Fracture Plating
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The various bones and fracture positions dictate the different types of plate available. The DCP or dynamic compression plate and the screw holes allow compression of the fracture site to be applied as the screws are tightened up in the angled screw holes. Small plates are used to fix the lateral malleolus of the ankle and the wrist end of the ulna forearm bone and for this job they are often very thin at an easily mouldable one millimetre. Other plates have been designed for use in fractures close to joints and these have reduced device size and thickness and added options for the flexibility in fixation required.
Fractures of the upper femur are fixed by using plates with a 95 degree angle so that the mechanical axis of the upper femur can be restored at this angle. Inserting this kind of fixation requires that the surgeon thinks in three dimensions as are all must be correctly aligned to restore normal anatomy. Reconstruction plates are less thick than dynamic compression plates and can be contoured in three dimensions for the acetabulum and pelvis. Fractures close to or next to prostheses such as hip replacements or knee replacements are fixed with larger plates with the addition of cerclage wires.
Strong fragment compression and close anatomical restoration of normal alignment can lead to a very stable fixation and if this is produced by the fixation then primary healing will be the main healing process. There is dead bone close to the fracture site and this is absorbed by bone absorbing cells known as osteoclasts, after which blood vessels grow in along with bone producing cells known as osteoblasts. Osteoporosis under a plate can occur from the interruption in blood supply which can be produced by the fixation. Once the plate is removed the bone is less strong and along with the screw holes this means care needs to be taken in physiotherapy for the patient because of this.
In normal fixation using a plate the area is opened up and the blood clot is removed and the fracture fragments are restored to the best anatomical alignment possible. After a fracture the blood supply through the bone has been interrupted so the main blood supply around the fracture comes from the periosteum, the bone membrane lining. It is essential that this membrane is not disturbed or stripped off in the operation as this could reduce the blood supply to the fracture area and delay healing. If unstable fractures with many fragments are to be fixed then a plate which bridges across the gap can be used, with limited operative exposure. It is fixed to the major fragments and works by keeping the bone length, alignment and rotation but cannot suffer much in the way of load.
The Less Invasive Surgical Stabilisation plating system (LISS) is a modern fixation system which limits the contact between the metal and the bone, lowering the risks of the blood supply in the damaged area becoming compromised. These designs are more mouldable to the bony contours and have the ability to apply locking screws, allowing these designs to keep the desired bony alignment whilst simultaneously managing to resist significant forces during the period of healing. Choice of these newer designs is indicated in managing fractures of the end of bones such as the radius, humerus and femur.
If there is enough room for easy fixation and the fracture is of a more stable type then conventional plating techniques may be used for fixing breaks of the shafts of bones such as the radius, ulna and humerus. Locking screws are more appropriate if the bone is osteoporotic or the fixation options are limited. Future development will likely lead towards locking techniques being the first option for all fractures, but they are much more expensive and wider use awaits reduction in costs. If the costs of revising the fixation due to malunion by conventional plating are factored in then the more expensive initial system looks more cost neutral.
Nails
It was in the 1930s that Kuntscher refined the intramedullary nailing technique which then became the treatment of choice for shaft fractures of the femur. Humeral and tibial fractures as well as femoral breaks nearer the bone ends were the next progression. Early joint movement and weight bearing walking is allowed by this.
Article Source: Articlelogy.com
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