Authors of section

Authors

Jörg Auer, Larry Bramlage, Patricia Hogan, Alan Ruggles, Jeffrey Watkins

Executive Editor

Jörg Auer

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Double-plate fixation

1. Principles

Complete cartilage removal

Complete cartilage removal is important to provide for maximum contact between the opposing subchondral bone plates. With compression, generated by the fixation technique, frictional forces are generated between the subchondral bone plates, which maximizes strength and stability of the fixation, providing maximum patient comfort and allowing early removal of postoperative cast support.

Complete cartilage removal...

Plate placement

The implant positioning in the middle phalanx is in the proximal epiphyseal region. The distal end of the plates should not impinge on the proximal attachment of the distal interphalangeal joint capsule and should be positioned abaxially to avoid the extensor process. The distal plate screw should engage a substantial portion of the palmar/plantar eminence fragment provide maximum strength of the fixation.

double plate fixation

Further considerations

It is important, that the screws through the distal aspect of the plates engage the eminence fragments to provide for reestablishment of the palmar/plantar support and to reduce the fractures on the palmar/plantar aspect of the middle phalanx.
Alignment of the proximal articular fracture components indirectly establishes alignment of the distal articular fractures except in cases of major comminution at the distal interphalangeal joint.
Two plates are necessary to neutralize the bending forces acting across the pastern joint and provide transarticular compression to encourage arthrodesis.

It is important, that the screws through the distal aspect of the plates engage the eminence fragments

AO teaching videos

Middle phalanx fracture arthrodesis using two 3-hole 4.5 LC-DCPs and lag screws

2. Preparation and approach

With the appropriate preparation and draping of the surgical site, this procedure is performed with the patient placed in lateral recumbency and through the dorsal approach.

plate fixation transarticular lag screws

3. Reduction and fixation of the major central axial eminence fragment

In most cases, the proximal articular surface of the middle phalanx is reconstructed with the joint dorsally luxated to allow direct visualization of the major fracture fragments.
Alignment is generally achieved through a combination of flexion and extension of the digit and placement of large pointed reduction forceps to engage the major eminence fragments from dorsal to palmar/plantar.

In most cases, the proximal articular surface of the middle phalanx is reconstructed with the joint dorsally luxated...

Once the major central axial eminence fragment is reduced a 4.5 mm cortex screw is placed in lag fashion from dorsal to palmar/plantar to compress the reduced fracture fragments.

Once the major central axial eminence fragment is reduced a 4.5 mm cortex screw is placed in lag fashion...

4. Plate preparation

Plate selection

A combination of PIP plates and/or 4-5 hole narrow LCP are used in most cases. Other plate constructs have been used successfully, including narrow, 4.5 mm DCPs and LC/DCPs.
The technique for fixation with DCP or LC/DCP is described for uniaxial eminence fractures as an example. For more details click here.

Show plate

The plates are contoured to approximate the dorsal surface of the distal proximal phalanx and proximal middle phalanx with the stacked combi-hole into the plate positioned over the proximal end of middle phalanx.
The distal end of the plate is then bent slightly to ensure that the middle phalangeal plate screw is directed into the major substance of the eminence fragment.

Note: Plate contouring of DCPs and LC-DCPs is identical but there are not drill guides that screw into the plate holes.
Plate bending

5. Reduction and Fixation

Reduction and placement of the first plate

Usually, the second eminence fracture can be reduced with a pointed reduction forceps. Once reduced, either a 5.5 mm or a 5.0 mm locking head screw is positioned through the distal hole of the first plate. This screw is located abaxial to the first screw and engages the major eminence fracture fragment that has not been stabilized by the axial lag screw.

Usually, the second eminence fracture ...

Application of the second plate

The second plate is applied on the opposite abaxial side and, the distal screw engages the eminence fragment.

The second plate is applied on the opposite abaxial side and, the distal screw engages the eminence fragment.
double plate fixation

Fixation to the proximal phalanx

The middle and proximal phalanges are realigned and the plates fixed to the proximal phalanx using 5.5 mm cortex screws placed in a load position in the second hole proximal to the joint.

The middle and proximal phalanges are...

The remaining holes are filled with locking screws with both juxta-articular locking screws placed bicortically and the proximal most locking screw in a four hole plate monocortically.

Note: If DCPs or LC-DCPs are used only 4.5 mm or 5.5 mm cortex screws are used in all plate holes.

The remaining holes are filled with locking screws ...

Additional screw

There are cases where it is beneficial to put an additional screw into major fracture fragments. This screw is placed through a stab incision with careful intraoperative radiographic or fluoroscopic control to ensure precise positioning.

There are cases where it is beneficial to put an additional screw into major fracture fragments.

Note: This fracture was repaired with a 4-hole and a 3-hole narrow DCP with 5.5 mm cortex and 4.5 mm cortex screws.

double plate fixation

Confirmation

The final construct configuration is checked with appropriate imaging to ensure appropriate length and positioning of all implants.
It is important that screws of appropriate length are used and that they do not protrude significantly beyond the palmar/plantar cortex of the proximal and middle phalanges.

Note: This was repaired with a 4-hole PIP and a 3-hole DCP in addition to a 5.5mm cortex screw.

The final construct configuration is confirmed with appropriate imaging to ensure appropriate length and positioning of all impl

6. Aftercare

The horse is put in a half-limb cast for recovery.
This cast is changed 2-3 weeks post surgery. The horse is maintained in the second cast or a bandage cast for an additional 3-6 weeks, depending on the perceived strength and stability of the fixation and horse’s progress postoperatively.
The horse is confined in the stall for 3 months. After 6 weeks, providing the horse’s clinical and radiographic progress is satisfactory, hand-walking exercises are introduced.
After 3 months, including the 6 weeks of hand-walking exercise, gradual access to free paddock activity is allowed providing the clinical and radiographic progress is satisfactory.

plate fixation transarticular lag screws