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404/ CURRENT CONCEPTS REVIEWSOUBORN REFERT
ACTA CHIRURGIAE ORTHOPAEDICAEET TRAUMATOLOGIAE ECHOSL., 79, 2012, p. 404410
Fixation of Osteoporotic Fractures in the UpperLimb with a Locking Compression Plate
Stabilizace osteoporotickch zlomenin horn konetiny pomoc hlov stabilnuzamykateln dlahy (LPC) pehled souasnch pstup
NEUHAUS, V., KING, J. D., JUPITER, J. B.
Hand and Upper Extremity Service, Massachusetts General Hospital, Orthopaedic Surgery, Boston, Massachusetts, USA
Locking Compression Plate (LCP) has the advantageous feature that screws can be locked in the plate leaving an angu-lar stable construct. There is no need to have contact between the plate and the bone to achieve stability resulting fromfriction of the plate-bone-construct. Therefore the plate does not need to be contoured exactly to the bone and the healingbones periosteal blood supply is not affected. The LCP is used as a bridging plate to gain relative stability in multi-frag-mentary, diaphyseal or metaphyseal fractures. Depending on the fracture, the combination hole can also allow the LCP toachieve absolute stability similar to conventional fixation techniques.
Osteoporotic fractures have significant impact on morbidity and mortality. Proximal humeral and distal radius fracturesare typical examples. These osteoporotic and often comminuted fractures are ideal settings/indications for LCP utilizationin the upper extremity. However, the data quality is due to mostly small study populations not so powerful. Unquestionablythere has been a clear and fashionable trend to choose operative treatment for these fractures, because the angular sta-bility allows stable fixation and early functional mobilization.
Key words: concepts, current, fractures, Locking Compression Plate, osteoporotic, review.
Reconstruction of complex fractures and nonunionsin the upper limb in the elderly patient with underlyingosteoporosis and prior to the development of the Loc-king Compression Plate (LCP) was challenging (20, 23).The development of LCP in the last ten years has dra-matically changed the treatment not only of distal ra diusand proximal humeral fractures, but also of complexfractures and nonunions (Fig. 1af). This article will pre-sent an overview about the principles of LCP and thecurrent concepts utilizing LCP in treating osteoporoticupper extremity fractures.
Locking Compression Plate (LCP) has the advanta-geous feature that screws can be locked easily in the pla-te achieving an angular stable construct. There is no needto have contact between the plate and the bone to getstability resulting from friction of the plate-bone-con-struct (42). As a consequence the plate does not need to
be contoured as exactly as possible to the bone. Ano theradvantageous aspect of this technique is that the healingbones periosteal blood supply is not affected. The LCPis broadly used as a bridging plate to gain relative sta-bility in multi-fragmentary diaphyseal or metaphysealfractures (12). An open approach is possible, but a lessinvasive, as in MIPO (minimal invasive plate osteosynt-hesis), is preferred and affords less harm to the soft-tis-sue coverage. The reduction is mostly achieved by indi-rect means. Yet there are important features to beconsidered according to Gauthier and Sommer (12).First the plate must be of appropriate length. The pro-portion of plate length and fracture length has to be con-sidered. They concluded that the plate length should be2 to 3 times the fracture length in comminuted fracturesand 8 to 10 times in simple fractures. Second the platemust be positioned well, so that all the screws can beadequately positioned in the bone to maximize ancho-rage of the bicortical screws. Third the appropriate num-ber of screws is needed, usually three on each main frag-
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ment. One last issue is the complete loss of the surgicalfeeling of the quality of the bone during screw inser tionand tightening.
Depending on the fracture, the combination hole canallow the LCP to achieve absolute stability similar toconventional open reduction and internal fixation tech-niques using Low Contact Dynamic Compression Pla-tes (LC-DCP). The main indications therefore are arti-cular fractures or simple diaphyseal (AO type A)fractures (42). However, a precise contouring is manda-tory in this situation. In osteoporosis the loss of reduc-tion is often encountered with conventional plate-screw-
bone-constructs due to the thin bone cortex and conse-cutively short working length of the screws in the cor-tex (12). This leads to malalignment and in the case ofinstability to nonunion. A combination of conventionaland locking screws is possible and is showed in dia-gram 1. Anatomical reduction is achieved with the pre-cise contoured plate and conventional screws. Supple-mental locking head screws improve the pullout forcesof the osteosynthesis and the resistance against bendingand torsion.
Another example of the combination of conventionaland locking screws is the use of absolute and relative
Fig. 1af. This 38-year-old patient had a complete amputa tionof his arm and had a replantation four years ago. He presen-ted to our office with this complex nonunion of the left distalhumerus. Radiographs are showing the peri-operative sequ-ence of events and treatment (open reduction and internal fixa-tion nonunion with anterior and posterior capsular release).After two years he can do pushups and the x-rays show goodhealing of the nonunion.
Diagram 1. In osteoporosis loss of reductionis often encountered with conventional pla-te-screw-bone-constructs due to the thinbone cortex and consecutively short workinglength. A combination of conventional andlocking screws is possible. (Reprinted fromInjury, Int. J. Care Injured, Vol 34, MichaelWagner, General principles for the clinicaluse of the LCP, Page No. S-B35, Copyright(2003), with permission from Elsevier).
good bone quality
a b c de f
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(Fig. 2ae). Especially osteoporotic and often commi-nuted fractures are ideal indications for LCP in the upperextremity (40) (Fig. 3ac). LCP therefore has greatlyinfluenced the treatment of these fractures. Because ofthe angular stability it allows stable fixation and earlyfunctional mobilization.
Osteoporosis, the stability of the osteosynthesis inosteoporotic fractures, soft tissue quality, comorbidi -ties, and the age of these patients can impair bone hea-ling (5, 13). Bisphosphonates (up to 5 years) and cal -cium-supplements are therapeutic and preventive inosteoporosis. Therefore they can reduce the overall riskof fractures, however the effect on bone healing is con-troversial. In addition, long-term bisphosphonates canpromote atypical femoral fractures as recently publis-hed data shows, but the absolute risk is small (38, 39).There are so far no atypical fractures reported in theupper extremity.
Proximal humeral fracturesHertel emphasized the main difficulties in proximal
humeral fractures as there being a weak bone, a tendencytowards comminuted fractures, and reduced patientscompliance (17). These issues are ideal indications forlocking plates as discussed earlier.
Neer distinguished fractures with no or minimal dis-placement (Neer I) versus displaced fractures (displacedmore than 1 cm or angulated more than 45 degrees). Thedisplaced fractures are - based on the fracture localiza-tion and the amount of segments - further subdivided(Neer II - VI) (29). As a basic principle non or minimallydisplaced proximal humerus fractures can be treatednon-operatively with excellent or good results in nearly90% (11). In contrast, conservative treatment of displa-ced proximal humeral fractures can lead to a worse out-come. Therefore the number of fragments and their dis-placement influences the decision to proceed withoperative treatment. The indication for operative treat-
stability in articular fractures with extension into the dia-physis (42). The articular component can be fixed withabsolute stability using conventional screws whereas themetaphyseal / diaphyseal part is bridged (relative stabi-lity) while adhering to the locking compression techni-que.
LCP is mainly used in proximal humeral, distal ra -dius, distal ulna, peri-articular metacarpal, phalangeals,osteopenic, or comminuted / multifragmentary diaphy-seal fractures, and reconstructions in case of nonunionand malunion (37). In the next section we focus on a fewof these topics
Osteoporotic fracturesOsteoporotic fractures have significant impact on
morbidity and mortality as well as social and economicimplications (2, 10, 14, 44). Patients with osteoporoticfractures have also an increased risk having a secondfracture in the future (10). Typical osteoporotic fractu-res of the upper extremity are proximal humeral anddistal radius fractures. The lifetime risk of sufferinga proximal humeral fracture is nearly 14% in a standardEuropean city (25). The risk for distal forearm fractures(22%) is higher in women while the risk in men is usu-ally lower than 6%. The prevalence of osteoporosis inwomen with distal radius fractures can be as high as 34%(31). Because it is considerably higher compared to con-trol groups it may therefore be seen as a risk factor forthese fractures. These fractures occur classically in elderpatients after a fall and subsequently from the direct frac-turing impact (32). Due to the growing numbers of olderand active people, treating phys