Rotation Correction Plates 1.5 and 2.0. Reposition ... - Osteosyntese

Rotation Correction Plates 1.5 and 2.0.Reposition plates for fracturesand osteotomies at the metacarpals andphalanges.Anatomically precontouredMinimal irritation of ligaments and soft tissue thanks to a flatplate and screw profile, rounded edges and polished surfaces.Transversally elongated holesAn elongated hole transversal to the axis of the plate shaftallows intraoperative inspection of the reduction and allowsthe surgeon to correct the rotational axis of the bone if necessaryAngular stability 2.0 mm locking screws can be used in the head. Cortex orlocking screws can be used in the shaft, depending on theplate size.The design of the plate head makes it easy to adjust to theanatomy of the condyles.Two shaft lengthsTwo different shaft lengths of the plates allow fragment-specifictreatment of fractures of the metacarpals and proximalphalanges.2 Synthes Rotation Correction Plates 1.5 and 2.0 Technique Guide

Indications and ContraindicationsIndications1.All fractures of the phalanges and metacarpals, where theexact reposition is difficult or where a rotational error caneasily occur.– subcapital fractures of the metacarpals (in particular impactedcompression fractures)– transverse fractures– short oblique fractures– comminuted fractures– defect fractures (circular saw injuries)– amputation injuries to the fingers (with primary shortening)– Winterstein fracture, Rolando fracture2.Corrective osteotomies for fractures of the phalanges ormetacarpals that have healed with axial errors and/or rationalerrors.In the case of metaphyseal fractures, comminuted fracturesand osteoporotic bone, the clinical results can be improvedby the angular-stable screw/plate connection.ContraindicationsEasily reduced oblique or spiral fractures that can be preciselyand firmly stabilized using screw osteosynthesis.4 Synthes Rotation Correction Plates 1.5 and 2.0 Technique Guide

Case StudiesCase 1Subcapital comminuted fracture of the 2nd metacarpalbone42-year-old man, fall from bike.Compressed fracture of the metacarpal head with 4 mmshortening and 20° ulnar malangulation. Instable, subcapitalimpacted compression zone with bony collateral ligamenttears. Primary treatment with plaster splint with only 30°flexion of the metacarpophalangeal joints.Intraoperative far distal angular stable fixation of the head,compensating for errors in the length and rotation. Immediateactive exercise treatment.Preoperative, dorsopalmar and obliquePostoperative, dorsopalmar and lateralSynthes 5

Case studiesCase 2Pseudoarthrosis of the 4th metacarpal bone followingfailed screw osteosynthesisPreoperative withpseudoarthrosis and 6 mmshortening, dorsopalmar32-year-old woman with screw osteosynthis treated elsewhere.The patient presented with pain, swelling and rotationalerror 6 months after the primary treatment.Intraoperatively, an anatomical reposition is no longer possible.Angularly stable fixation close to joint. Proximal with cortexscrews. Immediate active exercise treatment.Postoperative followingcompensation of length androtational error, dorsopalmarPostoperative, laterale6 Synthes Rotation Correction Plates 1.5 and 2.0 Technique Guide

ImplantationIf fractures to the metacarpals or the proximal phalanges aremisaligned, the function of the hand can be severely affected.Especially rotational misalignments are problematicbecause of crossing and scissoring digits whenever fullflexion of the fingers to a fist is attempted. Even minor rotationalerrors in the fingers frequently have to be surgicallycorrected after a fracture has healed.For metacarpal fractures and fractures of the proximal phalanges,optimal recovery of hand function includes the meticulousrestoration of alignment, length and rotation of digitsand metacarpals. A careful approach needs to be chosen inorder not to further compromise the soft tissue situationwhich again requires proper reconstruction. The fixation hasto be stable enough in order to facilitate immediate activeand passive finger exercises.ApproachesFor the metacarpal bones, the 2nd ray may be approacheddorso-radially above the palpable bone, the 5th ray dorsoulnarabove the bone, and the 3rd and 4th metacarpal eitherdirectly above the respective bone or between both of themwhen two adjacent bones are affected.The proximal phalanges are usually approached through themedian line of the respective bone.Synthes 7

3Bending the plate head and plate shaft1Instruments329.921 Bending Pin for LCP Plates 2.0, with thread347.901 Pliers, flat-nosed, pointed,for Plates 1.0 to 2.4If necessary, bend the plate to suit the anatomical conditions.1. Preferably bend the plate head with two bending pins.2. Ensure that the shaft is bent between the combinationholes, as it will otherwise be difficult to insert thelocking screws. We recommend using two pairs of pliers.Note: The design of the plate holes allows a certain degreeof deformation tolerance. Locking is, however, not as efficientif the thread holes are significantly deformed. For thisreason the surgeon should avoid bending the plate by insertingthe bending pins into a combination hole.2Warning: The plate should ideally not be cut. The sharp cutedges can damage the radiodorsal tendons and can irritatethe soft tissue.Synthes 9

Implantation4Position platePosition the plate near the joint. The transverse elongatedhole must be on the far side of the fracture on a section ofbone that is intact. First fix the head or condyle region nearthe joint using two 2.0 mm locking screws to support thejoint surfaces and to prevent repositioning loss.Please refer to page 19 for information on inserting the lockingscrews.Caution: Ensure that there is no dorsal or palmar damage tothe cartilaginous joint surfaces by either the plate or thescrews and that the collateral ligaments are not unintentionallyfixed.Tip: If the axis and the length of the bone are not yet exactlyset the plate can be fixed to the bone with plate holdingforceps and the Kirschner wire can be removed. The lengthand the axis of the bone can now be corrected using theplate and the plate holding forceps. The Kirschner wire canbe left in place if it is already fixing the exact position and isnot blocking the transverse elongated hole.10 Synthes Rotation Correction Plates 1.5 and 2.0 Technique Guide

5Insert screw into elongated holeInsert and carefully tighten a standard cortex screw in theexact position in the central part of the transverse elongatedhole. Either select 1.5 mm or 2.0 mm cortex screws dependingon the plate size.Please refer to page 16 for information on inserting the cortexscrews.Synthes 11

Implantation6Check result of repositioningProp up the forearm with the elbow supported on the operatingtable while the wrist is at maximum flexion. In thisposition the finger joints are straightened by the tenodesiseffect of the extensor tendons. Check the axis and the rotationof the fingers.Place the wrist passively in the maximum extension positionwhile compressing the forearm anteriorly in the middle of itsshaft. In this position, the tenodesis effect of the flexor tendonsand the compression of the forearm muscles will causethe fingers to flex to nearly form a fist. This way, rotationalerrors of the digits are easily detected.Check the repositioning result with thewrist at maximum extensionReleasing and tightening the cortex screw in the transverselongitudinal hole ensures that the optimum position of thefinger can be identifiedSet the optimum finger positions by releasing and tighteningthe elongated hole screw12 Synthes Rotation Correction Plates 1.5 and 2.0 Technique Guide

7Final fixationFix a screw in the optimum position distal or proximal to thetransverse elongated hole. The other holes may remainfree or can be fitted with additional cortex screws. The holeabove the fracture line generally remains free.Please refer to page 16 for information on inserting the cortexscrews.Note: For 2.0 correction plates either 2.0 mm lockingscrews or 2.0 mm cortex screws may be used in the shaft.Only 1.5 mm cortex screws are used in the stem of 1.5/2.0correction plates.The synovial sheath above the plate should be closed with aresorbable 6/0 suture as far as possible. The extensor tendonis readapted in the median line with a resorbable 5/0 suture.After fitting a «size 6» Redon Drain, close the skin with asingle button suture and then apply an elasto-compressivebandage.Synthes 13

Implantation8Postoperative treatmentPost-operatively, the hand is consequently put upright. Removethe Redon Drain one day post-operatively. Subsequently,active and passive finger exercises should be startedwith the aim of full extension and flexion within a week.14 Synthes Rotation Correction Plates 1.5 and 2.0 Technique Guide

Implant removalTo remove locking screws, first unlock all screws from theplate; then remove the screws completely from the bone.This prevents rotation of the plate when removing the lastlocking screw.Synthes 15

Insert cortex screwsInstruments for correction plates 2.0311.012 Handle, medium,with Mini Quick Coupling314.676 Screwdriver Shaft Stardrive 2.0,with Holding Sleeve, length 66 mm,for Mini Quick Coupling323.200 Universal Drill Guide 2.0319.005 Depth Gauge for Screws 2.0 and2.4 mm, measuring range up to 40 mm310.507 Drill Bit 1.5 mm with marking,length 96/82 mm, 2-flute,for Mini Quick Coupling513.140 Drill Bit 2.0 mm, length 67/55 mm,2-flute, for Mini Quick CouplingAdditional instruments required forcorrection plates 1.5/2.0314.667 Screwdriver Shaft 1.5, cruciform,with Holding Sleeve, length 66 mm,with Mini Quick Coupling312.140 Double Drill Guide 1.5/1.1319.003 Depth Gauge for Screws 1.3 to 1.5 mm,measuring range up to 24 mm513.030 Drill Bit 1.1 mm, length 45/33 mm,2-flute, for Mini Quick Coupling16 Synthes Rotation Correction Plates 1.5 and 2.0 Technique Guide

1Predrill screw holePredrill the holes for the combination screws either neutrally(support) or eccentrically (compression) into the non-threadbearing part of the combination hole using the universal drillguide that is appropriate for the screw diameter.Cortex screw 2.0 mm: Use the 1.5 mm drill bit for athreaded hole and the 2.0 mm drill bit for a gliding hole.Note: For rotation correction plates 1.5/2.0 use the universaldrill guide 1.5/1.1 for 1.5 mm cortex screws. Use the 1.1 mm drill bit for the threaded hole and a 1.5 mmdrill bit for the gliding hole.Neutral pre-drillingEccentric pre-drilling2Determine screw lengthDetermine the screw length using the 2.0 mm depthgauge.Note: Use the 1.5 mm depth gauge for 1.5 mm cortexscrews.Synthes 17

Insert cortex screws3Pick up screwPick up the selected 2.0 mm cortex screw with the screwdrivershaft Stardrive 2.0 with holding sleeve and the correspondinghandle.Notes– A self-holding screwdriver (such as 313.842/313.843)Stardrive 2.0 can also be used.– If using 1.5 mm cortex screws the cruciform screwdrivershaft with holding sleeve should be used.4Insert self-tapping standard screwsInsert the self-tapping standard screws with the screwdriver.18 Synthes Rotation Correction Plates 1.5 and 2.0 Technique Guide

Insert locking screwInstruments311.012 Handle, medium,with Mini Quick Coupling314.676 Screwdriver Shaft Stardrive 2.0,with Holding Sleeve, length 66 mm,for Mini Quick Coupling323.034 LCP Drill Sleeve 2.0, with Scale,for Drill Bits 1.5 mm with marking319.005 Depth Gauge for Screws 2.0 and2.4 mm, measuring range up to 40 mm310.507 Drill Bit 1.5 mm with marking,length 96/82 mm, 2-flute,for Mini Quick Coupling1Use LCP drill sleeveScrew and lock the drill sleeve vertically into the thread ofthe selected hole.Synthes 19

Insert locking screw2Predrill screw holePredrill the screw hole with the 1.5 mm drill bit throughthe drill sleeve for locking screws 2.0 mm to the requireddepth and then read the screw length directly from the drillsleeve scale.3Determine screw length (optional)Determine the screw length using the 2.0 mm depthgauge for screws, as shown on page 17.20 Synthes Rotation Correction Plates 1.5 and 2.0 Technique Guide

4Pick up screwPick up the selected screw with the screwdriver shaftStardrive with holding sleeve and the corresponding handle.Note: A self-holding screwdriver (such as 313.842/313.843)Stardrive 2.0 can also be used.5Insert self-tapping locking screwsManually insert the locking screws with the screwdriver.Carefully tighten the locking screw, as excessive force is notnecessary to effectively lock the screws.Synthes 21

ImplantsPlatesX46.354 Rotation Correction Plate 1.5/ 2.0,shaft 4 holes, head 2 holes, length 27 mmX46.355 Rotation Correction Plate 1.5/ 2.0,shaft 5 holes, head 2 holes, length 32 mmX47.354 LCP Rotation Correction Plate 2.0,shaft 4 holes, head 2 holes, length 34 mmX47.355 LCP Rotation Correction Plate 2.0,shaft 5 holes, head 2 holes, length 40 mmLocking screwsX01.876–900Locking Screw 2.0 mm,self-tappingStandard screwsX01.356–381X00.806-824Cortex Screw 2.0 mm,self-tappingCortex Screw 1.5 mm,self-tappingAll screws 2.0 mm with Stardrive T6 drive.All screws 1.5 mm with cruciform drive.X=2: Steel (SSt)X=4: Titanium (plates)Titanium alloy TAN (screws)22 Synthes Rotation Correction Plates 1.5 and 2.0 Technique Guide

BibliographyBüchler U, Gupta A, Ruf S (1996) Corrective Osteotomyfor Post-traumatic Malunion of the Phalanges of the Hand.J Hand Surg 21B:33–42Freeland AE, Geissler WB, Weiss APC (2001) OperativeTreatment of Common Displaced and Unstable Fractures ofthe Hand. JBJS 83A (6):928–945Gollamudi S, Jones WA (2000) Corrective Osteotomy ofMalunited Fractures of Phalanges and Metacarpals.J Hand Surg [Br] 25(5):439–441Green DP (1986) Complications of Phalangeal andMetacarpal Fractures. Hand Clin 2:307–28Gross MS, Gelberman RH (1985) Metacarpal RotationalOsteotomy. J Hand Surg [Am] 10:105–8Ring D (2005) Malunion and Nonunion of the Metacarpalsand Phalanges. JBJS 87A:1380–1388Schaefer M, Siebert HR (2000) Finger- und Mittelhandfrakturen.Unfallchirurg 103:582–592Strauch RJ, Rosenwasser MP, Lunt JG (1998) MetacarpalShaft Fractures: The Effect of Shortening on the ExtensorTendon Mechanism. J Hand Surg [Am] 23:519-23Trumble T, Gilbert M (1998) In Situ Osteotomy forExtra-articular Malunion of the Proximal Phalanx.J Hand Surg 23A:821–826Van der Lei B, Robinson PH, Klasen HJ (1993) CorrectionOsteotomies of Phalanges and Metacarpals for Rotationaland Angular Malunion: A Long-term Follow-up and aReview of the Literature. J Trauma 35(6):902-90824 Synthes Rotation Correction Plates 1.5 and 2.0 Technique Guide

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