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