Because of the large number of locations where fractures occurs and the different bones involved there is a variety of plates available. The dynamic compression plate or DCP allows a sliding technique to be used because of the screw holes being angled away from a central point. Once the screws are inserted and tightened they apply an inwards compression force, bringing the fragments into stronger contact. The ulna and the ankle lateral malleolus are fixed with thin plates of about one mm in thickness which can be shaped to the area required. Fractures close to a joint need specially designed plates to facilitate fixation and reduce impingement.

Upper femoral fractures are often stabilised with a plate which has an angle of 95 degrees to restore the normal anatomy of the upper femoral area. Internal fixation with this plate demands three dimensional thinking on behalf of the surgeon so that the anatomy can be restored to the normal relationships. Reconstruction plates can be moulded to the contours of the pelvis and acetabulum in three dimensions as they are thinner than dynamic compression plates. If a fracture is next to or just below a joint replacement prosthesis they are often managed with larger plates which also include the ability to use cerclage wiring.

Plate fixation along with good anatomical reduction and compression of the fragments against each other provide high levels of stability to the fracture. The fracture will undergo primary healing if there is no gap and the fixation is very stable. The dead bone close to the fracture site is absorbed by the osteoclasts, bone absorbing cells, followed by the growth of blood vessels into the area, followed by osteoblasts which are bone producing cells. Some osteoporosis of the area under the plate may be produced due to disruption of the blood flow locally by the plate and when the plate is removed the lowered bone density and the screw holes needs to be borne in mind when planning rehabilitation.

Internal fixation with a plate involves opening up the fracture site and removing the blood clot, reducing the fragments to an anatomically acceptable alignment. A fracture interrupts the blood supply across and around a fracture and the remaining blood supply is provided by the periosteal bone lining. The periosteum should be preserved and not stripped away during the operation or healing could be delayed from reduced vascular supply. Unstable comminuted fractures are more difficult to fix and bridge plates are used to fix the two main parts and keep the important aspects of the bone in line, the rotation, alignment and length of the bones. However this form of weaker fixation cannot tolerate any significant level of load.

More modern plating techniques include the LISS (Less Invasive Surgical Stabilisation) which makes less contact with the bone surface along its length, limiting potential disturbance in the membranous blood supply. Locking screw methods are typical newer designs, which offer great advantages over older systems by adhering to bony contours better also. These designs should allow greater forces to be tolerated while the fracture is still being held in the desired position. These are of particular use in fractures of the distal and proximal humerus, distal femur, distal radius and distal tibial fractures.

If there is enough room for easy fixation and the fracture is of a more stable type then conventional plating techniques may be used for fixing breaks of the shafts of bones such as the radius, ulna and humerus. Locking screws are more appropriate if the bone is osteoporotic or the fixation options are limited. Future development will likely lead towards locking techniques being the first option for all fractures, but they are much more expensive and wider use awaits reduction in costs. If the costs of revising the fixation due to malunion by conventional plating are factored in then the more expensive initial system looks more cost neutral.

Nails

Nailing techniques were standardised in the 1930s by Kuntscher, who made them the default management options for femoral shaft fractures, the option gradually being extended to breaks in the tibia and humerus as well as femoral fractures nearer the bone ends. Inserting a nail stabilises the fracture for early joint mobilisation and ambulation.