Plating a fracture clearly disrupts the soft tissue envelope around a fracture. Why, then, is surgical plating ever used?
Here three types of surgical fixation devices seen in the femur
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Plate |
Intramedullary nail (rod) |
External fixator |
One famous orthopaedic surgeon said “fractures heal despite internal fixation, not because of it”.
Surgical implantation of bone plates increase risk of non-union. We use them nonetheless, because they likewise decrease the risk of mal-union (healed, but crooked). Plates can be used to restore alignment, especially near the joint line, where even slight deformities are poorly tolerated (ie, if the bone heals but the joint is not aligned, the patient is not helped).
Note: this question applies to plates which are a particularly disruptive form of internal fixation. Other means of fixation, such as intra-medullary rods, are less disruptive because they are inserted at a distance and funneled through the center of the bone (medullary canal).
Nails too are invasive of course; it is reasonable, then, for you to ask why they are ever chosen. Simply: because casting the bone in some instances would lead to too much immobilization. The nail seen above, for example, replaces a whole body cast.
The external fixator is probably the least desirable fixation device: it is held by pins, which connect the bone to the (dirty) outside world; and these pins (and the fixator itself) are not very rigid either. The external fixator chosen when no other option exists. In the photo shown, the patient had a gun shot wound with lots of soft tissue and vascular damage. The fixator holds the bone in place while those injuries are addressed. A patient with a gun shot wound with lots of soft tissue and vascular damage may have his fixator removed and replaced by a nail once the soft tissue issues are under control—that is, the fixator may be temporary.
Technical/Biological note: the periosteum, the lining of the bone, is the source of the cells that heal the fracture. Periosteal stripping at the time of surgery may make it easier to get the bone seen and the plate inserted, but will also prevent healing! Surgeons are taught to avoid getting hung up on achieving “perfect” looking xrays, especially at the cost of biological disruption.
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