basic principles and techniques of internal fixation of fractures
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Basic Principles and Techniques of Internal Fixation of Fractures. Brett D. Crist, MD Original Author: Dan Horwitz, MD; March 2004 Revision Author: Michael Archdeacon, MD, MSE; January 2006 New Author: Brett D. Crist, MD; October 2009. “Common” Definitions of Fracture Healing. Union - PowerPoint PPT PresentationTRANSCRIPT
Basic Principles and Techniques of Internal Fixation of Fractures
Brett D. Crist, MD
Original Author: Dan Horwitz, MD; March 2004Revision Author: Michael Archdeacon, MD, MSE; January 2006
New Author: Brett D. Crist, MD; October 2009
“Common” Definitions of Fracture Healing
• Union– Bone’s mechanical stability restored to withstand normal loads
• Clinically: no pain at fracture site• Radiographically: 3 out of 4 cortices with bridging callus
• Delayed Union – Fx not consolidated at 3 months, but progressive callus
• Non Union– No improvement clinically or radiographically over 3
consecutive months– A fibrocartilaginous interface
From: OTA Resident Course – Russel, T
High Energy vs. Low Energy
• “High Energy" – Direct axial load or bending force– Fall from height/Motor vehicle crash– Soft tissue envelope significantly
damaged – Comminuted fracture patterns– Open fractures
• “Low Energy“– Twisting mechanism or direct load
on weak bone– Fall from standing– Less soft tissue injury– Simple fracture pattern
“High Energy"
“Low Energy"
Fracture Patterns• Fracture patterns occur based on mode, magnitude
and rate of force application to bone– Bending Load → transverse fx with wedge segment
• 3-point Bend →Wedge fragment
• 4-point Bend → Segmental fragment
– Torsional Load → oblique or spiral fx
– Axial Load → Articular impaction (Plateau, Pilon, etc.)
Fracture Patterns• Understanding these patterns and the inherent
stability of each type is important in choosing the most appropriate method of fixation and surgical approach
High Rate of HealingHigh Rate of Healing
Spectrum of Healing
Absolute Stability =10 Bone Healing
Relative Stability =20 Bone Healing
Biology of Bone HealingTHE SIMPLE VERSION...
Fibrous Matrix > Cartilage > Calcified Cartilage > Woven Bone > Lamellar
Bone
Haversian Remodeling
Minimal Callus
Callus
Biology of Bone Healing
• Direct/Primary bone healing– Requires rigid internal fixation
and intimate cortical contact –absolute stability
– Minimal callus formation
– Cannot tolerate fracture gap
– Interfragmental compression will minimize fracture motion
– Relies on Haversian remodeling with bridging of small gaps by osteocytes (cutting cones)
Figure from: OTA Resident Course - Russel
Biology of Bone Healing
• Indirect/Secondary Bone Healing = CALLUS– Divided into stages
• Inflammatory Stage
• Repair Stage
– Soft Callus Stage
– Hard Callus Stage
• Remodeling Stage
3-24 mo
– Relative stabilityFigures from: OTA Resident Course - Russel
Practically speaking...
Primary/Direct Bone Healing
• Simple fracture patterns • See the fx during surgery
and directly reduce and fix with:– Lag screws– Plates and screws
Secondary/Indirect Bone Healing
• Complex fracture patterns• Don’t directly see the
fracture during surgery (use fluoro)
• Indirectly reduce the fx and fix with:– IM Rods – Bridge plate fixation– External fixation– Cast
• Relative Stability
• Absolute Stability
– IM nailing– Ex fix– Bridge plating–Cast
– Lag screw/ plate
– Compression plate
Fixation Stability
Absolute
(Rigid)
Relative
(Flexible)
Spectrum of Stability
Cast
IM Nail
Compression Plating/ Lag
screw
Ex Fix
Bridge Plating
Practically speaking….
• Most fixation probably involves components of both types of healing. Even in situations of excellent rigid internal fixation one often sees a small degree of callus formation...
Relative (Rigid)
Absolute
(Flexible)
No callus
Fixation Stability
Callus
Reality
Functions of Fixation
• Interfragmentary Compression– Lag Screw
• Plate Functions– Neutralization
– Buttress
– Bridge
– Tension Band
– Compression
– Locking
• Intramedullary Nails– Internal splint
• Bridge plate fixation– Internal splint
• External fixation– External splint
• Cast– External splint
*Not internal fixation
Indications for Internal Fixation
• Displaced intra-articular fracture
• Axial, angular, or rotational instability that cannot be controlled by closed methods
• Open fracture
• Polytrauma
• Associated neurovascular injury
MULTIPLE REASONS EXIST BEYOND THESE...
Benefits of Internal Fixation
• Earlier functional recovery
• More predictable fracture alignment
• Potentially faster time to healing
Screws• Cortical screws:
–Greater number of threads–Threads spaced closer together (pitch is (smaller pitch)–Outer thread diameter to core diameter ratio is less–Better hold in cortical bone
• Cancellous screws:– Larger thread to core diameter ratio –Threads are spaced farther apart (pitch is greater)– Lag effect with partially-threaded screws – Theoretically allows better fixation in cancellous bone
Figure from: Rockwood and Green’s, 5th ed.
Lag Screw Fixation
• Screw compresses both sides of fx together– Best form of compression– Poor shear, bending, and
rotational force resistance
• Partially-threaded screw (lag by design)
• Fully-threaded screw (lag by technique)
1
2
Figure from: Schatzker J, Tile M: The Rationale of Operative Fracture Care. Springer-Verlag, 1987.
Lag Screws• “Lag by technique”
• Using fully-threaded screw
• Step One: Gliding hole = drill outer thread diameter of screw & perpendicular to fx
• Step Two: Pilot hole= Guide sleeve in gliding hole & drill far cortex = to the core diameter of the screw
Lag Screws
• Step Three: counter sink near cortex so screw head will sit flush
• Step Four: screw inserted and glides through the near cortex & engages the far cortex which compresses the fx when the screw head engages the near cortex
Figure from: Schatzker J, Tile M: The Rationale of Operative Fracture Care. Springer-Verlag, 1987.
Lag Screws
• Functional Lag Screw - note the near cortex has been drilled to the outer diameter = compression
• Position Screw - note the near cortex has not been drilled to the outer diameter = lack of compression & fx gap maintained
Figure from: OTA Resident Course - Olsen
Lag Screws
• Malposition of screw, or neglecting to countersink can lead to a loss of reduction
• Ideally lag screw should pass perpendicular to fx
Neutralization Plates
• Neutralizes/protects lag screws from shear, bending, and torsional forces across fx
• “Protection Plate"
Figure from: Schatzker J, Tile M: The Rationale of Operative Fracture Care. Springer-Verlag, 1987.
Buttress / Antiglide Plates
• “Hold” the bone up• Resist shear forces during
axial loading – Used in metaphyseal
areas to support intra-articular fragments
• Plate must match contour of bone to truly provide buttress effect
• Order of fixation:• Articular surface compressed with
bone forceps and provisionally fixed with k-wires
1. Bottom 3 cortical screws placed • Provide buttress effect
2. Top 2 partially-threaded cancellous screws placed
• Lag articular surface together3. Third screw placed either in lag or
normal fashion since articular surface already compressed
Buttress Concepts
Figure from: Schatzker J, Tile M: The Rationale of Operative Fracture Care. Springer-Verlag, 1987.
Antiglide/Buttress Concepts
• Plate is secured by three black screws distal to the red fracture line
• Axial loading causes proximal fragment to move distal and to the left along fracture line
• Plate buttresses the proximal fragment
• Prevents it from “sliding”
• Buttress Plate
– When applied to an intra-articular fractures
• Antiglide Plate
– When applied to diaphyseal fractures
Bridge Plates
• “Bridge”/bypass comminution
• Proximal & distal fixation• Goal:
– Maintain length, rotation, & axial alignment
• Avoids soft tissue disruption at fx = maintain fx blood supply
Tension Band Plates
• Plate counteracts natural bending moment seen w/ physiologic loading of bone
– Applied to tension side to prevent “gapping”
– Plate converts bending force
to compression
– Examples: Proximal Femur & Olecranon
JOINT SURFACE
Tension band
Tension Band Theory • The fixation on the opposite side from the articular surface
provides reduction and compressive forces at the joint by converting bending forces into compression • The fracture has tension forces applied by the muscles or load
bearing
Load applied to bone
• The tension band prevents distraction and the force is
converted to compression at the joint • The tension band functions like a door hinge,
converting displacing forces into beneficial compressive forces at the joint
JOINT SURFACE
Tension band
Load applied to bone
• Wires can be used for tension band as well
• Ex: Olecranon and patella• 2 K-wires from tip of olecranon
across fx site into anterior cortex to maintain initial reduction and anchor for the tension wire
• Tension wire brought through a drill hole in the ulna
• Both sides of the tension wire tightened to ensure even compression
• Bend down and impact wires
Classic Tension Band of the Olecranon
Figure from: Rockwood and Green’s, 4th ed.
Compression Plating• Reduce & Compress
transverse or oblique fx’s– Unable to use lag screw– Exert compression
across fracture • Pre-bending plate• External compression
devices (tensioner)• Dynamic compression w/
oval holes & eccentric screw placement in plate
Examples- 3.5 mm Plates
• LC-Dynamic Compression Plate:– stronger and stiffer– more difficult to contour.– usually used in the
treatment radius and ulna fractures
• Semitubular plates:– very pliable – limited strength– most often used in the
treatment of fibula fractures
Figure from: Rockwood and Green’s, 5th ed.
Figure from: Rockwood and Green’s, 5th ed.
Compression
• Fundamental concept critical for primary bone healing
• Compressing bone fragments decreases the gap and maintains the bone position even when physiologic loads are applied to the bone. Thus, the narrow gap and the stability assist in bone healing.
• Achieved through lag screw or plating techniques.
Plate Pre-Bending Compression
• Prebent plate– A small angle is bent into the
plate centered at the fracture
– The plate is applied
– As the prebent plate compresses
to the bone, the plate wants to straighten and forces opposite cortex into compression
– Near cortex is compressed via standard methods
• External devices as shown
• Plate hole design
Plate Pre-Bending Compression
Screw Driven Compression Device
• Requires a separate drill/screw hole beyond the plate
• Concept of anatomic reduction with added stability by compression to promote primary bone healing has not changed
• Currently, more commonly used with indirect fracture reduction techniques
Figure from: Schatzker J, Tile M: The Rationale of Operative Fracture Care. Springer-Verlag, 1987.
Dynamic Compression Plates
• Note the screw holes in theplate have a slope built intoone side.
• The drill hole can be purposely placed eccentrically so that when the head of the screw engages the plate, the screw and the bone beneath are driven or compressed towards the fracture site one millimeter.
This maneuver can be performed twice before compression is maximized.
Figure from: Schatzker J, Tile M: The Rationale of Operative Fracture Care. Springer-Verlag, 1987.
Dynamic Compression Plating
• Compression applied via oval holes and eccentric drilling– Plate forces bone to
move as screw tightened = compression
Lag screw placement through the plate
• Compression can be achieved and rigidity obtained all with one construct
• Compression plate first
• Then lag screw placed through plate if fx allows Figure from: Rockwood and Green’s, 5th ed.
Locking Plates
• Screw head has threads that lock into threaded hole in the plate
• Creates a “fixed angle” at each hole
• Theoretically eliminates individual screw failure
• Plate-bone contact not critical Courtesy AO Archives
Locking Plates
• Must have reduction and compression done prior to using locking screws– CANNOT PUT CORTICAL SCREW OR LAG
SCREW AFTER LOCKING SCREW
Locking Plates
• Increased axial stability
• It is much less likely that an individual screw will fail– But, plates can still
break
Locking Plates
• Indications:– Osteopenic bone– Metaphyseal
fractures with short articular block
– Bridge plating
Intramedullary Nails• Relative stability• Intramedullary splint• Less likely to break with
repetitive loading than plate
• More likely to be load sharing (i.e. allow axial loading of fracture with weight bearing).
• Secondary bone healing• Diaphyseal and some
metaphyseal fractures
Intramedullary Fixation
• Generally utilizes closed/indirect or minimally open reduction techniques
• Greater preservation of soft tissues as compared to ORIF
• IM reaming has been shown to stimulate fracture healing
• Expanded indications i.e. Reamed IM nail is acceptable in many open fractures
Intramedullary Fixation• Rotational and axial
stability provided by interlocking bolts
• Reduction can be technically difficult in segmental and comminuted fractures
• Maintaining reduction of fractures in close proximity to metaphyseal flare may be difficult
• Open segmental tibia fracture treated with a reamed, locked IM Nail.
• Note the use of
multiple proximal interlocks where angular control is more difficult to maintain due to the metaphyseal
flare.
• Intertrochanteric/Subtrochanteric fracture treated with closed IM Nail
• The goal:• Restore length,
alignment, and rotation
• NOT anatomic reduction
• Without extensive
exposure this fracture formed abundant callus by 6 weeks
Valgus is restored...
Reduction Techniques…some of the options
Indirect Methods
• Traction-assistant, fx table, intraop skeletal traction
• Direct external force i.e. push on it
• Percutaneous clamps
• Percutaneous K wires/Schantz pins—”Joysticks”
• External fixator or distractor
Direct Methods
• Incision with direct fracture exposure and reduction with reduction forceps
Reduction Techniques
• Over the last 25 years the biggest change regarding ORIF of fractures has probably been the increased respect for soft tissues.
• Whatever reduction or fixation technique is chosen, the surgeon must minimize periosteal stripping and soft tissue damage.– EXAMPLE: supraperiosteal plating techniques
• Pointed reduction clamps used to reduce a complex distal femur fracture
• Open surgical approach• Excellent access to the fracture to place lag screws with the
clamp in place • Remember, displaced articular fractures require direct
exposure and reduction because anatomic reduction is essential
Direct Reduction Technique
• Place clamp over bone and the plate• Maintain fracture reduction• Ensure appropriate plate position proximally and distally with respect to the bone, adjacent joints, and neurovascular structures• Ensure that the clamp does not scratch the plate, otherwise the created stress riser will weaken the plate
Reduction Technique - Clamp and Plate
Figure from: Rockwood and Green’s, 5th ed.
Percutaneous Plating
• Plating through modified incisions– Indirect reduction
techniques
– Limited incision for:• Passing and positioning
the plate
• Individual screw placement
– Soft tissue “friendly”
•Classic example of inadequate fixation &
stability
•Narrow, weak plate that is too short
•Insufficient cortices engaged with screws through plate•Gaps left at the fx site
Unavoidable result = Nonunion Figure from: Schatzker J, Tile M: The Rationale of
Operative Fracture Care. Springer-Verlag, 1987.
Failure to Apply Concepts
Summary
• Respect soft tissues
• Choose appropriate fixation method
• Achieve length, alignment, and rotational control to permit motion as soon as possible
• Understand the requirements and limitations of each method of internal fixation
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