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Using Metal Plates to Stabilize Finger Fractures

Posted on: 11/30/1999
Complex fractures of the long bones of the fingers (called metacarpal bones can be challenging to set in place and hold until healing takes place. The same is true for the phalanges (shorter bones of the fingers) with similar fracture patterns.

Simple, nondisplaced fractures may do well with a finger splint, but displaced (separated) or comminuted fractures (many small bone fragments) usually require surgical stabilization. Metal implants may be used to hold the bones together during fracture healing. These plates are made of titanium, stainless steel, or a titanium alloy. The plates can be locking or non-locking.

In this article, hand surgeons compare locking versus non-locking plates for hand fractures and discuss the advantages and disadvantages of the different compositions (titanium, stainless steel). They say there are no studies currently comparing results using non-locked and locked plating for hand fractures.

Likewise, there are no studies reporting clinical outcomes between titanium and stainless steel implants for finger fractures. Their thoughts and opinions on these two characteristics of metal implants used to stabilize finger fractures may help surgeons making treatment decisions for their patients. The information may also help stimulate future studies to improve treatment of hand fractures.

Let's start with the materials used to make metal implants. Titanium (or a mixture of titanium and other metals) is a lighter, more flexible material than stainless steel. It "flexes" more with the bone, which has some elasticity to it.

Titanium doesn't interfere with MRI signals. And the body accepts it more readily than other implant material. These features of titanium seem to help bone formation (called the callus) needed to heal fractures. There are fewer cases of nonunion reported when titanium is used over stainless steel.

The only downside of titanium implants mentioned is the increased rate of implant breakage compared to stainless steel. There seems to be a greater tendency for the titanium implants to break when the surgeon tries to remove the hardware (after fracture healing is complete). Both titanium and stainless steel can leave tiny pieces of debris and set off a tissue reaction inside the finger.

What about locking versus non-locking plates? Again, there are no studies comparing the clinical outcomes using these two types of metal implants for finger fractures. Reviewing what is known about when and how to use these may be helpful to hand surgeons.

Locking plates provide more stability than non-locking plates. They are used most often with unstable, comminuted (severe) finger fractures. There is less pressure on the bone with the locking plates. This feature helps reduce injury to the nearby tendons and interferes less with microvascular circulation inside the bone.

The locking plates have two other features not present in non-locking plates. One is the ability to use screws with different angles. The other is a far cortical locking mechanism on the other side of the fracture. This feature has not been studied in hand fractures yet. But other studies show far cortical locking stimulates bone growth by allowing a tiny bit of movement within the bone fragments. That movement signals bone to form the needed callus to stabilize the fracture.

The major limitations of locked plating are the tendency to be too stiff to allow fracture healing. A little movement within the bone fragments actually helps with bone healing. Studies show locking plates have fairly high nonunion rates when used in other bones. Studies of limitations using the locking plates for metacarpal or phalangeal fractures of the hand have not been reported.

The non-locking plates help reduce severely displaced bone fragments. There is less tendon irritation and less scar tissue formed when the non-locking plates are used. The surgeon can choose to put the screws in place in a double row using either a parallel or staggered pattern. It is also possible to choose different sized-screws for better fixation if that is required.

There are some disadvantages to non-locking metal plates. For example, the screws have enough wiggle to them that they can start to loosen causing plate loosening and implant failure. The non-locking plates don't work as well with patients who have decreased bone density, bone loss, or comminuted fracture patterns. Simply stated, the non-locking plates may not provide enough fixation to create a stable fracture site.

In summary, the uses of titanium versus stainless steel locking and non-locking metal plates for fracture stabilization of the hand are discussed. New technology and advances in plating makes this a timely review for surgeons treating hand fractures.

The authors suggest it is time now for additional improvements in plates so that they can be used for more hand fractures, especially in older adults with fragile bones. These are the patients most likely to fall and develop hand fractures that will need plating. Continued improvements in materials and new locking strategies may make it possible to increase the use of these devices.

References:
Mark A. Yaffe, MD, et al. Non-Locked and Locked Plating Technology for Hand Fractures. In The Journal of Hand Surgery. December 2011. Vol. 36A. No. 12. Pp. 2052-2055.

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