Plates come in several flavors, and are named for their function.
In
general, there are compression, neutralization and buttress plates.
Compression plates are used for fractures that are stable in compression.
They may be used in combination with lag screws, and they may provide
dynamic compression when used on the tension side of bone. The
dynamic compression plate is one of the most common types of plates,
and can be recognized by its special oval screw holes. These holes have a
special beveled floor to them with an inclined surface. If desired, this
inclined surface can be used to pull the ends of the bone together as the
screws are tightened.
Plates come in several flavors, and are named for their function. In
general, there are compression, neutralization and buttress plates.
Compression plates are used for fractures that are stable in compression.
They may be used in combination with lag screws, and they may provide
dynamic compression when used on the tension side of bone. The
dynamic compression plate is one of the most common types of plates,
and can be recognized by its special oval screw holes. These holes have a
special beveled floor to them with an inclined surface. If desired, this
inclined surface can be used to pull the ends of the bone together as the
screws are tightened.
dynamic compression plate (DCP) bridging a fibular fracture — the arrow
is pointing to a syndesmosis screw which is bridging the tibiofibular
syndesmosis, whose ligaments have been torn during the injury — also
noted is a medial malleolar fracture bridged by a screw channel, but
apparently little else. What is holding the parts of this fracture together?
the medial malleolar fracture above is held together by one of these
screws, made of a radiolucent polycarbonate material, which is designed
to eventually be absorbed by the body — this type of screw is known
locally as “stealth hardware”
A new variety of dynamic compression plate is currently undergoing trials
at UW. This variant is called a low contact dynamic compression plate
(LCDC plate). This plate is distinguished from the conventional DCP by the
way it is undercut under each screw hole and between adjacent screw
holes. The rationale for this design is as follows. Whenever one clamps a
plate down against the surface of a bone, one markedly diminishes the
periosteal blood supply to that area. Theoretically, one would expect this
to slow healing of the fracture beneath that plate. The undercutting of the
plate decreases the amount of contact that the plate makes with the bone
surface, and hopefully will increase the periosteal blood supply and, it is
hoped, fracture healing as well.
under surface of a low contact dynamic compression (LCDC) plate showing
the typical undercutting beneath each screw hole and between each screw
hole
low contact dynamic compression (LCDC) plate bridging a humeral shaft
fracture — note the undercutting between each screw hole — also noted
is a humeral fracture through the distalmost screw hole
Another type of plate seen commonly at UW is the reconstruction plate,
which is widely used for the repair of pelvic and calcaneal fractures. This
plate is fairly malleable, and can be readily shaped and trimmed to length
for support of fractures through complex bony surfaces. These are also
occasionally used for posterior fusion of the cervical spine.
reconstruction plate
right acetabular fracture bridged by two reconstruction plates and
multiple screws — the extra plate seen laterally is probably a spring plate
— also noted is the proximal end of an intramedullary femoral nail
Neutralization plates are designed to protect fracture surfaces from
normal bending, rotation and axial loading forces They are often used in
combination with lag screws.
Buttress plates are used to support bone that is unstable in compression
or axial loading. These plates are often used in the distal radius and tibial
plateau to hold impacted and depressed fragments in position once they
have been elevated.
buttress plate bridging a humeral neck fracture — note that 2 of the 3
most proximal screws have backed out (they are loose!) and that 2 of
them may penetrate into the joint space
Yet another type of plate commonly seen on postoperative films is the
blade plate. This plate is usually shaped at an oblique or right angle and is
designed to be used with subtrochanteric femoral fractures or
supracondylar fractures of the femur. It is also occasionally used to bridge
a femoral osteotomy. One arm of this device has a chisel-shaped end that
is driven into the bone, bridging the fracture. The other arm is used as a
side plate and anchored to the bone with multiple screws.
blade plate bridging a distal femoral fracture — note that the distalmost
screw is broken, and the plate itself is broken just above the fracture line
at a screw hole — a broken screw fragment is also noted proximally from
a previous fixation attempt — a channel is also noted distal to the current
blade plate secondary to a previous failed blade plate
There are a variety of devices used to treat femoral fractures. The blade
plate above and the Jewett nail below are not used so commonly these
days, but patients still walk into orthopedic clinic wearing these devices
every day. The most common device used nowadays is the dynamic hip
screw, also shown below. Its main design goals are to resist angular
deformation while permitting early fracture impaction by allowing
shortening along the axis of the lag screw. This device is specifically
designed to treat intertrochanteric fractures, but is occasionally used to
treat subtrochanteric fractures as well. Like the blade plate, it has a side
plate that is attached to the distal femur with several cortical screws.
Rather than a blade, this plate has a hollow metal barrel through which a
large lag screw is placed. This large lag screw is placed so that it bridges
the femoral fracture. Ideally, this lag screw should go right down the
center of the femoral neck on every radiographic view, and its tip should
be in the subchondral bone of the femoral head. The hollow barrel of the
side plate holds the lag screw, and hence the femoral neck and head at an
anatomic angle for healing. It also allows the lag screw to slide distally as
the ends of the fracture impact and the fracture fragments move closer
together. When followed over time, is quite common to see evidence of
this impaction as the lag screw telescopes down into the barrel of the side
plate. The average amount of impaction seen with these devices is about 7
mm.
a comminuted intertrochanteric fracture of the proximal left femur
bridged by a dynamic hip screw
These devices can fail just like any other device. The cortical screws
holding the sideplate to the bone may come loose. The sideplate may
fracture at a screw hole. The lag screw may perforate the articular surface
of the femur. These complications and many more await the eagle-eyed
radiologist.
Dynamic hip screws (DHS) are a popular device used to bridge fractures of
the well-vascularized intertrochanteric area. However, when the fracture
occurs a bit more proximally in the femoral neck, parallel screw fixation is
often used instead. The rationale here is that the parallel screws will cause
less trauma to the tenuously supplied proximal head and neck fragment
than a larger screw such as the DHS. If the screws are placed parallel to
each other, they can allow the fragments of bone to impact together,
much as a DHS will. Knowles pins, (shown below) were once commonly
used for this purpose, although other types of screws are more commonly
used today.
Knowles pins bridging the right physeal line in a patient with a slipped
femoral capital epiphysis
Parallel screw fixation of a femoral neck fracture with cannulated screws
Another type of pin used currently at Harborview is the percutaneous pin.
They are commonly used there to treat humeral neck fractures. These
pins have a self-threading screw tip and are placed under C-arm
fluoroscopy.
comminuted fracture of the surgical neck of the humerus bridged by four
percutaneous pins
Wires
A variety of wires are used by orthopedic surgeons. One common type is
the cerclage wire, in which the wire is placed around the circumference of
the bone to pull various fracture fragments together. In the example
below, two cerclage wires are used in conjunction with an intramedullary
nail to provide support for the comminuted fragments above the
transverse fracture.
femoral fracture bridged by an intramedullary nail and two cerclage wires
Yet another type of wiring seen in orthopedic surgery is called tension
band wiring. This type of wiring may be placed either by itself, as shown in
the patellar fracture below, or in conjunction with a screw or Kirschner
wire. These tension band wires perform a sort of “biomechanical judo”, in
that they take the normal muscular pull that is trying to pull the fracture
fragments apart, and use it in a clever way to force the bony fragments
together in compression. In the example below, one can see that the
actual location of the tension band wire is important. If the wire is placed
too far posteriorly (left drawing), the muscular pull on the wire will cause
the fracture to gape open anteriorly (distraction). When the wires are
placed far enough anteriorly (right drawing), the muscular pull now causes
the patellar fragments to be pushed firmly together in compression.
patellar fracture bridged by tension band wire
This same sort of biomechanical judo is employed when the tension band
wire is used with a wire or screw. In the example below, a fracture is seen
through the olecranon process. In a situation like this, the triceps muscle
group will exert a large force tending to pull the proximal fragment far
away from the rest of the ulna. Even when the fracture has been bridged
by one or more screws, there is a tendency for these screws to be pulled
out by the triceps. The addition of a tension band wire as shown below will
convert some of the triceps traction into compression of the ends of the
bone together and prevent the screw from pulling out.
olecranon fracture bridged by cancellous screw and tension band wire
As I have already alluded, the Kirschner or “K” wires are a very handy
device in the hands of the orthopedist. Besides their usage with
cannulated screws, they are used in many other ways to help reduce and
stabilize fractures. A K wire is essentially an unthreaded segment of
extruded wire which is drilled into bone like a drill bit. The major
advantage of a K wire is that it is very small and relatively noninvasive as
hardware goes. It can be placed through an articular surface or even
across an open physeal plate without injury. K wires can be used for either
temporary or final stabilization. They can be placed between bones as
shown below, or they can be used as an intramedullary device to bridge a
fracture of a small tubular bone. They are commonly used to help piece all
of the fragments of a comminuted fracture prior to placement of the final
fixation device, especially with an intraarticular fracture.
Kirschner wires (“K” wires) used to stabilize a distal radial fracture
Rods & Nails
A large variety or devices are placed down the intramedullary canal of
bones, ranging from Kirschner wires up to large femoral nails. One can
generally classify these devices by whether intramedullary reaming is
necessary prior to placement of the device. With the first nails placed
down the femoral shaft, the medullary space first had to be reamed out so
that the large nail would not shatter the bone as it was hammered down
the shaft. However, reaming is an invasive procedure, and can
compromise the already tenuous blood supply of the medullary space.
Reaming can also lead to thermal osteonecrosis, especially if the
medullary canal is small, a tourniquet is used during reaming, or there is
marked soft tissue injury. If intraosseous pressure becomes elevated
during reaming, fat emboli to the lungs are possible. For these reasons, a
variety of unreamed devices have been developed. The Rush rod, shown
below, has a chisel-like tip, and is commonly used for fibular shaft
fractures, and occasionally in other tubular bones as well.
Rush rod bridging a distal fibular fracture
Another type of unreamed nail is the Ender nail. These nails also have a
chisel-like end. These nails are usually used three or four at a time, and
pushed through a cortical hole up or down the shaft of the bone and
across the fracture under fluoroscopic control.
Ender nails bridging a femoral shaft fracture with subsequent callus
formation
The odds-on favorite nowadays for fixation of fractures of the femoral or
tibial shaft is a reamed or unreamed nail like the ones shown below.
These nails permit early weight-bearing and can be placed with closed
technique, which avoids damage to soft tissue and to the periosteal and
muscular blood supply. If the fracture is transverse and otherwise
uncomplicated (not comminuted, rotated or too near the end of the bone),
the nail may be placed by itself. However, interlocking screws are very
commonly added both proximally and distally to provide stability in cases
of comminution, and to prevent shortening of the bone or rotation of the
fracture fragments. When these screws are used, the nail is commonly
referred to as an “interlocking” nail.
Segmental fracture of the tibia, bridged by an intramedullary nail with a
proximal interlocking screw — the distal interlocking screws have been
removed
Subtrochanteric fractures are a particularly difficult type of fracture to
treat, and they behave very differently from a garden variety
intertrochanteric fracture. In the latter fracture type, a dynamic hip screw
(DHS) can be used to merely provide angular support. Longitudinal
support by the DHS is not as important in this fracture type, since the
ends of the bone tend to impact against each other in a stable manner.
Subtrochanteric fractures, on the other hand, put a huge stress on a DHS,
especially along the sideplate. For this reason, special nails such as the
Zickel nail shown below and the gamma nail have been developed. These
devices are much stronger devices than the DHS, and offer a much shorter
moment arm for rotational forces to act upon than the DHS. On the minus
side, these nails are also more invasive.
Zickel nail bridging a subtrochanteric fracture
Spinal Fixation Devices
The prototypical spinal fixation device is the venerable Harrington rod.
These tend to come in two flavors: distraction and compression. The
hooks are designed to be placed under the lamina or transverse
processes, and the device is either extended or compressed to the desired
position. Sometimes both types of rods will be used in the same spine.
Harrington distraction rod and compression rod
patient with thoracic scoliosis, convex to the right, bridged by a Harrington
rod and bone graft along the concave side of the spine
bilateral Edwards rods bridging a spinal fracture
Harrington and Edwards rods have been largely superseded by other
newer devices. The most common spinal fixator that I see these days is
some form of posterior spinal rod. These rods are usually used in pairs,
and are attached to pedicular screws which are anchored in multiple
vertebral bodies above and below the site of treatment.
The images above are anteroposterior (AP) and lateral views of bilateral
posterior spinal rods bridging L4, L5 and S1. This patient underwent spinal
fusion following a laminectomy done for spinal stenosis. The small metal
cage seen in the L5-S1 disk space contains bone graft material which will
hopefully promote osseous fusion at this site.
External Fixation
All things being equal, orthopedists generally prefer to treat fractures in a
closed fashion. Failing that, they would prefer to treat them with internal
fixation. However, sometimes there are extenuating circumstances that
preclude the use of internal fixation. External fixators can be very helpful
in these circumstances.
Indications for External Fixation
Open fracture with massive soft tissue damage
To provide instant fixation in cases of polytrauma
May be the only way to treat fractures with deficient bone stock or
infection (external fixation allows easy access to wounds)
The weak link in the external fixation system are the threaded pins that
are anchored in the bone. These pins should pass through the cortex on
either side of the medullary space, and only a few millimeters of the pin
tip should ideally protrude through the distal cortex. The usual
complications of this fixation system are loosening or infection (or both) of
the pins. Lucency developing about a pin as it travels through the cortex is
evidence of loosening of that pin. Infection is a much harder diagnosis to
make radiographically. Long before signs of radiographic infection
develop, the orthopedist will make the diagnosis by seeing pus oozing up
along the pins as they exit the skin. Even the presence of periosteal new
bone formation about the pin tracts is unhelpful, since these drilled holes
are after all fractures of a sort, and fractures do produce callus, even
without infection.
external fixator bridging a tibial fracture
external fixator bridging an unstable distal radial fracture
There is one late finding which is said to be pathognomonic of pin tract
infection. This has been termed the “ring” sequestrum sign, although the
sequestrae thus formed actually are shaped like cylinders, rather than
rings. The appearance of this finding is due to the particular geometry of a
pin and pin tract, which are cylindrical in shape. As a pin tract becomes
infected, the bone immediately adjacent to the pin becomes infected first,
and a certain amount of it dies. The viable bone adjacent to this infected
dead bone then becomes hyperemic and becomes relatively osteopenic.
The infected dead bone remains at its original density. Once the pin has
been removed, if one looks directly down the pin tract with a radiograph,
this cylinder of dead bone looks like a “ring”. Occasionally, such a cylinder
will be dense enough to also be seen when viewed at 90 degrees to the
pin tract, and it presents as two parallel dense lines surrounded by lucent
zones.
