Internal fixation of radial shaft fractures: Anatomical and biomechanical principles
Authors:
J. Bartoníček 1,2; O. Naňka 2; M. Tuček 1
Authors‘ workplace:
Klinika ortopedie 1. LF UK a ÚVN Praha
přednosta: prof. MUDr. J. Bartoníček, DrSc.
1; Anatomický ústav 1. LF UK Praha
přednosta: prof. MUDr. K. Smetana, DrSc.
2
Published in:
Rozhl. Chir., 2015, roč. 94, č. 10, s. 425-436.
Category:
Monothematic special - Summary statement
Overview
Radius is a critical bone for functioning of the forearm and therefore its reconstruction following fracture of its shaft must be anatomical in all planes and along all axes. The method of choice is plate fixation. However, it is still associated with a number of unnecessary complications that were not resolved even by introduction of locking plates, but rather the opposite. All the more it is surprising that discussions about anatomical and biomechanical principles of plate fixation have been reduced to minimum or even neglected in the current literature. This applies primarily to the choice of the surgical approach, type of plate, site of its placement and contouring, its working length, number of screws and their distribution in the plate. At the same time it has to be taken into account that a plate used to fix radius is exposed to both bending and torsion stress. Based on our 30-year experience and analysis of literature we present our opinions on plate fixation of radial shaft fractures:
We always prefer the volar Henry approach as it allows expose almost the whole of radius, with a minimal risk of injury to the deep branch of the radial nerve.
The available studies have not so far found any substantial advantage of LCP plates as compared to 3.5mm DCP or 3.5mm LC DCP plates, quite the contrary. The reason is high rigidity of the locking plates, a determined trajectory of locking screws which is often unsuitable, mainly in plates placed on the anterior surface of the shaft, and failure to respect the physiological curvature of the radius. Therefore based on our experience we prefer “classical” 3.5mm DCP plates.
Volar placement of the plate, LCP in particular, is associated with a number of problems. The volar surface covered almost entirely by muscles, must be fully exposed which negatively affects blood supply to the bone. A straight plate, if longer, either lies with its central part partially off the bone and overlaps the interosseous border, or its ends overhang the bone laterally. In a locking plate with a fixed determined trajectory of screws, the locking screws in the central holes of the plate pass off the shaft centre only through a thin interosseous border (medial position), or screws at the ends of the plate are inserted eccentrically (lateral position). Both these techniques reduce stability of internal fixation. Where the plate overlaps the interosseous border, it is difficult to control the mutual rotation of the two main fragments. A shorter LCP plate increases rigidity of fixation, suppresses bone healing and often leads to non-union.
Placement of the plate on the lateral surface of the radius is more beneficial from the viewpoint of the bending and torsion stress. Lateral surface of the radius is a tension site, its distal half is not covered by muscles which eliminates the necessity to release them, the interosseous border is not obscured by plate and all this allows a safe control of rotational position of fragments. A properly pre-bent plate follows the physiological curvature of the lateral surface of the radius. Full tightening of standard screws will fix both main fragments firmly to the apex of plate concavity and increase stability of the internal fixation. Due to the shape of the cross-section of the radial shaft, the trajectory of screws is the longest in case of lateral placement of the plate, which increases rotational stability.
We place the plate always in a minimal three-hole length on each main fragment. Transverse two-fragment fractures may be fixed with a 2+2 configuration, i.e. with two screws on each main fragment. Fractures with an inter-fragment or comminuted zone are fixed in the 3+3 mode. More extensive comminutions, defects or segmental fractures require 4 plate holes on each fragment, but not more. When drilling screw holes the drill must be directed into the interosseous border. As a result, the screw has the longest trajectory and the best fixation in the bone. Perforation of the anterior or posterior surface of the radius considerably shortens the trajectory of the screw and thus reduces stability of internal fixation.
Key words:
radial shaft fractures − internal fixation − forearm fractures
Sources
1. Bartoníček J, Kozánek M, Jupiter J. History of operative treatment of diaphyseal fractures of the forearm. J Hand Surg Am 2014;39:335−42.
2. Stewart RL. Forearm fractures. In: Stannard PJ, Schmidt AH, Kregor PJ (eds). Surgical treatment of orthopaedic trauma. New York, Thieme 2007:340−63.
3. Jupiter JB. AO manual of fracture management − elbow and forearm. Stuttgart, Thieme 2009.
4. Morgan SJ. Forearm fractures: Open reduction internal fixation. In Wiss DA (ed): Fractures. Third edition. Philadelphia, Wolters Kluwer 2013:215−32.
5. Gaulke R. Diaphyseal fractures of the forearm. In Browner BD, Jupiter JB, Krettek Ch, Anderson PA (eds): Skeletal trauma. Philadelphia, Elsevir-Saunders 2015:1313−46.
6. Streubel PN, Pesántez RE. Diaphyseal fractures of radius and ulna. In Court-Brown CH, Heckman AD, McQueen MM, Ricci WM, Torneta P (eds). Rockwood and Green´s Fractures in Adults. 8th edition. Philadelphia, Wolters Kluwer 2015, 1121−78.
7. Müller ME, Allgöwer M, Willeneger H. Technik der operativen Frakturbehandlung. Berlin, Springer 1963.
8. Müller ME, Allgöwer M, Willeneger H. Manual der Osteosynthese. Berlin, Springer 1969.
9. Čech O, Stryhal F. Moderní osteosyntéza v traumatologii a ortopedii. Praha, Avicenum 1972:123−32.
10. Müller ME, Allgöwer, M, Willeneger H, et al. Manual der Osteosynthese. Berlin, Springer 1977.
11. Gross E. Osteosynthese bei Vorderarmfrakturen. (Bericht über 311 nachkontrolierte Fälle der AO). AO Bulletin Sommer 1979.
12. Čech O, Stryhal F, Beznoska S, et al. Stabilní osteosyntéza v traumatologii a ortopedii. Praha, Avicenum 1982:145−52.
13. Hager W (ed). Brüche und Verrenkungensbrüche des Unterarmschaftes. H Unfallheilkunde 201. Berlin, Springer 1986
14. Müller ME, Allgöwer M, Willeneger H, et al. Manual of internal fixation. Berlin, Springer 1991.
15. Heim U, Pfeifer KM. Periphere Osteosynthese. 4. Auflage. Berlin, Springer 1991:113−51.
16. Heim D. Forearm shaft fractures. In Rüedi T, Murphy WM (eds): AO principles of fracture management. New York, Thieme 2006:341−55.
17. Woo SLY, Lothringer KS, Akeson WH, et al. Less rigid fixation plates: historical perspectives and new concepts. J Orthop Res 1984;1:431−49.
18. Tornkvist H, Hearn TC, Schatzker J. The strength of plate fixation in relation to the number and spacing of bone screws. J Orthop Trauma1996;10:204–08.
19. ElMaraghy AW, ElMaraghy MW, Nousiainen M, et al. Influence of the number of cortices on the stiffness of plate fixation of diaphyseal fractures. J Orthop Trauma 2001;15:186–91.
20. Sanders R, Haidukewych GJ, Milne T, et al. Minimal versus maximal plate fixation techniques of the ulna: the biomechanical effect of number of screw and plate length. J Orthop Trauma 2002;16:166−71.
21. Oestern H-J, Unterarmschaftfrakturen. In: Schmit K-P, Towfigh H, Letsch R (Hrsg): Tscherne Unfalchirurgie. Ellenbogen, Unterarm, Hand. 1 Ellenbogen-Unteram. Berlin, Springer 2001:181−96.
22. Schulte LM, Meals CG, Neviaser RJ. Management of adult diaphyseal both-bone forearm fractures. J Am Acad Orthop Surg 2014;22:437−46.
23. Weckbach A, Blattert TR. Die Untearmschaftfraktur des Erwachsenen. Unfallchirurg 2002;73:627−41.
24. Anderson LD, Sisk D, Tooms RE, et al. Compression-plate fixation in acute diaphyseal fractures of the radius and ulna. J Bone Joint Surg 1975;57-A:287–97.
25. Hertel R, Pisan M, Lambert S, et la. Plate osteosynthesis of diaphyseal fractures of the radius and ulna. Injury 1996;27:545–8.
26. Leung F, Chow S-P. A prospective, randomized trial comparing the limited contact dynamic compression plate with the point contact fixator for forearm fractures. J Bone Joint Surg 2003;85-A:2343−8.
27. Crow BD, Mundis G, Anglen JO. Clinical results of minimal screw plate fixation of forearm fractures. Am J Orthop (Belle Mead NJ) 2007;36:477–80.
28. Stevejens CT, Ten Duis HJ. Plate osteosynthesis of simple forearm fractures: LCP versus DC plates. Acta Orthop Belg 2008;74:180−3.
29. Lindvall EM, Sagi HC. Selective screw placement in forearm compression plating: results of 75 consecutive fractures stabilized with 4 cortices of screw fixation on either side of the fracture. J Orthop Trauma 2006;20:157–62.
30. Henle P, Ortlieb K, Kuminack K, et al. Problems of bridging plate fixation for the treatment of forearm shaft fractures with the locking compression plate. Arch Orthop Trauma Surg 2011;131:85−91.
31. Bartoníček J. Operační přístupy u zlomenin hlavičky a diafýzy rádia. Acta Chir Orthop Traumol Čech 1988;55:497−516.
32. Bartoníček J, Jehlička D, Stehlík J. Dlahová osteosyntéza zlomenin proximální poloviny diafýzy radia. Acta Chir Orthop Tramatol Čech 1995;62:86−93.
33. Bartoníček J. Diafyzární zlomeniny předloktí. Acta Chir Orthop Traumatol Čech 2000;67:133−37.
34. Jo MJ, Tencer AE, Gardner MJ. Biomechanics of fractures and fracture fixation. In Court-Brown CH, Heckman AD, McQueen MM, Ricci WM, Tornetta P (eds). Rockwood and Green´s Fractures in Adults. 8th edition. Philadelphia, Wolters Kluwer 2015:1−42.
35. Schütz M, Rüedi TP. Principles of internal fixation. In Court-Brown CH, Heckman AD, McQueen MM, Ricci WM, Torneta P (eds). Rockwood and Green´s Fractures in Adults. 8th edition. Philadelphia, Wolters Kluwer 2015:155−94.
36. Perren SM. Evolution of the internal fixation of long bone fractures. The scientific basis of biological internal fixation: Choosing a new balance between stability and biology. J Bone Joint Surg 2002;84-B:1093−1100.
Labels
Surgery Orthopaedics Trauma surgeryArticle was published in
Perspectives in Surgery
2015 Issue 10
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