The fracture is anatomically reduced using traction, tenting and rotating movements, followed by the application of one or two pointed reduction forceps.
3. Fixation (through an open approach)
Ideally two 3.5 mm interfragmentary cortex screws are inserted to fix the fracture. If necessary the screw heads can be countersunk such that they are flush with bone surface, which allows the placement of a plate directly over them. The reduction forceps are subsequently removed.
The first plate is contoured to cover the most distal aspect of the proximal fragment and attached to the bone either with the help of the push-pull device or through a position screw applied in neutral position though a plate hole near an end of the plate. The screw is inserted perpendicular to the long axis of the bone.
Subsequnetly a second position screw is inserted through a plate near the distal end of the plate, also in neutral position. In adult horses it may be advantageous to apply some axial compression but usually it is not necessary if good anatomic reduction was achieved and interfragmentary are positioned well.
Note: Excessive axial compression through the plate(s) following interfragmentary fixation of the fracture may be detrimental because it may disrupt the perfect anatomic reduction achieved initially. Foals are especially prone to such complications.
Next one to two screws are placed in the center of the plate. If the screws cross the fracture plane they are inserted in lag fashion.
If two plates are implanted is best to apply now the second plate similar to the first one.
If locking compression plates are used at least two locking head screws are now inserted in the proximal and distal fragment of both plates.
The remaining screws are inserted taking care to avoid inadvertent contact with any previously inserted screw.
All screws are checked for tightness.
If only one plate is used, all remaining screws are inserted and solidly tightened. Where ever possible and needed additional cortex screws are inserted across fracture lines in lag fashion.
4. Skin closure
The longitudinally split common/long digital extensor tendon is sutured with a simple continuous suture pattern of a 2-O monofilament synthetic absorbable suture material. The subcutaneous tissues are subsequently closed in identical fashion as the tendon and the skin is closed with skin staples or simple interrupted monofilament nylon sutures.
The patient is kept in a box stall for one month with some hand grazing after two weeks. The bandage is maintained for 2-3 weeks and changes at 4-day intervals. At the end of the first month the patient is allowed some exercise in a small paddock for one additional month.
Follow up radiographs are taken 2 months postoperatively. The remaining postoperative period is managed dependent upon the result of the follow up radiographs.
More information about implant removal can be found here.