Anatomic fracture reduction is a valuable tool in the arsenal of any orthopaedic surgeon responsible for fracture care. Primary bone healing, or Haversian remolding, occurs in response to a low strain environment with anatomic reduction and absolute stability constructs. Simple diaphyseal fractures will have a high strain environment if not fixed anatomically, but once able to get the anatomic reduction and fix it with interfragmentary compression by lag screw and neutralization plate, then absolute stability is created and the strain at the fracture site decreases. 1 Occasionally, anatomic constructs can be difficult to achieve even when indicated by preoperative imaging. When difficulty arises, we have found that minifragmentary plating can be a valuable reduction tool while attempting an intraoperative definitive surgical construct. Using unicortical plates to help with provisional reductions have been shown to help with metaphyseal, diaphyseal, peri-articular and acetabulum fractures.2 These provisional plates can even be used through open fracture wounds or through the planned surgical incisions, and are ideal if there is no additional dissection needed. 3 The unicortical plates discussed in current techniques can be applied extramedullary or intramedullary and about half will be removed at the end of the case depending on fracture stability and difficulty in reduction.2
We present a novel technique for obtaining anatomic fracture reduction using intramedullary minifragmentary plate fixation in two distinct cases.
Diaphyseal fractures where anatomic reduction is possible from preoperative planning by imaging, but common preliminary reduction techniques with clamps, joysticks, k-wires, external fixator, traction, or direct/indirect manipulation is difficult. If there is access to the intramedullary canal due to the fracture characteristics such as large butterfly or wedge fragments, then application of a minifragmentary plate in the canal to assist with the reduction is an option. When extramedullary minifragmentary plating would be in the way of the final construct if used, but canal access is possible, an intramedullary minifragmentary plate can be used.
Fracture patterns that do not allow access to the intramedullary canal without having to cut bone or disrupt significant soft tissue biology around the bone. Articular fractures or fractures of the acetabulum or pelvis. Comminuted fracture patterns or fractures with bone loss that are not amenable to anatomic reduction based off preoperative imaging.
In both cases presented later, the Stryker Variax 2.3mm minifragmentary plating system was used. However, any minifragmentary plating system would suffice. The plate should be placed on the intramedullary cortex across the fracture line that needs reduction. Even though anatomic reduction of this fracture component is preferred, it is still possible to compress the fracture since this intramedullary plate is not a rigid construct. We recommend a flexible plating system, under 2.4mm, so there is still some room to “fine tune” the fracture should it be necessary. Short, unicortical screws can be utilized, usually 6mm, even in larger long bones such as the femur. We do not recommend more than three screws on either side of the fracture in an effort to keep the construct less rigid. Final construct placement should always be taken into consideration so the intramedullary plate does not interfere with final construct placement and screw trajectory.
The main advantage of this technique is a biologically friendly approach to obtaining fracture reduction. In the first case presented, anatomic metatarsal length could not be maintained with an external fixation system alone and the soft tissue environment did not initially allow extramedullary plating. In case two below, it would not have been possible to place a medial plate on the femoral shaft without significant soft tissue disruption. The intramedullary surface is readily accessible, does not require a soft tissue dissection and allows a temporary reduction of fracture fragments when attempting an anatomic fracture reduction construct. We do not routinely use this technique but have found it to be very useful when having difficulty obtaining anatomic fixation.
The first case is a thirty-one-year-old male who sustained a gunshot injury to his right first metatarsal with significant bone loss in the metatarsal shaft (Figure 1). This patient was brought to the operative room for an initial irrigation and debridement. Due to his soft tissue envelope, dorsal plating was not possible at the time of this initial surgery. The application of a Stryker Hoffman micro external fixation system did not allow the maintenance of the anatomic length of the metatarsal shaft (Figure 2) so a Stryker Variax 2.3mm minifragmentary plate was placed on the intramedullary side of the lateral cortex of the metatarsal. This plate in conjunction with the external fixator allowed for anatomic metatarsal length restoration (Figure 3). An antibiotic spacer was then inserted within the bone defect (Figure 4 and 5). The patient was kept non-weight bearing in this post-operative period.
The second case involved an eighty-eight-year-old female who fell from a standing height and suffered a periprosthetic femoral shaft fracture below a short cephalomedullary implant and above a total knee arthroplasty (Figure 7 and 8). Preoperative imaging demonstrated a simple butterfly fragment so it was felt that anatomic reduction was indicated. Utilizing an extensile lateral approach to the femoral shaft, the femur was exposed, and anatomic restoration was attempted. Due to the fracture characteristics, it was difficult to anatomically reduce the lateral butterfly fragment while maintaining a medial fracture reduction; therefore, a Stryker Variax 2.3mm minifragmentary plate was secured to the intramedullary side of the medial cortex. This allowed the lateral butterfly fragment to be reduced and secured with 3.5mm cortical screws placed with a lag technique all while maintaining the medial femoral length (Figure 9). A long periprosthetic distal femur plate was then applied to the lateral cortex of the femur as the definitive construct (Figure 10).
Pearls and Pitfalls
- Use minifragmentary plating system
- Unicortical screws (about 6mm)
- No more than 3 screws on either side of the fracture line for less rigid construct
- Keep final fixation construct in mind
- Limited access to intramedullary canal to get enough screws in
- Gets in way of definitive fixation with either plate or nail
- Periosteal stripping or increased soft tissue dissection to gain access to canal
- Difficult hardware removal if hardware breaks or gets infected
The patient in case one was brought back to the operating room for removal of the external fixation at approximately eight weeks in an attempt to give him a “Pin Holiday” as well as treat his pin tract infection which resolved with antibiotics after the removal of the external fixation.
He again returned to the operating room six weeks later for definitive surgical fixation with removal of the antibiotic spacer, removal of the intramedullary plate, bridge plating technique on the dorsal cortex of the first metatarsal as well as an iliac crest bone graft (Figure 6).
At eight months follow up, the first patient is healed and ambulating without difficulty.
The patient in case two was unfortunately lost to follow-up.
- Schutz M and Ruedi TP: Principles of Internal Fixation, in Court-Brown CM, Heckman JD, McQueen MM, Ricci WM, Tornetta III P, McKee M, eds: Rockwood and Green’s Fractures in Adults, ed 8. Philadelphia, PA, Wolters Kluwer Health, 2015, vol 1, pp 195-226.
- Archdeacon MT, Wyrick JD: Reduction Plating for Provisional Fracture Fixation. J Orthop Trauma 2006 Mar;20(3):206-11.
- Evans AR, Henley MB: Tibial Shaft Fractures, in Gardner MJ, Henley MB: Harborview Illustrated Tips and Tricks in Fracture Surgery, Baltimore, MD, Philadelphia, PA, Lippincott Williams & Wilkins, a Wolters Kluwer business, 2011, pp 277-301.