Corollary: Plates Are Not the Panacea

Corollary: Plates Are Not the Panacea 22

Fig. 22.1 Volar locking plates are not the panacea. There are several ways they may fail. The first way, that I learned the hard way from the case presented in this chapter, and other similar cases, has already been discussed in Chapter 1. Nevertheless, it needs to be reiterated at the end of this atlas: Volar locking plates hold the fragments via screws providing support to the subchondral bone.

Plates whose two rows of distal locking screws do not interdigitate close to the subchondral bone surface will provide only a tenuous support (right). One does not need to be an engineer to understand that if any comminution exists, secondary loss of reduction will occur much more often than we can infer from the single case presented in the previous chapter.

Fig. 22.2 The message is that not all plates are the same, even if they are locking and have similar appearances. Judge for yourself in this example:

A platform effect is created on the left by the crossing of the two rows of screws (a). (b) In this plate, the ulnar portion is well supported, but the screws are far from the subchondral bone in the scaphoid fossa, leaving this area at risk of subsidence. (c) In this other plate not only are the screws far from the subchondral bone in the scaphoid fossa, but the second row of locking screws is too far away to be able to provide any support to any portion of the subchondral bone. Lack of support is evident in the case discussed in the previous chapter (d).

In summary, poor reduction might be cited as the cause once the loss of fixation is seen in the postoperative radiographs, but arthroscopy has demonstrated that the system may fail to provide the support that the industry promised.

Fig. 22.3 Furthermore, rim fractures may be insufficiently fixed with current plates (see Chapter 9). The volar ulnar corner may benefit from other brands such as TriMed™ or the Orbay’s hook addition in the Geminus™. My preference is to manage this scenario by a separate volar ulnar approach.

Fig. 22.4 Additionally, because of the plates’ preset direction, they are unforgiving even to minimal errors in positioning, which is magnified when one makes major mistakes. These are the most common errors seen.

Fig. 22.5 Finally, the flexor tendon irritation, secondary to any plate, deserves some attention in this last chapter. Wrists are minimally tolerant to increases in volume. Large plates, loss of reduction, overuse, and likely a combination of all of these lead me to foresee an enormous increase in flexor tendon problems such as this case in the office.

This high-profile executive sustained a wrist fracture while skiing. The fracture was plated on the day of injury. Before presentation to our office 2 years later, his thumb had undergone two operations. He complained of thumb pain when the wrist was brought into extension and wrist pain and tendon irritation when moving the thumb interphalangeal joint. The plate, which was suspiciously too radial and prominent distally, was found to have caused an 80% tear of the FPL tendon. The plate was removed and the FPL tendon was repaired, yielding acceptable function.