Alternative Methods of Management

Alternative methods of management for this case are open reduction and fixation with another type of plate or with screws alone, or closed reduction and K-wire fixation (Table 40-1).

Alternative plates would include any of the 1.5- or 2.0-mm minifragment plate systems. Because they are usually applied dorsally, these plates may be more bulky and can cause more problems with tendon gliding. Another disadvantage of these plates is that they lack the torsional stability afforded by the blade. Finally, it is difficult to attain rigid fixation of small condylar fragments with a simple dorsal plate. The principles of their application would be the same as for the blade plate, that is, fixation of the condyles first, followed by reduction and fixation of the shaft to the condyles.

Table 40-1 Alternative Methods of Management

Alternative Implants

Advantages

Disadvantages

Minicondylar blade plate (1.5 or 2.0 mm)

Provides excellent torsional stability and resistance

Potential for malreduction if the blade is not inserted in the correct plane to shear forces

Standard minifragment plate

Easier to adjust the angle of the plate relative to the phalanx

Implant typically applied dorsally and may interfere with extensor mechanism Useful only in select fracture patterns

(2.0 mm T- or L-shaped plate) Lag screw fixation

Interfragmentary compression

(1.5 or 2.0 mm) Kirschner wire fixation

Technically easier, closed method Does not allow for early active motion

Either 1.5- or 2.0-mm screws can be used in isolation for selected fractures of the proximal and middle phalanges. Their use requires a fracture with minimal comminution and a long oblique or spiral pattern (i.e., in length at least 1.5 to 2 times the width of the base).

Fixation with K wires, although perhaps technically easier, may lead to suboptimal results due to the inability to secure the fracture rigidly enough to allow for immediate motion of the digits. This method should be reserved for the case of the multiple digit injured hand when time allotted for fracture fixation is limited, or in a relatively simple fracture where minimal fixation is required.

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