14295_C04.qxd 11/1/06 2:07 PM Page 66

66 4 Evolving Concepts in Plate Fixation

A

B Figure 4–16 Drawings demonstrating (A) sliding the locked plate under the submuscular plane, (B) attaching the handle to the plate proximally, and final fixation with unicortical screws. 14295_C04.qxd 11/1/06 2:07 PM Page 67

Locking Plates and Plating Systems 67

Figure 4–17 Use of the (A) “whirlybird” to reduce (B) the bone to the plate during a locked plating. Reproduced with permission from Springer (Operat Orthop Traumatol 2001; 13:178–197).

A

A,B

B Figure 4–18 (A) Placement of a locked plate that is not centered in the midlateral plane. (B) This causes very poor purchase in the proximal screws due to the transcor- tical location of the screws. Reproduced with permission from Springer (Unfallchirurg 2000:103; 428–436).

Figure 4–19 Diagram of the cable technique to determine frontal plafond. The cable is then placed over the two sites, and the knee is plane alignment. The patella is directed anteriorly, and the image in- imaged. The position of the cable relative to the center of the knee tensifier is used to locate the center of the femoral head and the tibial joint indicates the frontal plane alignment. 14295_C04.qxd 11/1/06 2:07 PM Page 68

68 4 Evolving Concepts in Plate Fixation

Figure 4–20 The notch sign (left) and Blu- mensaat’s line are two methods to judge sagittal plane alignment with hyperflexion of the distal femur fracture, the notch dis- tance, and the angle formed between the shaft and Blumensaat’s line and the shaft increase (C) relative to normal (B).

A

B

C

(Fig. 4–21). This measurement can be compared with the has an asymmetric shape, with external rotation, the lesser uninjured contralateral limb to determine proper length. trochanter appears more prominent as it becomes less se- Rotational alignment can be difficult to determine radi- cured by the proximal femoral shaft. In internal rotation, ographically intraoperatively. Because rotational defor- the lesser trochanter appears smaller as it disappears mities are often not obvious on plain radiographs, these behind the proximal femoral shaft. With the patella posi- deformities have traditionally received less attention than tioned directly anteriorly, the hip can be imaged to visual- deformities in other planes. The lesser trochanteric shape ize the lesser trochanter. The trochanteric shape needs sign can be useful to determine femoral rotation intra- to be compared with that of the uninjured contralateral operatively (Fig. 4–22A–D). Because the lesser trochanter side. 14295_C04.qxd 11/1/06 2:07 PM Page 69

Locking Plates and Plating Systems 69

Position 1 Position 2

Meter stick

Figure 4–21 Drawing of the meter stick technique used to determine femoral length.

Internal rotation External rotation

Lesser Lesser trochanter trochanter larger smaller

ABCD

Figure 4–22 (A) The lesser trochanteric shape sign can help determine rotational alignment when compared with (B) the contralateral side. (C) The lesser trochanter is smaller with internal rotation of the proximal fragment and (D) larger with external rotation of the proximal fragment.