A 45-year-old man accidentally discharged a gun while putting it in his pocket when he got into a car. He sustained an open fracture of the shaft of his right femur. The patient was conscious and in a stable condition to transfer to the hospital. There was no neurovascular injury of the right lower limb.
Indication for MIPO
This patient had an open fracture with soft-tissue damage as a result of a gun shot wound. Debridement of the wound should be performed as soon as possible. As the patient was operated on a normal operating table for debridement, bridge plating using a MIPO technique was planned to continue the operation on the same table without transferring the patient to a fracture table for femoral nailing.
a–c Preoperative x-rays show a fracture of the upper shaft of the right femur with comminution.d Right thigh with severe soft-tissue swelling showing bullet-hole entry wound, and exit wound on the medial aspect of the right femur.
Preoperative planning
Preoperative planning determines plate length to serve as the bridging plate as well as the type, the number, and sequential placement of screws for fixation. On each fragment proximal and distal to the fracture 3–4 screws are fixed into the plate holes while leaving some holes without screws. The length of the plate that spans the fracture zone also has no screws (Fig 17.2-2).
a–b The most proximal plate hole lies about 2 cm above the vastus ridge and requires precontouring to adapt to the shape of the bone. In the proximal part there are 4 screws for a 5-hole section of plate, so the plate-screw density is 0.8. Six holes span the comminuted fracture zone without screws, so the plate-screw density is 0. In the distal part there are 4 screws for a 5-hole section of plate, so the plate-screw density is 0.8. In this case the length of the plate will be 5+6+5 = 16 holes. The total plate-screw density is eight screws for a 16-hole plate, which is a density of 0.5 (see also chapter 17.1 Femur, shaft—introduction, Fig 17.1-4).c In this case the 16-hole precurved femoral LCP is used to preserve the anterior bowing of the femur. The plate is positioned and a cortex screw is inserted into the second hole to hold the plate in place. The most proximal LHS will pass through the femoral neck into the femoral head for stability of fixation. The guide wire is fixed through the threaded drill guide to check the correct position in AP and lateral before insertion of LHSs.d The guide wire is removed and an LHS is inserted, with additional locking head screws inserted below the cortex screw. The cortex screw is then replaced with an LHS for better stability.e–f Once the proximal fixation is complete the plate will lie along the distal femur. Manual traction is performed as indirect reduction and then a cortex screw is inserted through the last hole of the plate. Length, axial, and rotational alignment are checked intraoperatively. The threaded guide is attached and a hole is drilled for the next LHS insertion.g–h When alignment is correct an additional LHS is inserted and the cortex screw is replaced with an LHS.
Only gold members can continue reading. Log In or Register to continue
Humerus, proximal
Humerus, shaft—introduction
Humerus, shaft: wedge fracture, bending wedge—12-B2
Femur, distal: extraarticular simple fracture—33-A1.2
Extraarticular, bifocal closed fracture—42-A1, and articular trimalleolar ankle fracture—44-C2.3 (closed transverse fracture of the medial malleolus, lateral malleolus, and posterior malleolus)
Tibia and fibula, distal—introduction
