The problem of plate fracture after fracture surgery has been a difficult problem in the orthopedic field. According to the relevant literature, the fracture rate of internal fixation devices in the United States is 8%, and the preliminary statistics in China is 4%. The main reasons for this are as follows.
1, the instability of the fracture is the main objective factor causing the plate fracture.
When the fracture is unstable, the load that should be carried by the bone itself is more burdened by the steel plate, which eventually leads to the plate fracture.
2. Premature exertion and weight bearing and incorrect functional exercise are the subjective factors of plate fracture.
For example, the average healing time of femoral stem fracture is 14-15 weeks, so complete weight-bearing should be avoided within three months; for example, the affected limb should be suspended in the early postoperative period after clavicle fracture, and it is prohibited to lie on the affected side to prevent lifting, supporting and exerting force with the affected arm.
3.Inadequate grasp of preoperative indications and improper selection of steel plates.
The length of the selected steel plate is not long enough, resulting in the fracture of the steel plate due to insufficient force arm. The length should reach 4-5 times of the diameter of the fracture stem, but for long oblique or comminuted fractures, it mainly depends on the number of effective screws of the steel plate.
② Insufficient width and thickness of the plate, or unsuitable for plate fixation.
4, improper intraoperative operation and insufficient surgical skills.
It also includes.
① improper fracture anatomical repositioning, such as improper fracture repositioning or plate contralateral to the cortical defect when the bone at the fracture can not assume the role of connection, the plate will bear the full load on the bone and become the fulcrum. Bone defects are implanted in one stage as much as possible.
Improper intraoperative plate placement. The plate is not placed on the tension side or the center of the plate is not placed on the fracture line. There is also repeated shaping of the plate in surgery, so that the mechanical properties of the plate change and the strength decreases or there are too few screws and the holding force of the screws is not enough.
(3) Too much periosteal stripping, which damages the local blood flow and affects the growth of bone scab, and the operation is too long or does not strictly comply with the aseptic operation, resulting in acute and chronic infection.
5, the metal material is different, electrolytic reaction occurs, accelerating the fatigue of the plate or the plate itself has quality problems.
In this regard, we should strictly grasp the indications, indications and contraindications of surgery before, during and after surgery, as well as detailed preoperative preparation and strict compliance with medical operation specifications during and after surgery, and inform patients and their families of possible problems during and after surgery, communicate with tertiary physicians before surgery and sign the surgical consent form. Postoperative care and functional exercises were given accordingly. At the same time, the principles of fracture treatment were emphasized again: reduction, fixation and functional exercise. Proper functional exercise can prevent the stiffness of adjacent joints and reduce the loss of function, while inappropriate functional exercise will lead to secondary fractures, screw loosening and plate fracture. For medical workers in response to such events, we will summarize the lessons learned.
Prevention of steel plate fracture.
1, to master the surgical pointers, indications, contraindications, do the surgery should be done do not want to do the surgery.
According to the fracture site, fracture type, the patient’s age, gender, occupation, physical and psychological condition, socio-economic ability and the doctor’s technical level and hospital equipment conditions and other comprehensive situation, a high degree of responsibility for the patient spirit, appropriate decisions, not rigid.
2.Pre-operative preparation.
Make a good pre-operative plan and discussion, have a thorough consideration for the surgical plan, and have a good response to the possible situations that may occur during the operation. Improve the necessary preoperative examination, carefully read the X-ray, CT and other examinations, choose the best way of internal fixation, prepare one or more kinds of internal fixation materials, and do a good intra-departmental or intra-hospital discussion for difficult surgery.
3. Pre-operative preparation should be adequate, such as good preparation of pre-operative medication and blood transfusion, and special requirements for anesthesiology and operating room should be informed in advance.
Do preoperative signature and communication, and perform the obligation to inform carefully about the necessity of surgery, surgical plan, surgical risk, postoperative complications, etc., do preoperative communication, and sign the surgical consent form.
4. Reduce surgical errors, improve surgical skills, review anatomy carefully before surgery, and be familiar with surgical access.
Summarize the experience of success and failure, orthopedic surgeons cannot become surgical craftsmen, but become real orthopedic surgeons.
5.Good postoperative management.
Early management.
a. For the degree of stability of fixation in surgery, whether to add external fixation.
b, according to the operation until the early postoperative functional exercise.
Management of discharge.
a. Discharge from the hospital to fill out the protocol of precautions for internal fixation of steel plates.
b. Regular return visits, urge the patient to come to the hospital for follow-up on time, and intervene in time to deal with slower fracture healing and the appearance of instability to avoid disputes.
Pay great attention to post-operative review, and fill in the follow-up register to maintain close contact with the patient, do not develop the paralysis of “once and for all” after the surgery. The patient should be informed to have a follow-up visit at least once a month, so that the physician can give guidance according to the specific situation, and to take a film for review to understand the healing speed of the fracture and whether there are signs of plate failure. If no bone scab appears 4 months after surgery, or if the bone scab breaks, or if there is bone resorption in the screw tract under the plate at the fracture end, external protection should be given, and later, if the bone resorption does not improve, another surgical implant or a different fixation method should be performed, otherwise failure of the endophyte will occur soon. Patients should not be allowed to squat or go up and down stairs when they are not fully weight bearing, because the tensile stress on the knee is 2.5 – 3.3 times the body weight, which can easily cause endophyte failure.
It is important to remember that timely review during the active weight-bearing period is an important tool to prevent plate fracture after internal fracture fixation. The causes of postoperative plate fracture are complex, but as long as the indications for plate fixation are strictly mastered, the principles of biomechanical fixation are strictly followed, the surgical skills are mastered, the timing and methods of postoperative functional exercise and weight-bearing are highly valued, the importance of timely review is repeatedly advised, and a follow-up and review registration system is established, the majority of plate fractures can be avoided.