2. Objectives
ā¢ Identify what fracture patterns are best suited for
relatively stable fixation techniques
ā¢ Identify two common extramedullary techniques for
obtaining relative stability
ā¢ Identify several fundamental features of bridge plating
ā¢ Understand several surgical techniques unique to bridge
plating
3. Relative stabilityāreview
ā¢ Applied load to fracture exceeds the preload
ā¢ Small amount of motion between fragments leads to
callus formation and āindirect bone healingā
ā¢ Healing occurs if the interfragmental strain remains
below the critical strain level for the repair tissue
ā¢ The more fragments present, the less strain between
fragments and the less rigid the construct requirement
4. Ideal fracture patterns for ārelatively
stableā fixation methods
ā¢ Multifragmentary
diaphyseal fractures
ā¢ Multifragmentary
metaphyseal fractures
ā¢ Not amenable to anatomical
reduction and absolute stability
6. Aim of technique
ā¢ To preserve the vascularity of the fracture site and
fracture fragments
ā¢ To provide sufficient stabilization to promote union
7. External fixation
ā¢ External fixator may be used as provisional or definitive
management of fracture
ā¢ Provisional fixators are used mainly to treat the soft
tissues
ā¢ Definitive fixators treat both bone and soft tissues
14. Relative stability: plates
ā¢ Extraperiosteal exposure of bone
ā¢ Indirect reduction to achieve anatomic alignment
ā¢ Implants that minimize bone necrosis
ā¢ Longer plates
ā¢ Judicious use of screws with balanced fixation
ā¢ Infrequent bone grafting
15. Epiperiosteal exposure of bone
ā¢ Fractures disrupt the normal blood
supply to bone (predominantly
intramedullary via nutrient artery)
16. Epiperiosteal exposure of bone
ā¢ After fracture the surrounding soft tissues provide an
ā¢ extraosseous blood supply
ā¢ Proliferation of periosteal osteoblasts occur when
vessels
ā¢ grow from the musculature to the periosteum
17. Epiperiosteal exposure of bone
ā¢ Damage to the periosteum:
ā¢ Escape of hematoma
ā¢ Diffusion of pluripotent mesenchymal cells
ā¢ Necrosis at the fracture site
21. Implants that minimize bone necrosis
Limited contact dynamic compression plate
LC-DCP
Less invasive stabilization system LISS
22.
23. Fewer screws/longer plates
ā¢ Longer plates improve the construct by increasing the
lever arm of the plate
ā¢ Longer plates require fewer screws to achieve optimal
fixation (near fracture and farthest from fracture)
ā¢ The strain on longer plates is reduced as is the strain on
the screws
ā¢ Fewer screws minimize damage to the bone
ā¢ A tensioned plate without lag screws acts as an elastic
but rigid spring
26. Bone grafting is unnecessary
Rozbruch et al, 1998
ā¢ Incidence of primary bone grafting femoral
ā¢ Shaft fractures: 16% to 4%
Krettek et al, 1997
ā¢ 92% union in proximal and distal femur fractures without
bone grafting
Kregor et al, 1999
ā¢ 97% union rate (Type A and C supracondylar femoral
fractures) without bone grafting
27. Planning and reduction technique in
fracture surgery
ā¢ Fracture configuration
ā¢ Implant templates
ā¢ Plan fixation construct
ā¢ Step-by-step operative plan (open vs MIPO)
46. Summaryārelative stability using
extramedullary techniques (plating)
ā¢ Extraperiosteal exposure of bone
ā¢ Indirect reduction to achieve anatomical alignment
ā¢ Implants that minimize bone necrosis
ā¢ Longer plates
ā¢ Judicious use of screws with balanced fixation
ā¢ Infrequent bone grafting