Role of locking compression plate in long bone fractures in adults - a ...
Role of locking compression plate in long bone fractures in adults - a ... Role of locking compression plate in long bone fractures in adults - a ...
Walia et al without radial nerve exploration for humerus and lateral approach for fracture shaft femur was taken. Fracture tibia was approached anterolaterally. All the fractures were fixed with LCPs taking care to protect the periosteal blood supply. Bone grafting was done in old ununited fractures and in fresh cases with fracture comminution of high grade. Internal fixation in open fractures was carried out after thorough irrigation and debridement. Splintage and immobilization was applied as per fixation achieved. Early range of motion exercises were started where a stable construct was achieved. RESULT Table 1 Fracture Location Fig. 1: LCP in tibia Preoperative and post-operative Xrays No. Fresh Non-union Closed Open Femur 25 19 4 2 Tibia 15 6 5 4 Humerus 10 5 1 4 60% of cases were of closed nature. All 4 femur open fractures were Gustillo Grade III open while 1 tibial and I humeral fracture was grade III. Four tibial fractures were grade 1 open. 20% of cases were old ununited fractures. The age group of the patients in this study varied between 18-70 years (average 53.1 years) with majority of the patients in fifth to seventh decade of life. Follow-up in our series ranged from 6-24 months. All fractures united in this series without the need for any supplemental procedure. The average time for union in fresh femur fractures was 16.4 weeks. 2 of the 4 open fractures and 1 of 2 non-unions in femur took more than 20 weeks to unite. The average time for union of fresh tibial fractures was 17.1 weeks while the non-unions united in an average of 17.75 weeks. The average time of union for fresh humeral fractures was 13.3 weeks. The union time in non unions ranged from 12 to 20 weeks with a mean of 15.25 weeks Full weight bearing in cases of fracture tibia and femur was done in 14 cases within 12-16 weeks, 20 cases within 17-20 weeks and in 2 cases after 20 weeks. Range of motion at knee in femoral fractures was more than 90 degrees in 90% of the cases. Range of abduction was more than 140 degrees in 80 % of the cases with fracture shaft humerus and elbow flexion was more than 90 degrees in 85% of the cases. Fig. 2: LCP in femur pre and post operativeX rays Fig. 3: Three months follow up X ray of proximal humerus fracture Pb Journal of Orthopaedics Vol-XI, No.1, 2009 42
Role of locking compression plate in long bone fractures in adults 2 cases had wound infection problems which healed with antibiotics and local wound care. Shortening was present in one case that was operated more than 40 days after injury with considerable fibrosis and overlapping of fragments; shortening was done in this case to achieve compression at the fracture site. Results were unsatisfactory in 2 cases of fracture humerus as both of them were having concomitant injury to the ipsilateral elbow, which hampered early rehabilitation. Evaluation of the results of fracture femur and tibia was done by Modified Mehrotra’s grading. According to this grading, 72% of the cases achieved excellent results, 20% fair and 8% poor. In case with humerus fractures achieved 80% satisfactory and 20% unsatisfactory. DISCUSSION Locking compression plates have been designed to overcome the pitfalls of conventional plates particularly when dealing with difficult problems such as comminuted, metaphyseal and osteoporotic fractures. Locked plates have become an attractive alternative to conventional plates as they can be used as “bridge plates” to preserve fragmentary blood supply, they provide fixed angular stability with the potential for improved fixation in osteoporotic bone, and they reduce the risk of primary loss of reduction as exact plate-contouring is not required 5 Wagner(2003) in his paper on general principles for the clinical use of locking compression plate, made comment that Internal fixator (A term used for locking compression plates) is a construct in which the screws (Pins/Bolts) are locked in the plate (Frame). Forces are transferred from the bone to the screw plate threaded connection. Rigid compression of the Plate on the bone is therefore not required to achieve stability. Locking the screw in the internal fixator increases the stability, and the risk of loss of reduction due to the toggling of the screws is eliminated 3 . Numerous case series have reported the successful use of LCPs in a variety of clinical situations such as metaphyseal fractures, intraarticular fractures, fractures in osteoporotic bones as well as difficult non-unuions 6-10. In our study, we found that the implant with locking head screw, when used in difficult fractures like type C3 provided good fixation. Even in osteoporotic bones, the locking implant provided good anchorage. With locked fixation, a good purchase is achieved between the threaded plate and threaded screw head. The screws virtually act as pegs resisting axial rotation, translation and bending, in porotic bone 10 . In our study we found that we could achieve union in all the nonunions and comminuted fractures. This compares well to the reported results in literatures 11.12 . In conclusion, it can be said that, if biomechanical principles are followed, locking plates provide excellent fixation in difficult situations like comminuted fractures, osteoporotic fractures and periarticular fractures. REFERENCES 1. Smith WR, Ziran BH, Anglen JO and Stahel PF:Locking plates: tips and tricks. J Bone Joint Surg Am 2007; 89:2298-2307 2. Wagner,M. General principles for the clinical use of LCP. Injury 2003; 34 suppl. 2; B 31-42. 3. Frigg R. Locking compression plate (LCP). An osteosynthesis plate based on the Dynamic Compression Plate and the Point Contact Fixator (PC-Fix). Injury. 2001; 32(suppl 2):63–66. 4. Gautier E, Sommer C. Guidelines for the clinical application of the LCP. Injury. 2003; 34(suppl 2):63–77. 5. Kubiak EN, Fulkerson E, Strauss E and Egol KA : The Evolution of Locked Plates: JBJS Am 2006 ;88:189-200. 6. Bjorkenheim JM et al ,Internal fixation of proximal humeral fractures using locking compression plate. Acta orthop scand: 75(6)741-745 . 7. Egol et al .Biomechanics of locking compression plates. J orthop trauma2004;18;488-493. 8. Fankhauser et al .A new locking plate for treatment of proximal humeral fractures. Clinical orthop related research 2005;430;176- 181. 9. Fulkerson et al;Fixation of the diaphyseal fractures with a segmental defect ; A biomechanical comparison between locking compression plate and the conventional plates;J orthop trauma2005;19;597- 603. 10. Shah Alam Khan, Prasoon Shamshery, Vikas Gupta,Vivek Trikha, Manish Kumar Varshney and Ashok Kumar :Locking Compression Plate in Long Standing ClavicularNonunions With Poor Bone Stock: J Trauma. 2008;64:439–441. 11. Ring D, Kloen P, Kadzielski J, Helfet D, Jupiter JB. Locking compression plates for osteoporotic nonunions of the diaphyseal humerus. Clin Orthop Relat Res. 2004;425:50-4. 12. Wenzl ME, Porte T, Fuchs S, Faschingbauer M, Jurgens C. Delayed and nonunion of the humeral diaphysis—compression plate or internal plate fixator Injury. 2004;35:55-60. Pb Journal of Orthopaedics Vol-XI, No.1, 2009 43
Walia et al<br />
without radial nerve exploration for humerus and lateral<br />
approach for fracture shaft femur was taken. Fracture tibia was<br />
approached anterolaterally. All the <strong>fractures</strong> were fixed with<br />
LCPs tak<strong>in</strong>g care to protect the periosteal blood supply. Bone<br />
graft<strong>in</strong>g was done <strong>in</strong> old ununited <strong>fractures</strong> and <strong>in</strong> fresh cases<br />
with fracture comm<strong>in</strong>ution <strong>of</strong> high grade. Internal fixation <strong>in</strong><br />
open <strong>fractures</strong> was carried out after thorough irrigation and<br />
debridement. Spl<strong>in</strong>tage and immobilization was applied as per<br />
fixation achieved. Early range <strong>of</strong> motion exercises were started<br />
where a stable construct was achieved.<br />
RESULT<br />
Table 1<br />
Fracture Location<br />
Fig. 1: LCP <strong>in</strong> tibia Preoperative and post-operative Xrays<br />
No. Fresh Non-union<br />
Closed Open<br />
Femur 25 19 4 2<br />
Tibia 15 6 5 4<br />
Humerus 10 5 1 4<br />
60% <strong>of</strong> cases were <strong>of</strong> closed nature. All 4 femur open <strong>fractures</strong><br />
were Gustillo Grade III open while 1 tibial and I humeral fracture<br />
was grade III. Four tibial <strong>fractures</strong> were grade 1 open. 20% <strong>of</strong><br />
cases were old ununited <strong>fractures</strong>.<br />
The age group <strong>of</strong> the patients <strong>in</strong> this study varied between<br />
18-70 years (average 53.1 years) with majority <strong>of</strong> the patients <strong>in</strong><br />
fifth to seventh decade <strong>of</strong> life.<br />
Follow-up <strong>in</strong> our series ranged from 6-24 months.<br />
All <strong>fractures</strong> united <strong>in</strong> this series without the need<br />
for any supplemental procedure. The average time for union <strong>in</strong><br />
fresh femur <strong>fractures</strong> was 16.4 weeks. 2 <strong>of</strong> the 4 open <strong>fractures</strong><br />
and 1 <strong>of</strong> 2 non-unions <strong>in</strong> femur took more than 20 weeks to<br />
unite.<br />
The average time for union <strong>of</strong> fresh tibial <strong>fractures</strong> was<br />
17.1 weeks while the non-unions united <strong>in</strong> an average <strong>of</strong> 17.75<br />
weeks. The average time <strong>of</strong> union for fresh humeral <strong>fractures</strong><br />
was 13.3 weeks. The union time <strong>in</strong> non unions ranged from 12<br />
to 20 weeks with a mean <strong>of</strong> 15.25 weeks<br />
Full weight bear<strong>in</strong>g <strong>in</strong> cases <strong>of</strong> fracture tibia and femur<br />
was done <strong>in</strong> 14 cases with<strong>in</strong> 12-16 weeks, 20 cases with<strong>in</strong> 17-20<br />
weeks and <strong>in</strong> 2 cases after 20 weeks.<br />
Range <strong>of</strong> motion at knee <strong>in</strong> femoral <strong>fractures</strong> was more<br />
than 90 degrees <strong>in</strong> 90% <strong>of</strong> the cases. Range <strong>of</strong> abduction was<br />
more than 140 degrees <strong>in</strong> 80 % <strong>of</strong> the cases with fracture shaft<br />
humerus and elbow flexion was more than 90 degrees <strong>in</strong> 85% <strong>of</strong><br />
the cases.<br />
Fig. 2: LCP <strong>in</strong> femur pre and post operativeX rays<br />
Fig. 3: Three months follow up X ray <strong>of</strong> proximal humerus fracture<br />
Pb Journal <strong>of</strong> Orthopaedics Vol-XI, No.1, 2009<br />
42
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