Overview
Definition:
Binding plate fixation is a surgical technique used in orthopedic trauma to stabilize bone fractures
It involves using a specially designed plate that acts as a tension band over a bone, typically in areas of high tensile stress, such as the olecranon, patella, or calcaneus
The plate is secured to the bone with screws, and a wire or other flexible fixation device is passed through holes in the plate and around the bone fragments, creating a "binding" or "tension band" effect
This redirects tensile forces away from the fracture line, promoting healing
It is particularly effective for transverse or short oblique fractures in metaphyseal or epiphyseal regions.
Indications:
Primary indications include fractures subjected to significant tensile forces, such as olecranon fractures (Type II or III), patellar fractures (transverse or comminuted transverse), and calcaneal fractures (specifically the posterior tuberosity)
It is also considered for certain distal clavicle fractures and some periarticular fractures where tension forces are a predominant factor.
Clinical Significance:
The binding plate technique offers a biomechanically sound method for managing fractures prone to gapping or displacement under tensile load
By converting tensile forces into compression across the fracture, it enhances stability and facilitates early mobilization, which is crucial for restoring joint function and preventing stiffness
Understanding this technique is vital for orthopedic residents preparing for DNB and NEET SS examinations, as it is a commonly tested surgical principle.
Indications
Olecranon Fractures:
Olecranon fractures, particularly transverse and oblique types, where the pull of the triceps muscle creates significant tensile forces
This technique is an alternative to traditional tension band wiring.
Patellar Fractures:
Transverse patellar fractures that are amenable to tension band principles
It provides robust fixation and allows for early range of motion exercises to prevent patellofemoral adhesions.
Calcaneal Fractures:
Fractures involving the posterior tuberosity of the calcaneus, which are under tension from the Achilles tendon
The binding plate helps to stabilize these fragments.
Other Fractures:
Certain distal clavicle fractures, some distal radius fractures, and periarticular fractures where tensile forces can be redirected
It may also be used for some intra-articular fractures where fragment stability is paramount.
Preoperative Preparation
Imaging Assessment:
Detailed radiographic evaluation including AP, lateral, and oblique views of the affected bone
CT scan may be required for complex fractures to assess comminution and articular involvement
Specific attention to fracture pattern and displacement is critical.
Patient Evaluation:
Thorough medical history, physical examination, and assessment of comorbidities
Preoperative optimization of the patient's general health is essential, especially for elderly or medically compromised individuals.
Instrumentation Selection:
Selection of appropriate sized binding plate, screws of correct length, and tension band wire (e.g., stainless steel Kirschner wire or braided non-absorbable suture)
Pre-bending the plate to match the bone contour may be necessary.
Surgical Planning:
Detailed surgical plan outlining the approach, reduction strategy, implant placement, and tension band application
Consideration of potential challenges and contingency plans.
Procedure Steps
Exposure And Reduction:
An adequate surgical incision is made to expose the fracture site
Gentle manipulation and careful reduction of bone fragments are performed using pointed reduction forceps or bone clamps
The goal is anatomical reduction, especially for intra-articular fractures.
Plate Application:
The binding plate is contoured to fit the bone surface and temporarily fixed with screws
The plate is typically placed on the tension side of the bone (e.g., dorsal aspect of the olecranon, anterior aspect of the patella)
Screws are placed in a bicortical fashion to provide purchase.
Tension Band Creation:
A tension band wire or suture is passed through the pre-drilled holes in the plate and around the bone fragments, or through separate drill holes in the bone distal and proximal to the fracture
The wire is then twisted or the suture is tied securely, applying compression across the fracture line.
Final Fixation And Closure:
The plate is definitively secured with screws
Stability of the construct is assessed
The wound is irrigated thoroughly, and the layers are closed in a meticulous fashion
A sterile dressing is applied.
Postoperative Care
Pain Management:
Adequate analgesia is provided using multimodal pain management strategies, including opioids and non-opioid analgesics
Regional blocks may be considered.
Wound Care:
Regular wound inspection for signs of infection or dehiscence
Dressings are changed as per protocol
Early mobilization of drains if used.
Mobilization And Rehabilitation:
Early range of motion exercises of adjacent joints are encouraged, typically starting within 24-48 hours, provided the construct is stable
Weight-bearing status is determined by fracture stability and surgeon preference, often with gradual progression
Physiotherapy is crucial.
Monitoring:
Close monitoring for signs of neurovascular compromise, infection, or implant-related complications
Serial radiographs are obtained to assess fracture healing and implant position.
Complications
Implant Related Complications:
Prominence of the plate or wire causing irritation, screw loosening or breakage, wire cut-out through the bone, or malposition of implants
These may require revision surgery.
Infection:
Superficial or deep surgical site infection
This is a significant complication that may necessitate surgical debridement, antibiotics, and potentially implant removal.
Nonunion And Malunion:
Failure of the fracture to unite (nonunion) or healing in an incorrect position (malunion)
This can be due to inadequate reduction, poor stability, infection, or poor patient compliance.
Stiffness And Arthrofibrosis:
Joint stiffness, particularly after periarticular fractures
This can result from prolonged immobilization, inadequate rehabilitation, or intra-articular comminution.
Key Points
Exam Focus:
Understand the principle of tension band wiring and its application with binding plates
Know the specific indications for olecranon, patellar, and calcaneal fractures
Differentiate from standard plating techniques.
Clinical Pearls:
Ensure anatomical reduction, especially in intra-articular fractures
The tension band should be snug but not overtightened to avoid compromising blood supply
Proper contouring of the plate is vital for optimal fit and function.
Common Mistakes:
Inadequate reduction leading to malunion
Over-tightening the tension band, causing vascular compromise
Incorrect placement of the plate on the non-tension side
Failure to address comminution adequately
Insufficient rehabilitation leading to stiffness.