Wrong selection of orthopaedic fracture fixation plates

A directive alert has been jointly issued with the British Orthopaedic Association on the risk of harm from the wrong selection of plates used for fixation of fractures.

A variety of fracture fixation plates are used in orthopaedic surgery including dynamic compression plates (DC plates) and reconstruction plates. These plates have different properties, importantly their rigidity and strength, and the two types are not interchangeable. Recent changes in the design of some reconstruction plates has made it easier to confuse types of plates that were once visually distinct.

Some organisations use an instrument tray system, where multiple plates and screws are contained on the same tray, which is replenished and resterilised after each operation. This creates a risk of confusing the types of plates used both at the point the tray is replenished and at the point a plate is selected for use. Where individual, sterilised packs for each different type of plate are used, the risk of wrong selection is likely to be lower but still exists, especially if both types of plates have been made ready for use.

To provide a stronger barrier to inadvertent wrong selection, the alert asks providers to put an action plan to purchase reconstruction plates as individually sterilised packs, ensure these packs are stored separately, and to ensure they are only fetched and taken out of their sterile packaging when specifically required.

Providers are also asked to identify all patients who have had a plate fitted since 1 February 2018 for the treatment of shaft fractures and undertake a retrospective review of patient X-rays to ensure the correct plate was used.

Patient safety alerts are shared rapidly with healthcare providers via the Central Alerting System (CAS).

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