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    03-06 Internal Fixation

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    The document discusses principles of internal fracture fixation, including goals of fracture repair, types of reduction techniques, advantages and disadvantages of open reduction, factors affecting fracture repair, and various internal fixation devices and techniques. Open reduction provides rigid fixation and allows early weight bearing but is more invasive. Fracture type, extent of soft tissue damage, patient factors, and surgeon experience also influence repair. Devices discussed include K-wires, cerclage wiring, intramedullary pins, interlocking nails, screws, and bone plates. Placement techniques aim to provide stable, rigid fixation while minimizing damage to blood supply.

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    03-06 Internal Fixation

    Uploaded by

    69016
    218 views69 pages
    The document discusses principles of internal fracture fixation, including goals of fracture repair, types of reduction techniques, advantages and disadvantages of open reduction, factors affecting fracture repair, and various internal fixation devices and techniques. Open reduction provides rigid fixation and allows early weight bearing but is more invasive. Fracture type, extent of soft tissue damage, patient factors, and surgeon experience also influence repair. Devices discussed include K-wires, cerclage wiring, intramedullary pins, interlocking nails, screws, and bone plates. Placement techniques aim to provide stable, rigid fixation while minimizing damage to blood supply.

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    internal fixation

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    The document discusses principles of internal fracture fixation, including goals of fracture repair, types of reduction techniques, advantages and disadvantages of open reduction, factors affecting fracture repair, and various internal fixation devices and techniques. Open reduction provides rigid fixation and allows early weight bearing but is more invasive. Fracture type, extent of soft tissue damage, patient factors, and surgeon experience also influence repair. Devices discussed include K-wires, cerclage wiring, intramedullary pins, interlocking nails, screws, and bone plates. Placement techniques aim to provide stable, rigid fixation while minimizing damage to blood supply.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    218 views69 pages

    03-06 Internal Fixation

    Uploaded by

    69016
    The document discusses principles of internal fracture fixation, including goals of fracture repair, types of reduction techniques, advantages and disadvantages of open reduction, factors affecting fracture repair, and various internal fixation devices and techniques. Open reduction provides rigid fixation and allows early weight bearing but is more invasive. Fracture type, extent of soft tissue damage, patient factors, and surgeon experience also influence repair. Devices discussed include K-wires, cerclage wiring, intramedullary pins, interlocking nails, screws, and bone plates. Placement techniques aim to provide stable, rigid fixation while minimizing damage to blood supply.

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    Download as PPT, PDF, TXT or read online from Scribd
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    of 69

    Principles of Internal Fixation

    Loretta Bubenik, DVM, MS Diplomate ACVS March 6, 2002

    Principles of Internal Fixation


    The Goals of fracture repair are
    Atraumatic technique Good reduction Stable fixation Early return to full function******

    Principles of Internal Fixation


    Open reduction
    Surgically exposure of the fracture site Implants placed internally

    Closed reduction
    Fracture site is not opened External fixation (casts, splints, etc.) Becoming more popular with advanced imaging

    Principles of Internal Fixation


    Advantages of open reduction
    Provides rigid fixation with few complications Allows weight bearing during fracture healing
    Health of the limb and joints Increases the circulation Promotes healing

    Internally placed implants are hidden


    No extensive care

    Principles of Internal Fixation


    Disadvantages of open reduction
    Invasive Potential for slow healing Infection Longer procedure Higher cost

    Principles of Internal Fixation


    Factures affecting fracture repair
    Type of fracture (simple/comminuted) Anatomical area fractured
    Articular Which limb Where on the bone

    Extent of soft-tissue damage Duration of the fracture

    Principles of Internal Fixation


    Factures affecting fracture repair
    Animals age, weight and temperament Owners finances and ability to provide aftercare Equipment available Surgeons experience.

    Tension

    Fracture Forces

    Bending

    Rotation

    Compression

    Orthopedic Wire

    Flexible Made of stainless

    steel Generally used in conjunction with other forms of fixation

    Full Cerclage

    Hemicerclage

    Interfragmentary

    Tension

    band

    Tension band
    Opposes tensile forces
    muscle / ligament

    converts tensile forces to compressive forces

    Wires

    Principles of full cerclage wire placement


    Fracture must be long oblique Bone must be reconstructed Use the appropriate size Never use a single cerclage wire Place wires ~ 1 cm apart Place wires ~ 0.5 cm from fracture

    Wires

    Principles of full cerclage wire placement


    Do not entrap soft tissues Place perpendicular to bone Lock wire in place where it changes diameter (K-wire or notch) Wires must be tight Do not bend ends over

    Wires

    Securing full cerclage


    Twisted wires
    Wire holders/pliers Wire tighteners

    Single and double loop wires


    Special tensioning device required

    Good

    Bad

    Wires

    Other facts
    Bending the twist Cutting the twist Twist vs loops Shift in bone diameter Blood supply

    Intramedullary (IM) Pins

    Very resistant to bending forces Require little equipment to place Easy to remove Do little damage to blood supply if
    properly used Inexpensive Closed or open techniques

    IM pins do not counteract


    rotational forces
    External fixator Plate Cerclage wires

    Use additional fixation

    Provide endosteal contact


    Fill 70% of the bone diameter

    Stacked pins
    Do not provide appreciable stability

    IM pins alone are

    poorly suited for comminuted fractures

    They cant withstand


    axial forces

    Collapse and

    instability will result

    Steinmann pins are

    most commonly used

    They pins vary in


    diameter
    Proportional to strength

    Vary in point
    morphology
    Chisel Trocar Threaded

    IM pin insertion
    Jacobs chuck Low speed drill Retrograde Normograde

    Retrograde Insertion:
    Pin inserted from fracture site and driven through epiphysis

    Normograde insertion
    Pin inserted at epiphysis and driven across fracture line

    Femur
    Retro or Normograde Extend hip

    Intertrochanteric fossa
    Direct laterally Over reduce

    Tibia
    Always Normograde
    Countersink or cut short

    Intra-articular

    Humerus
    Retro or Normograde
    Exit or start distal to greater tubercle on the lateral aspect Direct into medial aspect of condyle

    Radius
    Avoid IM pins in the radius Must go through a joint
    Radius is oval

    Kirschner Wires

    Small and elastic Usually used as:


    Transcortical pins (skewer wires) Pin and tension band fixation Cross pinning
    Dynamic pinning

    Interlocking Nails

    Specialized IM pin Locked in place with bone screws Counteracts all fracture forces Can be used for fractures of the femur,
    tibia, and humerus Can be placed open or closed Limited approach

    Interlocking Nails
    4, 4.7, 6, and 8 mm Various lengths Screw holes
    2 1 2 1 proximal, proximal, proximal, proximal, 2 2 1 1 distal distal distal distal

    Interlocking Nails
    A few specifics
    Chose the biggest nail possible Dont place an empty hole at the fracture site Place screws 2 cm away from fracture Try to use four screws total Use smaller screws for 6 and 8 mm nails Can dynamize the fracture

    Screws

    Cortical Screws
    More threads, low pitch, thin thread Only Fully threaded Used for cortical bone

    Cancellous Screws
    Less threads, steep pitch, wide thread Fully and partially threaded Used in soft bone

    Screws

    Used to secure bone plates to bone Used as primary means of fracture repair Used to hold fracture fragments in place Used to compress fracture fragments Used to form prosthetic ligaments

    Screws

    Positional screws
    Hold bone fragments in place Do not provide compression Threads engage both near and far cortex Must be placed perpendicular to bone
    if positioning small fragments

    Screws

    Lag principle
    Used to compress fracture fragments Used to hold plates on bone Threads only engage far cortex Must be placed perpendicular to the bone Can be accomplished with
    partially threaded screw over drilling near cortex

    Screws

    Screws

    Lag principle
    Used for interfragmentary compression Used for primary fracture repair
    Articular fractures Sacroiliac luxations

    Screws

    Do not over tighten the screw, this will cause stripping and screw loosening

    Bone Plates

    Necessary for many fractures Requires specialized equipment and

    training Not readily available in many practices More expensive than pinning

    Bone Plates

    Counteract
    Tension Compression Shear Bending Rotational forces

    Bone plates should be placed on the tension side of the bone

    Tension side of the bone

    Femur
    Craniolateral

    Radius
    Cranial

    Tibia*
    Craniolateral

    Unla*
    Caudal

    Humerus
    Craniolateral

    Mandible*
    dorsal

    Some are not plated on the tension side due to impracticality and added difficulty

    Plates are stronger if load sharing with the bone occurs

    Plates come in a wide variety of shapes and sizes

    Plates

    Functions
    Neutralization Compression Buttress

    Neutralization

    Plate protects primary

    repair from weight-bearing forces

    The weight-bearing load is


    shared by both the plate and the bone

    Compression

    Mechanical compression

    added to the fracture site

    The weight-bearing load is


    shared by both the plate and the bone

    Primary bone healing


    results

    Buttress

    Spans a gap to prevent


    collapse of a fracture

    All of the weight-bearing


    forces are transmitted through the plate

    Plates

    Plate placement
    Reconstruct the bone Contour plate Drill, measure, and tap screws (one by one) Apply screws from the fracture site out, alternating bone fragments Engage at least six cortices per a major bone fragment
    More for comminuted fractures if possible

    Plates

    Dynamic compression plates


    Allows compression of major bone fragments
    External compression

    Screws must be LOADED in order to get compression


    Plate can function in compression, neutralization, and as a buttress plate depending on how the screws are applied

    1) Load Drill Guide: Provides 1 mm compression,


    screws are placed eccentrically
    little displacement is provided.

    2) Neutral Drill Guide: Places the drill hole centrally, thus

    Loading a screw in the DCP for compression

    Applying compression to a fracture

    Plates-Rod constructs

    Used for comminuted fracture repair Decreases bending stress on plate Counteracts rotational and axial forces IM pin only needs to fill 30-40% of the
    canal diameter Monocortical screws are o.k.
    Make sure you engage enough cortices

    Removing Implants

    In general, it is recommended that all


    orthopedic implants be removed

    In practice, however, we rarely remove


    orthopedic implants

    Removing Implants

    Why dont we remove them


    Cost Post-op confinement required Traumatic surgery Anesthesia risk Potential for refracture

    Removing Implants

    When to recommend removal


    Interferes with function Loosening or Breakage Infection Thermal conduction Biological reaction to implants Young dogs?????

    Removing Implants

    Radiographs should document healing


    prior to removal
    Unless implant failure

    Warn owners about potential for bone


    breakage
    Cage rest required after plate removal

    Good idea to culture implants

    Removing Implants

    IM pins are easier to remove than plates


    Must leave pins long enough Not the same refracture worry

    Young dogs tend to over-grow the

    implants and they are hard to remove

    Plates on the pelvis and humerus should


    be left in place if not causing a problem

    Advantages of one over another

    IM pins are cheaper than plates and


    interfere with blood supply less

    Little equipment is required for pin


    placement

    IM pins can migrate, especially if motion


    is present

    Advantages of one over another

    IM pins must be combined with another


    form of fixation
    Cross pins can be used as a primary fracture repair in some instances

    IM pins are not ideal for comminuted or

    transverse fractures (limits to amendable fractures)

    Advantages of one over another

    Interlocking nails counteract all fracture


    forces and may do it better than plates

    Interlocking nails do require a lot of

    equipment and some expertise to place them, but are cheaper than plates

    Interlocking nails are limited by the type

    of fracture you can repair and the size of the animal

    Advantages of one over another

    Plates counteract all fracture forces Plates are versatile and can be applied to
    many fracture types and animal sizes

    Plating requires some expertise and


    expensive equipment

    Advantages of one over another

    Plating requires an aggressive surgical


    approach in most instances

    Plates may interfere with blood supply


    more than any of the other implants
    Clinically not a major problem

    Advantages of one over another

    Open approaches may delay fracture


    healing and predispose to infection
    Plates/screws Interlocking nails

    Closed approaches can be used with


    IM pins
    External fixator

    Interlocking nails require a limited approach

    Advantages of one over another

    Hidden implants allow early function with


    out hassle of extra care
    Casts and ex-fixators have added care

    Articular fractures generally require open


    approaches and stable fixation
    Plates are more ideal Lag screws are used in many instances

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