–6 weeks until bone healing is confirmed, more frequent assessment may be necessary for skeletally immature patients.