Professional Documents
Culture Documents
Reduction Technique
in Fracture Surgery
J.Mast R.Jakob R.Ganz
Planning and
Reduction Technique
in Fracture Surgery
Foreword by H. Willenegger
~ Springer
Jeffrey Mast, MD, Associate Clinical Professor
Department of Orthopedic Surgery
Wayne State University, Hutzel Hospital
4707 St. Antoine Blvd., Detroit, MI 48201, USA
Roland Jakob, MD
Department of Orthopedic Surgery
University of Berne, Inselspital
CH-3010 Berne, Switzerland
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© Springer-Verlag Berlin: Heidelberg 1989
Softcover reprint of the hardcover 1st edition 1989
Foreword
During the past 30 years, the Study Group for the Problems of Osteosyn-
thesis (AO) has made decisive contributions to the development of osteo-
synthesis as a surgical method. Through close cooperation among special-
ists in the fields of orthopedic and general surgery, basis research,
metallurgy, and technical engineering, with consistently thorough follow-
up, it was possible to establish a solid scientific background for osteosyn-
thesis and to standardize this operative method, not only for the more ob-
vious applications in fracture treatment, but also in selective orthopedics
where hardly any problems relating to bone, such as those with osteoto-
mies can be solved without surgical stabilization. Besides the objective
aim, the AO was additionally stimulated by a spirit of open-minded
friendship; each member of the group was recruited according to his pro-
fessional background and position, his skills, and his talent for improvisa-
tion.
Against this backdrop without even mentioning the schooling program
well known throughout the world I should like to add some personal and
general comments.
This book is written for clinicians, instructing them how to perform osteo-
synthesis with special reference to plating in all its varieties and in strict
accordance with the biomechanical and biological aspects and facts.
From this point of view, the chapter on preoperative planning merits par-
ticular emphasis. Not only is it conductive to optimal surgery, it will also
contribute to self-education and may found a school. Preoperative plan-
ning thus appears as a leitmotif throughout the whole book. The theme is
illustrated with a number of fascinating details and suggestions concerning
fracture repair and the different kinds of osteotomies, always closely
linked with further fundamental concepts: minimal disturbance of blood
flow, minimal hardware, optimal stability.
I perused with special interest the chapter on plate fixation. All plates
(straight and angled) were implanted with the patient on a conventional
operating table without X-ray control, even in the case of a segmental frac-
ture, shortening, or comminution. For such cases, the AO distractor is the
instrument of choice; the reduction can be achieved without external trac-
tion, avoiding the need for both the traction table and the technically de-
manding insertion of an interlocking nail. Following the precepts outlined,
the results are convincing, provided that the specific problems of the plate,
which is in eccentric position, are taken into consideration. The AO dis-
tractor simplifies the reduction of a fracture to be treated by intramedul-
lary nailing. In certain cases, the plate itself can be used as a reduction in-
strument, for instance by applying the plate first at the proximal part of
VIII
Preface
Contents
Chapter 1: Rationale . . . . . . . . . . . . . . . . . . . . . . . . . .. 1
References . . . 251
Glossary
Chapter 1: Rationale
This book is written with the purpose of sharing with you various tech-
niques that will facilitate your efforts to obtain a successful result in the
operative treatment of difficult extremity fractures. The primary objective
in these challenging operations is to apply the basic principles of stable
fixation with the least possible disturbance of the soft tissues.
Unquestionably, the correct application of the AOI ASIF techniques has
benefited thousands of patients. In mUltiple international conferences, or-
thopedic surgeons have learned the practical aspects of the use of com-
pression, neutralization, and splintage in fracture surgery. These basic
principles outlined in the AO manual [25] remain the foundation for the
successful application of the methods to be discussed. Satisfaction of this
prerequisite, allied with a better knowledge of the instrumentation and a
desire to maintain the viability of the surgical zone, gives us the ability to
enhance our results.
Logically, then, functional treatment can be extended to fractures with se-
vere comminution, emphasizing the biologic rather than the purely me-
chanical principles. This book will discuss the means of achieving fracture
reduction with the least motor input and the least devitalization of a living
tissue - bone - and yet produce an internal fixation that is mechanically
sound and conservatively applied.
The postoperative X-ray is the visual statement of the surgical interven-
tion. By analyzing the results of our prior cases we can follow the evolu-
tion of the sophistication of our technique, a direct expression of increased
understanding and improved skills. Similarly, it is interesting to compare
the editions of the Manual of Internal Fixation [25] from 1963 to 1979.
Comparing the reduction and fixation montages for various fracture types
the different editions, the reader sees the evolution of the system. This de-
velopment was assisted by critical review of the results of fixation; in AO
clinics, in courses, and in review of the materials in the AO Documenta-
tion Center (Bern, Switzerland).
What are the requisites for reduction? In general, these depend on the spe-
cific bone and on the anatomic location of the fracture in that bone. In the
diaphysis, we must be faithful to the axis of extremity by restoring the
bony shaft so as not to leave residual angulations in the frontal or sagittal
planes. In the horizontal plane, rotational alignment must be correct. In
young adults or active individuals, we should avoid shaft displacements
and shortening or lengthening, particularly in the lower extremities. How-
ever, the anatomic reduction of each fracture surface is not critical, nor
should it be the absolute goal in this region, especially if the trade-off for
anatomicity is the devitalization of the fracture zone [2, 9, 12].
2
In the metaphysis the same principles hold true. However, we often must
introduce bone or a suitable substitute into metaphyseal areas which have
lost substance due to the impaction of cancellous bone by axial forces
transmitted from the articular surface.
In the epiphysis, anatomic reduction requirements are more severe. The
articular surface and its subchondral supporting system demand accurate
repositioning of displaced fragments so that the joint surfaces remain
smooth and congruent.
Likewise, the distribution of the soft tissue that corresponds to the ana-
tomic segments of bone influences the surgical approaches and tactics
used to obtain a reduction. For example, indirect reductions in diaphyseal
femur fractures are logical because of the extensive muscular envelope
which surrounds the bone. If a plate is to be used, the surgical approach
must be conservative, taking care to preserve soft tissue attachments to all
of the fragments. Obviously, this favors traction reduction and intramedul-
lary fixation in this area as only one end of the bone is exposed. In con-
trast, in fractures involving the joint surface, the bone is more easily acces-
sible because of the relatively thin soft tissue envelopes surrounding it (the
exceptions being the acetabulum and the glenoid), and a direct reduction
followed by internal fixation may be possible.
Nevertheless, reduction and stable fixation of fractures remains a difficult
task. Knowledge of all the tricks in the fracture surgeon's repertoire is nec-
essary. The variations in technique presented in this book will hopefully
offer alternative and useful solutions for problem fractures.
The bone surgeon develops, with time and experience, a sense of balance,
a sense of the relationship of implants to the fracture pattern. The end re-
sult of a successful procedure is immediate satisfaction with a fixation
complex which is correct. In this context, "correct" implies an economy of
foreign material which satisfies the mechanical demands of the fracture.
The fixation montage will vary depending on the fracture configuration,
i. e., torsional fractures versus bending fractures, the presence of absence
of osteoporosis, and the presence or absence of preload. However, in the
end, each screw used should have a specific function. This may be to pro-
vide interfragmentary compression, fixation of the main implant, or both
Fig. 1.1, pages 5-7 (Figs. 1.1, 1.2).
Fig. 1.2, page 8 Anticipation and sequential stabilization are two helpful principles in frac-
ture surgery that are discussed in this volume. By "anticipation" we mean
preoperative planning. Using drawings, the surgeon can arrive at the best
methodes) of solving a difficult problem. The surgery is performed on pa-
per prior to being carried out in the operating room. In this manner, the
surgeon can better grasp the entirety of the problem and devise appropri-
ate solutions. The methods described should allow the surgeon to get a
feel for the kinetics of the surgical procedure. This sense of dynamics
comes from "playing" with the tracings, superimposing one on the other,
lengthening or shortening, angulating or displacing. If, as occasionally
occurs, drawings cannot be made from the fracture and the operation
cannot be planned (i. e., when there is too much comminution of bone),
modification of the usual approach is necessary, perhaps aiming for pri-
mary fusion in an articular fracture or indirect splinting in a diaphyseal
fracture. In the case of a different or unusual approach, preoperative sim-
3
ulation of surgery saves operative time and energy and avoids subsequent
problems.
The careful development of an operative plan allows more sophisticated
methods of indirect reduction to be carried out. This in turn leads directly
to maintaining viability of the bone fragments by limiting the amount of
dissection necessary to carry out the internal fixation.
Sequential stabilization means that each step in the operative procedure
increases the stability of the fractured bone. This is not a new concept. The
fracture table used by most orthopedic surgeons is a means of obtaining
relative control of unstable bone fragments. The problem is, however, that
traction is exerted indirectly on the entire limb, including the fractured
bone. Additionally, because the joints are not free to move, the fracture
table may be a hindrance. Also, the table is cumbersome outside of the op-
erative field, necessitating communication with an "unscrubbed surgeon"
who may be unfamiliar with basic orthopedic jargon. We have all experi-
enced the difficulties posed by a comminuted subtrochanteric fracture in
which the fracture table has been employed as an adjunct to operative fix-
ation. Visibility is compromised without doing extensive soft tissue strip-
ping, and in extension, for example, the lesser trochanter is displaced by
its attachment to the iliopsoas, which can make reduction of the proximal
medial fragments all but impossible without being able to move the hip
freely.
New instruments such as the femoral distractor and the articulating ten-
sion device provide, through localized distraction, ways of obtaining a re-
duction and at the same time increasing stability. The traction effect can
be obtained without sacrificing the mobility of the adjacent joints, and the
force is exerted directly on the bone in need of the traction. The use of
these instruments has allowed us to do many of the indirect reductions
that will be described.
"Dialing a reduction" with the femoral distractor gives the surgeon the
security afforded by a reduction accomplished with minimal energy, as
well as the knowledge that the maneuver can be repeated if necessary. This
approach replaces the suspense of the old approach: "pull hard and we
will see if we can get a clamp around it". The decision is now how and
where to insert a set of connecting belts so that the fracture will reduce
when the distraction is applied. Because the femoral distractor essentially
acts like an external fixator when we connect it, we have increased the sta-
bility of the fracture zone, which makes further steps easier to perform.
Fracture surgeons share the instability problems of the mountain climber.
The mountaineer has been schooled in basic techniques, has learned from
past experience, and approaches his task tactically. He has an array of
simple but effective devices - ropes, pitons, chucks, etc. - to keep his in-
stability relatively limited. He remains thoughtful, calm, and organized. In
tackling the problems of his climb, he protects himself with the knowledge
of how to use the equipment at his disposal. In principle, his plan is based
on controlling instability at each point along the way. The fracture sur-
geon's task is in a way similar. In the relative security of our operating
rooms we as well must deal with instability. The operative fixation of frac-
tures is a controlled conversion of instability to stability.
This is best accomplished when our approach has been thought out be-
4
forehand so that each step along the way is a secure one, permitting us to
reach our goals of maximum patient safety and a minimum of anxiety for
the surgeon. We too can move stepwise toward the eventual solution of the
problem confident that our result has restored the relationships of the
Fig. 1.3, page 9 bone and left nature minimally scarred (Fig. 1.3).
Fig.l.l. a A closed comminuted fracture though seventeen screws have been in- ~
of the femur in a 22-year-old male. b The serted, they have not been incorporated
operative treatment consisted of plate fix- into a stable fixation complex. There is
ation of the femur. This case illustrates a inadequate fixation proximal, between
problem produced by a deficient under- and distal to the segmental fracture lines.
standing of both the mechanics and the c The combination of these errors pro-
biology involved in the selected treat- duces a predictable failure, seen at
ment. The postoperative X-rays are seen 14 weeks. Biologic and mechanical fac-
at approximately 6 weeks after the opera- tors interact in the failure. The decreased
tion. In what appears to have been a diffi- vascularity due to the extent of the expo-
cult procedure a varus reduction has been sure increased the healing time of the
accomplished piece by piece with severe fracture and therefore placed greater de-
stripping of the periosteum. The stripping mands on the mechanical fixation, which
is implied by the fact that the screws were was also inadequate, being too short and
inserted at positions in the fracture zone not adequately spanning the fracture
circumferentially around the bone. The zone.
use of the two plates means that, al-
5
6
o
o
o
d The attempted repair was poorly conceived and again a failure be-
cause the mechanics of the plate were not considered. In this interven-
tion a bone graft was added. The avascular zone was bypassed but the
plate was "too long" for the segment of bone fixed (see diagram: note
abutment of end of plate against greater trochanter). There is a varus de-
formity and no preload exists. The femur is unstable. e Fixation fails in
14 weeks with irritation callus and loose screws. f The final, successful
procedure illustrates better principles. Bone grafting was carried out,
along with the application of the angled blade plate. The varus deformi-
ty has been corrected. The plate has been preloaded and there is only
minimal intervention at the site of the nonunion, where some revascular-
ization has already occurred. g The result is seen 3 years later. Unfortu-
nately, because of the previous mistakes in technique, the lateral cortex
of the femur has been destroyed, necessitating further procedures to re-
construct it and return the bone to normal so that it can stand alone
without the plate
7
8
healing is visualized at approximately 9 weeks after op- weight-bearing 1 day after his original surgery, testi-
eration. There is a softening of the fracture lines, each mony to the stability achieved. In contrast to the case il-
one of them slowly fading away. A sclerotic fragment is lustrated in Fig. 1.1, the surgical procedure was carried
seen along the medial cortex of the distal fragment out in a biological way by using the implant as a reduc-
which probably represents some avascularity due to the tion aid. Perfect mechanics were ensured by obtaining
original accident. This area is being successfully bridged axial compression by means of tensioning the plate, en-
by new bone formation along the most medial aspect of hanced by interfragmentary compression. The result
the fracture. d At 1 year and 2 months there is complete was a healed fracture of the femur with a functionally
healing and the fractured bone is well into the period of perfect extremity
remodeling. This patient was actually found to be fully
From: Moser H (1965) Heitere Medizin. Ein medizinisches Rilderbuch, 4th edn.
NebelspaIter-Verlag. Rorschach/Switzerland. (Reproduction with kind permission)
11
Chapter 2: Anticipation
(Preoperative Planning)
the soft tissues are intact, restoration of length and rotation results in al-
most complete reduction of the associated fragments. By tracing the frac-
ture fragments the surgeon can visualize what will happen when the proce-
dure is actually carried out, getting a sense of the "kinetics" of the
operation, the play-by-play scenario from start to successful conclusion. In
pseudarthrosis or malunion, partial or complete healing has occurred. In
these cases, the surgeon must discover the best way to correct the deformi-
ties. Ideally, such reconstructive surgery should be planned to be carried
out in a manner which allows for total correction of the deformity. All an-
gulations, malrotations, and displacements should be considered and an
osteotomy designed, when possible, that will correct all aspects of the
problem.
Planning from X-rays is possible provided one realizes the limitations of
the system [26]. Since torsional displacements are not well visualized in the
standard views there will always be a "built-in" source of error, especially
since internal rotation (varus) and external rotation (valgus) may express
themselves to modify the shadows projected in the frontal or sagittal
plane. Because of this one must sometimes utilize other techniques of
imaging, - axial views, CT scans, etc. - to appreciate how the rotation will
influence the outcome. In the end the clinical apprecation of the limb ori-
entation before and during the operation is the best way to minimize the
mistakes inherent in a approach that cannot eliminate this influence dur-
ing the planning stage.
Because X-rays represent a two-dimensional shadow of three-dimensional
structures, the following points must be kept in mind:
(1) There will always be magnification.
(2) If the deformity appears in both the AP and the lateral view, the X-ray
beam is not being directed in the plane of the deformity. That is to say,
the deformity is actually greater than is appreciated on either the AP
or lateral view and exists somewhere between the two. The plane of
the deformity and the actual magnitude of its angulation may be deter-
Fig. 2.1, page 20 mined by a simple geometric figure (Figs.2.1-2.3).
Fig. 2.2, page 21 (3) As has been mentioned, plain X-rays will not give a good indication of
Fig. 2.3, page 22 rotational or torsional deformities; these must be determined by CT
scan and/or clinical examination.
Osteotomies
As Milch [22] has instructed, there are in principle relatively few types of
osteotomy. Those most commonly used include the transverse and oblique
osteotomies. He writes that, every long bone may be classified as either
straight or bent, depending on the relations between its mechanical and
anatomic axes. Since the mechanical axis is invariably straight, it is possi-
ble to define a straight bone as one in which the mechanical axis is colli-
near with the anatomic axis. In the radius, ulna, tibia, and fibula the two
axes are so nearly the same that they may easily be recognized as straight
bones. In the humerus the head is eccentrically placed at the end of a short
anatomic neck, and as a result its proximal and distal articulations deter-
13
mine a mechanical axis which lies slightly medial to the anatomic axis;
nevertheless, the divergence between these two axes is so minimal that the
humerus too may be considered as clinically straight.
Dysfunction in straight bones is the result of displacement of the mechani-
cal axis caused by a deformity of the anatomic axis and includes clinical
entities such as mal unions and some forms of genu valgus. It should be
kept in mind that the changes are characterized by a change in direction of
the mechanical axis, and whether this arises in consequence of rotation,
angulation, transposition, or relative disproportion in length, the deformity
is essentially of a directional nature. Cure or improvement may be effected
through surgical procedures designed to correct deformity and to re-estab-
lish normal axial alignment. Such osteotomies are called directional oste-
otomies.
A bent bone may be defined as one in which the mechanical axis diverges
from the anatomical axis. The femur is a bent bone, as its long neck leads
to an axial divergence that is typical of the form and vital to the function
of the bone. The importance of the differentiation between the two bone
forms becomes clear when the femur is considered as the derivative of an
antecedent straight bone in which the upper end has been angulated. The
bending down of this upper portion to form the femoral neck has pro-
duced a medial displacement of the mechanical axis and a decrease in the
effective length of the bone. Because the limb has a specific orientation the
formation of a femoral neck leads to a multitude of clinical variations
which may be affected by the level, degree, and direction of angulation of
the neck. Dysfunction is the result of pathologic displacement of the me-
chanical axis, there being no disturbance in the direction of the anatomic
axis. Disability may arise from instability of the hip joint as a result of loss
or impairment of the normal anatomical fulcrum. Osteotomies of a bent
bone are more complex, giving rise to secondary effects that may be more
than solely directional.
In planning an operation these factors must be taken into account, and
with the drawings made the surgeon will be able to see what can be cor-
rected with which osteotomy, along with the effect the osteotomy will have
on congruency of the joint, overall length of the limb, and alignment.
Osteotomies may be employed to change length (lineal osteotomy), rota-
tion (torsional osteotomy), displacement (translational osteotomy), or an-
gulation (angular osteotomies). Most often more than one effect is desired
and a complex osteotomy must be performed.
Closing Wedge Osteotomy with Limbs Oblique to the Shaft Axis: With this
osteotomy, corrections may be made in one plane of reference, and the
other planes may be corrected to a moderate degree by passively sliding
14
the bones on their cut surfaces, thereby correcting a small amount of angu-
lation. Lengthening may be carried out by sliding the bones along one an-
other. If rotation is to be corrected, this must be anticipated and the limb
oriented before the wedge is cut from the fragment to be corrected [7]. If
this is not done, it will be necessary to leave an opening in the osteotomy
surfaces which may require bone grafting.
The advantages of an oblique osteotomy are
(1) the possibility of lengthening,
(2) the intrinsic rotational stability in the matching cut surfaces, and
(3) the ability to fix the osteotomy with a lag screw crossing the obliquity,
giving excellent compression of the surfaces. The osteotomy then may
be further neutralized with a plate.
Opening Wedge Osteotomy with a Transverse Limb Aimed at the Apex of the
Deformity: Generally speaking, with an opening wedge type of osteotomy,
one can correct all three planes and lengthen at the same time. When con-
tact is to be maintained between the two fragments the lengthening in the
diaphysis is restricted to half the length of the base of the opening wedge.
Opening Wedge Osteotomy Oblique to the Shaft Axis: This osteotomy al-
lows for the same corrections as above; however, additional lengthening
may be carried out without loss of contact between the two major frag-
ments. Because of the oblique surfaces a lag screw can be used to fix the
interpositional graft securely.
Step Cut Osteotomy: A step cut osteotomy is extremely effective when
there has been significant displacement as well as angulation. Essentially,
the osteotomy separates two major fragments with osteotomy surfaces per-
pendicular to the shaft axis, therefore allowing the restoration of length
and correction in all three planes. In the end it may be stabilized in most
cases by an intramedullary nail.
Barrel Vault or Arcuate Osteotomy: This osteotomy, described by Maquet
[16], allows angular corrections in one plane and correction of a displace-
ment at 90° to the plane in which the angular correction has been made. It
has been popularized by Maquet in the proximal tibia.
Other forms of osteotomy that are popular by reason of their enhancement
of the geometry of the cuts to provide stability or to facilitate lengthening
are the V-shaped, mortise and tenon, and Z-shaped procedures.
Modifications of the simple cuts described are frequently used to enhance
one or another feature as required. These modifications may vary from
fractional wedge corrrections (Y-shaped osteotomies) to cuts designed to
allow a fragment to remain attached to its soft tissues, such as may benefit
a lengthening procedure, or cuts with slightly unusual geometry to en-
Fig. 2.4, pages 23, 24 hance postcorrectional stability (Fig.2.4), for example the V-shaped, mor-
tise and tenon, and Z-shaped osteotomies.
Sometimes there is more than one site of deformity or other conditions
that should be corrected simultaneously. In these cases more than one
osteotomy may be needed in order to fully correct all angulations and dis-
placements. Such complex problems may be solved by using various com-
Fig. 2.5, pages 25, 26 binations of osteotomies (Fig. 2.5).
15
Once the entire fracture pattern has been drawn with the help of the out-
line of the normal side, an overlay of the appropriate implant for fixation
is placed in its proper position and traced onto the fracture drawing. The
best-sized implant and the correct position of the screws can be deter-
mined at this point. The desired number of screws are drawn in their cor-
rect locations at measured distances from bony landmarks such as tuber-
cles, epicondyles, joint lines, etc., all of which can be found by palpation
at surgery. A proper screw for a specific function, e. g., a lag screw, can be
planned, as well as the securing of the implant by a proper number of fixa-
tion screws required as dictated by the drawing of the fracture. This trac-
ing then represents the desired end result.
The surgical tactic must then be developed, determining the order of re-
ductions and their sequence [17], to facilitate the solution of the technical
problems at surgery. For example, it may be decided to reduce only the
joint and then introduce the implant, or to reduce the entire bone and only
then introduce the implant. Each step along the way is clearly marked on
Fig. 2.6, pages 27-29 the drawing, which can be used as a guide to help the surgical team under-
Fig. 2.7, pages 30-32 stand and anticipate all the steps in the procedure (Fig. 2.6, 2.7).
seating chisel, insertion of the seating chisel at the proper location and to
the proper depth, introduction of the plate of the proper size, application
of the articulating tensioner, distraction of the fracture, reduction of the
plate to the diaphyseal fragment, reduction of the metaphyseal fragments,
compression of the fracture fragments, and, finally, application of the
screws through and, if necessary, outside the plate. This is the plan - the
tactic - the surgeon will follow step by step in executing the operation.
Depending on the time available and the difficulty of the fracture to be
treated, planning can be detailed or brief. A brief plan in a case to be treat-
ed with a condylar blade plate may encompass only the tracing of the ar-
ticular fragments in their reduced position, onto which is traced in proper
position the outline of the blade of the plate to be used. This is the critical
step: since the angle of the plate is known, if the blade is precisely intro-
duced in known relationship to the fragments relative to the axis, then
bringing the plate to the bone with an appropriate clamp will restore the
angular relationships of the bone, and only rotation is left to contend with.
In this manner the plate itself will act as a splint around which the fracture
may be accurately reduced. The tracing of this critical step, however, must
inform the surgeon of the exact level of the window for introducing the
seating chisel, the direction the seating chisel must take in the bone in or-
der to obtain the correct axes, and the depth to which it must be intro-
duced.
With the AO condylar blade plate, proper insertion of the blade in the dis-
tal femur results in anatomic reduction of the distal femur when the plate
is placed under tension. Under these circumstances, the normal anatomic
axis of the femur is restored as the blade of the plate is at an angle of 95°
approximating the normal average anatomic axis of the femur, which is
98° in males and 100° in females. That is why this plate is so valuable in Fig. 2.10, page 36
the handling of supracondylar fractures of the femur and in cases where
Fig.2.11, pages 36-40
supracondylar osteotomies must be carried out to correct old traumatic re-
sidual deformities (Fig. 2.10). Figures 2.10-2.14 are illustrations of plan- Fig.2.12, pages 40-42
ning of fractures and osteotomies utilizing the principles discussed in this Fig. 2.13, pages 43, 44
chapter. Fig. 2.14, pages 45-47
20
a b
Fig.2.ia, b. Appreciating the deformity on X-ray. The b On the lateral view the same deformity is seen as pos-
case illustrated is an arbitrary one without a rotational terior apical angulation. There are not two deformities
component showing a deformity as it would appear on present; rather, the X-ray is centered away from the
an X-ray of the mid-distal junction of the tibia. a The plane of the actual deformity. The actual degree of the
deformity seen in the AP view is a varus deformity. deformity and its location can be determined using the
simple diagram shown in Fig. 2.2
21
!
I
---.- .
...::::::" X
..-'
"-'- -'-.
\
Fig. 2.2. The coordinates of the X-ray in Fig.2.1 have Construction of this right triangle with long leg equal to
been placed in a diagram at 90 0 to each other. They are the long legs of the other two triangles in the A-P-M-L
marked A-P (anterior-posterior) and M-L (medial-later- plane provides the angle X which can be measured with
al). Since the point at which the deformity occurs does a goniometer (or protractor).
not change, the shadow of the deformity can be con- An alternative trigonometric solution which can be ob-
structed in the corner of the coordinates with the actual tained with an inexpensive pocket calculator requires
value of the angulation and the direction of its displace- solving the equation.
ment appreciated on the AP view. This angle can be X = arctan ytan 2a + tan 2a'
called AP (a). Because the deformity occurs at the same Y = arctan (tan a/tana')
level, the angulation and direction of displacement seen
on the lateral view can be constructed starting at the Example
identical point in the corner of the drawing and sub- = 20 0 tan 20 0 = 0.364 tan 2 20° = 0.132
tending an angle lateral (a') equal to that seen from the =10° tan 100 =0.176tan 2 100 =0.031
shadow of the deformity on the lateral X-ray. The actual tan 2 20° = tan 2 10° = 0.163
plane of the deformity is somewhere between the planes X=arctan YO.163 = 21.98° = 22 0
of the AP and the lateral views, and the angle (X) of the
deformity will be larger than is seen in either view. We Y = arctan (0.364/0.176) = 64.20
would like to ascertain this angulation, and also the ex- The location of the plane of the deformity relative to the
act plane of the deformity relative to the AP and lateral A-P and M-L coordinates can then be obtained by mea-
projections. These values can be obtained if we rotate suring the angle between the A-P coordinate and the
the shadowed triangular projections about the A-P and long leg of the deformity, and an X-ray beam oriented
M-L axes placing them in the plane of these axes. If per- along this line will show the deformity at its greatest an-
pendiculars are constructed from the acute angle end of gulation. Likewise, the complement of this angle will
the bases of these triangles, in the A-P-M-L plane, their show no deformity, as the X-ray beam will pass tangen-
intersection (point P) defines the acute angle end of the tial to the deformity and therefore we will see no signifi-
deformity (right triangle whose opposite angle is X). cant shadow
22
-
From a practical standpoint these simple calculations al-
x.2ao low us to locate and appreciate the deformity and to
have an idea of how much of an error there will be in
preoperative planning of the correction of the deformity
from only one view. b The calculation is drawn for a
deformity displaying 20° varus in the AP projection and
20° recurvatum in the lateral projection. In this example
it is seen that the deformity exists in a plane halfway be-
A tween the AP and lateral projections, with X being 28° .
A It would not be optimal to plan an operative correction
b A from the standard views
23
'
hl "-,., '
c" r'
.. ~ -'>-
~
j
f\ ~J i
fIn ;/\\
,i IIi.~ i .
Y~j)
\ I
~ I
I
I
J
6
Fig. 2.6. a Planning from the sound side. Comminuted the plate. 6 Insertion of a connecting bolt into the femo-
segmental fracture of the femur with pertrochanteric ex- ral metaphysis at right angles to the femoral shaft axis.
tension. "Solving the jigsaw puzzle." b Tracing of the For this the remainder of the lateral approach to the
fracture. Solid lines are posterior, dotted lines anterior. femur must be executed. 7 Distraction. 8 Reduction of
c Tracing of the uninjured side. d Retracing with frag- the distal femur to the plate with a Verbrugge clamp.
ments separated so as to fully appreciate their size and 9 Tensioning of the plate. 10 Insertion of lag screws.
extent. e Tracing of the sound side with fracture lines II Insertion of fixation screws through the plate. i, j AP
included by superimposition of the sound side over the and lateral views of the femur 3 weeks postoperatively,
fractured side. f An implant has been traced over the re- showing the final result. Although there is a large poste-
duced fracture. This allows one to determine the length rior medial defect, the medial aspect of the fracture was
of the blade and plate which will be necessary, along not seen and the soft tissues remain intact. The plate
with the proper location of both lag and fixation screws, could be preloaded because of the anterior reduction.
which have been drawn in. This drawing represents the The lag screws and fixation screws have been inserted as
desired final result. g, h The surgical tactic in this case: planned. k, I Fracture healing at 9 weeks. Because of a
I Lateral approach to the proximal femur with anterior viable fracture zone, we see early signs of healing with
caps ulotomy. 2 Reduction of the trochanteric fragment softening of the fracture lines and filling in of the frac-
with temporary fixation. 3 Insertion of the seating chisel ture gaps. m, n At 53 weeks the fracture is completely
from a point 1 cm below the tip of the trochanter into healed and early remodeling is occurring along the dia-
the inferior quadrant of the femoral head. The seating physis. 0 Final X-ray after metal removal at 134 weeks.
chisel can be driven in to a depth of 80 mm. 4 Insertion Traces of previous internal fixation are still evident. This
of an 80-mm 20-hole 95° angled blade and reduction of patient had a subsequent trauma with a tension fracture
the proximal femur to the plate. 5 Insertion of a con- of the lateral femoral cortex. This problem was treated
necting bolt into the second plate hole perpendicular to by closed nailing
29
30
~J
31
h
32
33
\.
\ I
.
\
\
\.
\
Fig.2.S. The axes of the lower extremity. The femoral
shaft axis meets the mechanical axis of the knee joint at
99° medially. The tibial shaft axis is a continuation of
the mechanical axis of the lower extremity and has a re-
lationship of 6° valgus to the anatomic axis of the femur
above. The mechanical axis has a relationship of 3° to
the vertical axis of the body. These relationships are ex-
tremely valuable in planning operative surgery of the
lower extremity. (Redrawn from Muller [23])
34
<
35
o
b
o
o
o
o
o
o
o
o
o
Fig. 2.9. a Closed fracture of the distal femur with a along the lateral border with the blade parallel to the
large medial butterfly fragment. In this particular exam- joint. Second, the blade may be placed into the distal
ple the drawing has been broken down to its component fragment parallel to the joint and then, using the plate
parts. The anatomic axis of the femur and tibia is in- as a handle, the reduction made against the proximal
cluded, along with the mechanical axis of the knee joint. femoral metaphysis. Because of the soft tissues, if slight
Transparencies of the fracture components and the axes distraction is carried out by placing the articulating ten-
are provided in the pocket inside the back cover of the sion device off the end of the plate and opening it, the
book. The fragments can be cut out and reassembled in medial butterfly will be pulled into the defect along with
a reduced position around the axes. The reader can also the medial pillar. One can also see that variations in the
"play" with the effects caused by different positions of blade of the plate relative to the distal articular fragment
the blade of the plate relative to the distal femur frag- will result in a change of primary contact, medial or lat-
ment. This will show the varus and valgus effect caused eral with reduction to the diaphysis. Thus, one can see
by blade placement. This is exactly the method that that correct application of the seating chisel parallel to
would be used in planning such a reduction in the fron- the joint will result in preload of the bone implant com-
tal plane. Because at either end of the femur there is plex or primary contact medially. The remainder of the
usually an angular displacement in the sagittal plane planning consists of drawing in the important lag screw
(flexion relative to the fragment itself), the length as fixation for the medial butterfly along with the screws
seen on the AP view must be considered together with necessary to fix the plate to the proximal and distal frag-
what one sees in the lateral view. If the amount of flex- ment. b The fragments have also been created in the lat-
ion (or rarely, extension) is great, the length of the frag- eral view. The critical factor here is to know the distance
ment must be taken from the lateral view and extrapo- from the anterior and posterior margins of the distal
lated to the AP. In our example, there is only slight fragment to the midaxis of the plate, so that the plate
flexion of the distal fragment. Therefore this extrapola- may be used as a handle to reduce the fracture in the
tion is unnecessary. With this in mind, one can see that sagittal plane as well. With experience, this relationship
there are two ways to proceed. First, the fracture may be is not difficult and is found at surgery by following the
reduced about the axes and the implant then applied anterior cortex proximally as a guide
36
Fig. 2.10. The angle between the blade and the plate
portion of the condylar blade plate is 95° . The most im-
portant step in using this device is the exact placement
of the blade parallel to the end of the femur in the fron-
tal and sagittal planes. It can be then used as an instru-
ment for reduction regardless of the fracture configura-
tion in the metaphysis or diaphysis
37
•• •
•
I
• I
);
.~•
Fig. 2.11. a A 40-year-old female who was struck by a car while crossing the
street. Initial X-ray shows a comminuted proximal femur fracture with a
neck, trochanteric, and proximal femur component. The fracture was open.
She was treated by irrigation debridement and placed in balanced skeletal
traction. She was then transferred to our facility. b, c AP and very dark lat-
eral views of the same fracture with traction and internal rotation: note how
the X-ray is markedly improved. The fracture would like to reduce with the
restoration of length and rotation. This is an indication that an indirect re-
duction should be successful. d Tracing of the fracture from the X-ray tak-
en in traction. e Tracing of the normal femur. f By overlaying the normal
on the fractured side the fracture lines may be drawn into the outline of the
normal side. g By overlaying the template of the condylar plate series one
can see the proper relationship of the blade to the proximal fragment that
will allow the plate to be used for a splint for reduction of the fracture. This
has been traced into the drawing.
38
h Another procedure (the method actually used in this particular case) is il-
lustrated in the following. The head fragment is traced on a single piece of
tracing paper. i On a separate piece of tracing paper the trochanter is out-
lined. j, k The two fragments are now placed together as they appear on
the X-ray and are manipulated so that they are reduced. (We know that the
tip of the trochanter should point to the center of rotation of the femoral
head.) I Since to proceed in this way parallels the actual sequence of events
in surgery, the template for the 95° blade plate is next overlaid onto the two
fragments in its correct location.
39
f Result at 4 months after the operation. g, h, i At trates how planning may be based on the use of one of
2Y2 years there has been slow obliteration of the osteoto- the angled blade plates in which the fixed angle of the
my line. The femoral head remains congruent in the ace- plate provides a means of controlling the degree of cor-
tabulum with a good joint space. The patient has a full rection required. The final reduction of the osteotomy is
range of motion with no pain or limp. This case illus- facilitated by using the plate as a reduction aid
43
Jf
compressing the trochanteric nonunion. 10 Application of a Verbrugge
clamp to the plate, reducing the distal fragment and lateralizing it.
11 Distraction with the articulating tension desire off the end of the IZ II
plate, facilitating lateralization of the distal fragment. 12 Compression d
of the osteotomy and tensioning of the plate. 13 Insertion of final fixa-
tion screws.
44
e, f X-ray 4 months after surgery: consolidation of the surgery high in the trochanter to hold it in place during
nonunion and a good joint space. The patient was am- insertion of the seating chisel. One year after surgery.
bulating without external support and had no pain. Although the patient has no pain the upper screw pene-
g, h An additional lag screw was added at the time of trates the subchondral bone. Healing has taken place
45
Fig. 2.14. a, b A 32-year-old man who suffered a gunshot wound to the distal femur, with
an open comminuted fracture in the area. The patient had been treated by initial irrigation
and debridement followed by skeletal traction, and later a cast brace. He presented with
6\12 cm shortening, 15° varus, and 10° antecurvatum. He complained of a short extremity .
.•
.-.,..
and difficulty in ambulation. He had near-normal knee motion. His X-rays and AP and -..)..
lateral projection are presented. c, d Tracing of the deformed side superimposed on the
normal side. Shortening and varus are evident in the AP projection. The lateral shows a ...: .1
-.:... ...... .:
10° anteroapical angulation associated with a full shaft displacement. -......... .
46
13
10 --YoII.aJ16
12
II
e
f 9 h
wire 2 and then loosened so that it may be easily extracted once the osteotomy is
cut. The seating chisel will then act as a guide to the placement of subsequent
Kirschner wires. 4 A Kirschner wire is inserted at 45° to the seating chisel, giving
the direction of the oblique cut and the distal femur. 5 A Kirschner wire is
placed at 30° from the seating chisel and gives the direction of the cut to remove
the wedge which will correct the varus deformity seen on the X-ray. 6 Mter these
wires have been placed, the osteotomy is cut obliquely parallel to Kirschner
wire 4 four-fifths across the bone anteriorly or to a depth of about 6 cm. A sec-
ond cut is then made parallel with Kirschner wire 5 and terminated where it
meets the previous cut. The wedge removed represents the corrective wedge of
15° based laterally. 7 The proximal extent of the callus is determined and then
an obliquely oriented 4-cm-Iong saw cut is made parallel to the lateral cortex.
8· A transverse and longitudinal cut with a length of 3 cm is made through the
bone. 9 Completion of the osteotomy of the medial cortex. 10 A second cut is
made in the proximal fragment removing a block of bone equal to the width of
the callus and oriented obliquely to the horizontal plane. Its length is equal to
the amount of proposed lengthening. There is some flexibility to the final length,
given the trade off between medialization of the segmental fragment and the dis-
tal oblique osteotomy. 11 Insertion of the angled blade plate with a blade length
of 60 mm. 12 Reduction of the plate to the proximal shaft of the Verbrugge
clamp. 13 Distraction of the osteotomized distal femur. The articulating tension-
er is drawn in exaggerated fashion in order to show the displacement mechanics
clearly. 14 Correction of rotation between the distal and proximal fragment with
a standard reduction forceps (not shown in drawing). 15 Compression of the
osteotomy surfaces after reduction of the segmental block. 16, 17 Insertion of
the critical lag screws fixing the segmental osteotomy block into the montage af-
ter axial compression has been exerted. 18 Insertion of the fixation screws.
k, I Postoperative AP and lateral X-rays of the case illustrating the following:
correction of the varus, lengthening of the extremity in a fixation montage iden-
tical to the preoperative plan save for one anteroposterior lag screw. m, n Final
X-rays after plate removal showing healing of the osteotomy. The patient has re-
gained full knee motion. Cosmetically, his leg appears anatomic in regard to the
axis; however, he is still 1 cm short
48
buttress, but the fragments spanned by the plate are viable and capable of
rapid consolidation.
In such cases the early application of the plate allows it to be used as a
stable scaffolding to enable the manipulation of displaced fragments to be
carried out with improved leverage and less force.
Any relatively straight portion of any bone may be reduced by the applica-
tion of a straight plate. The principle is that previously described with the
intermeduallary nail, although a difference is that now the interference re-
duction is occurring along the external surfaces, not in the intramedullary
canal. The most simple and elegant demonstration of this is the "antiglide
plate" described by B. G. Weber in his book, Special Techniques of Internal
Fixation [33]. The antiglide reduction is elegant because it in addition auto-
matically places the plate in the optimum position for further axial load-
ing. Reduction is obtained by the screws pulling the bone fragment down
an inclined plane; then, when the reduction is complete, the axilla is locat-
ed in the best position to apply axial compression to the bone by tension-
ing the plate, by means of either the articulating tensioning device or the
DC holes.
The surgeon must contour the plate for this area of the tibia before reduc-
tion of the fracture, bearing in mind the normal contours of the bone
Fig. 3.2, page 60 (Fig. 3.2). Consider the shape of the lower half of the tibia. The surface
most convenient and conservative for plating is the medial face. This is a
subcutaneous border, and therefore surgical intervention causes little dis-
turbance of the musculature or the blood supply of the tibia. Obviously,
great care must be taken in handling the soft tissues, as any loss of skin
will definitely result in problems, that require sophisticated procedures to
resolve. If attention is paid to this important detail, problems rarely occur.
The surgical approach is made parallel and one finger lateral to the crest
of the tibia, crossing in a gentle curve from lateral to medial as the tibial
metaphysis is reached and then distally along the border of the anterior
pillar of the medial malleolus. A description of this surgical approach may
be found in the book Surgical Approaches for Internal Fixation by Th. Riie-
di and colleagues [29]. When swelling of the limb with loss of mobility of
the skin is anticipated, the incision may be made 2-3 cm lateral to the
crest. Placing the incision more laterally has a relaxing effect on the soft
tissues which may be valuable at the time of closure. The skin, subcutane-
ous tissues, and fascia of the anterior compartment are cut vertically as
one unit in line with the incision. Lifting the medial fascia of the compart-
ment anteriorly and medially, the dissection is carried out by separating
the muscle from the fascia of the anterior compartment until the crest of
the tibia is reached. The periosteum in this area, if not stripped by the frac-
ture itself, is elevated only to the degree necessary for exposure. On clo-
51
The reduction of a distal third oblique fracture with an antiglide plate is il-
lustrated in Fig.3.3. Figure 3.4 shows the application of this principle in a Fig.3.3, pages 61,62
fresh tibia fracture with an intact fibula. The patient is a 40-year-old man. Fig. 3.4, page 63
The injury was closed. Figure 3.5 illustrates application of the same princi- Fig. 3.5, page 64
ple at 8 weeks in another case.
If a lot of shortening is present, or if the fracture is old or comminuted, the
preceding technique may be modified by utilizing the articulating device
off the end of the plate. With this device, distraction or compression, de-
pending on the circumstances, can be exerted on a fracture through a plate
attached to the bone. These effects may be enhanced by inlaying the plate,
as with the standard DCP or by fashioning hooks or blades from the end
hole, as with a one-half tubular plate. (Fig.3.6), techniques which will be Fig. 3.6, pages 65, 66
discussed later (see Figs. 3.16, 3.17).
The articulating tensioner, first used in 1972, evolved from the original
plate-tensioning "outrigger" adapted from the plates of Danis [4]. Collabo-
ration between surgeons and instrument makers led to the development of
the new tensioner, which has a rotatable hook on one leg and a foot on the
other which takes a 4.5-mm cortical screw. The limbs are jointed to allow
the tensioner to function across angulations. The upper portion consists of
a strain gauge which is color-coded in yellow, green, and red to give a
rough indication of how much tension is being generated in the plate. The
addition of this instrument has allowed many innovations in the handling
of fractures with plates (Figs. 3.7 -3.9). Other fracture patterns besides the Fig. 3.7, page 67
oblique and spiral may be approached in a similar way. However, the arti- Fig. 3.8, page 68
culating tensioner is almost always needed for distraction so that the frag- Fig. 3.9, page 69
ment ends clear one another and a reduction in alignment can occur
Fig. 3.10, pages 70, 71
(Fig. 3.10). The plate is attached by a single screw to the shaft fragment
that is displaced to the side away from where the plate will eventually be
attached. In cases where there is no room distally or proximally for the ar-
ticulating tension device, an alternative is to place a single screw approxi-
mately 1 cm off the end of the plate, proximally or distally. The bone
spreader (Fig. 3.11) is then used, placing one foot against the screwhead Fig.3.11, page 72
and the other against the end of the plate. When the handles of the bone
spreader are squeezed together, the feet separate, pushing the plate and
distracting the fracture. In this instance, as with the articulating tension de-
vice, the plate is controlled on its proximal side by means of a Verbrugge
clamp (Fig.3.12) and fixed by one or two screws to the distal fragment. Fig.3.12, page 72
When distraction is complete, the Verbrugge clamp is tightened and the
laminar spreader is removed. A no. 0 or no. 1 Verbrugge clamp can then be
52
placed such that its broad plate - holding end embraces the screwhead
and the pointed end is placed in the distal hole of the plate. By closing the
clamp the fractures can be coapted. The compression is then achieved by
the usual method by means of the DC holes or by eccentric loading of a
one-half or one-third tubular plate.
When the distraction load is high, i. e., in internal fixation of a 4- to
6-week-old fracture, the plate may deform somewhat during distraction.
This usually does not constitute a problem, since this slight bending of the
plate will result in a little concavity against the relatively straight shaft por-
tion of the bone as distraction is applied. This concavity will straighten af-
ter reduction once tension is applied to the plate.
location. This plate may be flattened out in its distal aspect and contoured
very nicely to achieve an excellent buttress effect against the distal tibia.
Once flattened it has a very low profile which matches very nicely the
thickness of the cortex of the bone which it is substituting.
Forearm Fractures
The radius and ulna are relatively small bones with proportionate muscu-
lature, so that manual reduction techniques are more successful. In our ex-
perience, however, indirect reduction techniques have als~ been very use-
ful in the forearm. Because of the easy access and the relatively simple
Fig. 3.19, page 85 anatomy, segmental fractures and comminuted fractures of the ulna adapt
Fig. 3.20, pages 86-88 easily to this technique (Fig. 3.19). Although because of the "outcropping"
Fig.3.21, page 89 muscles the radius is a little less accessible, the technique is quite easily
Fig. 3.22, page 90 applied and equally successful (Figs. 3.20-3.22).
Acetabular Fractures
In certain instances in the operative treatment of acetabular fractures, the
plate functions as a reduction aid as well as a fixation implant.
Three examples will be described:
(1) fractures of the anterior wall or low anterior column,
(2) those associated with a comminuted quadrilateral plate, and
(3) fractures of the posterior column.
Fractures of the anterior column frequently occur in the middle or articu-
lar segment. In this region the bone is relatively thin and overlies the joint.
Additionally, there is often comminution extending into the quadrilateral
plate surface. The area is less accessible because of the overlying iliopsoas
muscle and obturator internus muscle. As a result, reduction with provi-
sional stabilization is frequently difficult to obtain.
Precurved plates simplify the maneuver to be described because less con-
touring is needed than is the case with a straight 3.5-mm reconstruction
plate. These plates are available with a 100 mm radius. Emile Letournel
has two plates with radii of 88 mm and 108 mm. According to his investi-
gations, these two sizes represent the two most common radii found in the
human pelvis. He uses the 88-mm plate for small pelves, and the 108-mm
plate for large pelves [14]. They are stiffer and plate contouring must be
exact as they do not deform under pressure from screw insertion.
55
Once the iliac wing has been reconstructed in high anterior column frac-
tures, or in low or very low anterior column fractures, early plate applica-
tion helps to reduce the fracture. A very slight concavity is fashioned in
the middle third of the selected curved plate to accommodate the mild ele-
vation associated with the iliopectineal eminence and a slight twist is im-
parted to the posterior portion of the implant, clockwise for a right acetab-
ulum and anticlockwise for a left acetabulum. Through the ilioinguinal
approach, the plate is slid underneath the musculature of the iliopsoas and
the femoral vessels. It is then attached to the body of the pubis with a sin-
gle screw and rotated along the superior pubic ramus and the pelvic inlet
around the screw until it sits congruently on the iliopectineal line and pel-
vic brim.
If necessary, slight distraction may then be effected by means of a push-
pull screw placed off the end of the plate in conjunction with an appropri-
ately sized bone spreader, as described for straight plates (see p. 82-90).
The wall or column fracture may then be aligned beneath the plate with an
instrument, after which the distraction force is removed. The plate is se-
cured posteriorly to the dense bone of the sciatic buttress with one or two
screws, and then screws are placed sequentially on alternating sides of the
fracture. As this is accomplished, the plate is pressed downward into the
bone. The curvature and length of the anterior column are restored and
the plate pushes the fracture in the articular segment down and into reduc-
tion. Finally, screws may be placed so that they are angulated medially,
penetrating the quadrilateral plate surface and securing the plate to the
bone over the reduced articular segment. The most posterior screws may
be quite long and may be lagged to fix posterior column fracture lines.
The feature of the bone that makes this possible is the fact that the pubic
tubercle and the posteriormost swelling of the sciatic buttress lie about on
the same level as the top of the iliopectineal eminence. Because of this, a
slight gap is left underneath the plate on both sides of this prominence.
With a malleable plate, such as the 3.5-mm reconstruction plate, or to a
lesser degree, the new AO 3.5-mm precurved pelvic reconstruction plate,
the screws will mold the plate to the bone as they are inserted, squeezing
the iliopectineal eminence downward (Fig. 3.23). Fig. 3.23, page 91
When a severe degree of comminution exists in the area of the quadrilater-
al surface of the medial wall of the pelvis, a reduction as well as buttress-
ing of the area may be effected by the use of a one-third tubular plate. The
plate is first flattened and then bent in an oblique fashion such that the
long bent limb projects anteriorly to the short limb. The bend should be
made at least 90°. This plate then may be used in conjunction with the
curved reconstruction plate by slipping the long end into the pelvis against
the quadrilateral plate and sliding the short end 'underneath the recon-
struction plate. The bent one-third tubular plate is then forced to open
against the quadrilateral surface by placing a large reduction forceps
against it at the apex of the bend. This pushes it against the quadrilateral
plate surface and slides it back over the pelvic brim under the recon-
struction plate. The reconstruction plate is then seated by tightening the
screws previously placed in it, bringing it flush against the pelvic brim and
trapping the one-third tubular plate underneath. The one-third tubular
plate is sprung against the medial wall, reducing and buttressing it simulta-
56
neously. The end screw-hole in the one-third tubular plate, projecting into
the internal iliac fossa, may be filled with a single screw to tag the plate in
position. The plate functions as a spring plate, which is of value at other
Fig. 3.24, pages 92, 93 sites as well for both reducing and buttressing a fracture line (Fig. 3.24).
Fig. 3.25, page 94 Clinical examples of this technique are illustrated in Figs.3.25 and 3.26.
Fig.3.26, pages 95, 96 In transverse fractures the ischiopubic segment is displaced inward along
a vertical axis through the pubic symphysis and the pelvic brim tilted in-
ward along a horizontal axis extending from the symphysis to the fracture.
A plate attached to the distal fragment may be extended by a clamp and
used to close the fracture gap once rotation is correct. The plate used in
this manner should be a flexible one, such as the 3.5 mm AO recon-
struction plate. The flexibility of this plate allows it to be stretched across
the fracture and then contoured as the screws are applied by their bite into
the bone. Dana Mears of Pittsburgh has described using the plate in this
manner [20]. He feels that it has been helpful to him in fracture lines which
cross low on the retroacetabular surface. We use this technique frequently
Fig. 3.27, pages 96,97 (Fig. 3.27). Figure 3.28 shows a variation of the technique in which the
Fig. 3.28, page 98 plate has been placed obliquely such that the plate itself can be utilized to
derotate the ischiopubic segment. The technique illustrated in Fig. 3.27
may be followed employing the Kocher-Langenbeck approach, while that
in Fig.3.28 would require an extended iliofemoral or triradiate approach.
Fig. 3.29, page 99 In the case illustrated in Fig. 3.29, the technical aspects of the surgery were
complicated by the fact that the patient was extremely obese. In such a
case, this method of reduction and fixation is a great help.
This chapter has dealt with the reduction of fractures by plates. We have
seen that in many cases the principles are the same, i. e., the reduction oc-
curs either through interference, as in the case of an antiglide mechanism,
or by distraction, which by increasing the tension in the soft tissues tends
to recentralize the fragments, causing them to approximate their previous
location in the fractured bone. The instruments which are helpful in ac-
complishing these technical maneuvers are the articulating tension device,
the bone spreader, the Verbrugge and standard reduction clamps, and the
large pointed reduction forceps. The surgeon must be careful to spare the
soft tissue connections to the fragments of the bone and keep bone expo-
sure to the absolute minimum. For this reason a favorite instrument is the
"dental pick." Detailed attention must be focused at all times on the skin
58
edges and the muscle and care must be taken to avoid unrecognized injury
to the soft tissue coverings by retractors. When the reduction has been ob-
tained, in most fracture patterns an attempt should be made to preload the
fractured area, impacting the bone longitudinally so that all fracture gaps
are overcome. Having accomplished this, lag screw should be inserted
where the clamps held the reduction during loading with the articulating
tension device. Finally, the minimum number of screws necessary to se-
cure the implant to the bone should be applied. This approach increases
the healing potential of the bone in plate fixation by limiting devasculari-
zation to the area immediately underneath the implant. By virtue of im-
proved biomechanics, the plate becomes a load-sharing rather than a load-
bearing device. Only the exact number of screws demanded by the
fracture configuration are used in the plate. This will decrease future mor-
bidity, as following implant removal every screwhole is a potential site for
refracture.
In some instances, because of comminution, it is impossible to improve on
the mechanics of the plate beyond providing a buttress function. This
should be recognized beforehand because of preoperative planning and
during surgery every effort should be made not to "get into" the fracture.
The plate acts as a scaffold to help to obtain axial realignment and to cor-
rect rotations, angulations, and displacements. The fracture zone is splint-
ed by the plate and should be left undisturbed and viable. Autogenous
,cancellous bone grafting is another means of extending the biological po-
tential of the approach but needs to be used only when bone substance is
missing or when, because of devascularization, prolonged healing is antic-
ipated. Care must be taken in inserting the bone graft to avoid further de-
vitalization of the soft tissue attachments to the bone fragments. Addi-
tional protection of the plate in these circumstances may be achieved by
utilizing one of the technique discussed in Chap.5.
Once the surgeon has begun to understand the use of the implant in reduc-
tion as well as fixation, many more applications will be appreciated. As a
consquence, the results of such surgical interventions will be better than
they have been in the past.
59
G
11
11
11
u
Fig.3.t. Theoretical diagram of a distal femur fracture these circumstances there is complete bone-to-bone con-
with a medial butterfly fragment. Because the normal tact, indeed impaction, tension in the plate and com-
angulation between the shaft and the end of the joint in pression in the bone are directly linked. At this point in
the frontal plane of the distal femur is greater than that a clinical case it is usually possible to remove the clamp
of the angled blade plate by several degrees, exact appli- holding the medial butterfly fragment in place and find
cation of the seating chisel followed by introduction of that it is absolutely stable before the application of the
the plate results in a preload along the medial cortex. If lag screw. After achieving this, the introduction of lag
longitudinal or axial compression is exerted while screws, providing trans axial compression, further en-
clamps maintain the reduction, the bone fragments are hances the fixation
free to impact fully, one on the other. Because under
60
r =:t 20 em
Fig.3.3a-e. Reduction of a distal third oblique fracture entation to the distal fragment is correct in the sagittal
using an anti glide plate. a Following surgical exposure, plane. The fit of the plate against the proximal fragment
a seven- to ten-hole plate, depending on the fracture, is will be a little tight at this point. To accommodate this,
selected. It is first twisted so that there is a torsion in the the distal screw may need to be loosened slightly. The
plate of approximately 25°, then it is placed in a bend- tightness of the proximal end of the plate against the
ing press and a mild concavity is pressed into its distal proximal fragment represents the plate-bone interfer-
two-thirds. This may be checked at surgery by using a ence that in the end will reduce the fracture. With only
marking pencil and a 20-cm length of suture thread to the distal screw in place, the alignment of the fractures
draw an arc on a flat surface against which the curve of will be improved. At this time rotation should be cor-
the plate can be checked. The curvature may also be as- rected by gently twisting the patient's foot, and therefore
certained by a comparison AP X-ray of the opposite the distal fragment, in the appropriate direction.
side. b The plate is then fixed to the distal fragment at c When little or no shortening is present, the next screw
the level of the buttress of the medial malleolus with one hole is drilled through the plate with a neutral drill
screw. Care must be taken not to enter the joint with the guide. The screw length, which will be a little greater be-
screw because it is so low and because the curve of the cause the plate is not yet positioned snug against the
plate has the natural tendency to direct the screw into bone, is measured and the screw is tapped and inserted.
the joint. Therefore the normal 3.2-mm drill guide is The distal screw and the second screw are then tight-
used and a screw is inserted parallel with the joint. The ened together, but not definitively. The distal fragment
screw is snugged but not definitively tightened. The of the fractured bone will be drawn in toward the plate.
plate is then rotated around the distal screw until its ori-
62
d If the level of the fracture permits, the next screw is in- proximal fragment with a load guide or with the exter-
serted before the previous two are completely seated, nal tensioning device. An oblique fracture should also
and, as a last step distally, all three screws are tightened be crossed by a lag screw; this may be facilitated by
together. Because of the correct approximation of the placing the plate in the best position for this as deter-
fractured bone and the plate in the distal fragment, the mined by the preoperative plan. e This illustration
antiglide mechanism is observed as the screw pulls the merely shows that if the plate is fixed first to the proxi-
bone to the plate, and the plate contacts the opposite mal fragment it will have no effect on the reduction. If,
fragment. This slides the fragments against each other, following fixation of the plate to the proximal fragment,
regaining the length. This exerts strain on the distal the screws are placed in the distal fragment, a large
screws biting into the bone of the· distal fragment. For amount of compression will be generated between the
this reason, the quality of the bone stock should be good fracture surfaces as the bone tries to elongate and can-
if this technique is to be used. Additionally, as can be not, because the distance between the screws is then
seen, because of the correct approximation of the frac- fixed. This technique for obtaining compression is
tured bone and the plate in the distal fragment, tension sometimes used in oblique osteotomy in the inter-
may be placed on the plate by loading the screw in the trochanteric area of the hip
63
Fig. 3.4. a, b A closed oblique fracture of the distal tibia with an intact fibula:
AP and lateral projections. There is 1 cm of shortening. There is no tender-
ness of the ankle or around the knee joint. c, d The fracture was treated with
an antiglide plate applied medially. The lateral side (muscular compartment)
was not entered. Healing of the fracture is seen on the follow-up X-ray at
10 weeks. Note the hole remaining off the end of the plate proximally where
the articulating tension device has been used to aid in regaining length, and
for additional control in tensioning the implant. Note the lag screw. A small
amount of callus is present posterior medially where the distal fragment had
been displaced. (Case courtesy of Dr. Brett Bolhofner of St. Petersburg, Flori-
da, USA)
64
Fig. 3.5. a, b A distal tibia-fibula fracture that was oper- and only the medial face of the tibia was ever surgically
ated at 8 weeks. The patient had been treated with "pins exposed. The postoperative fixation montage is seen.
and plaster" between the tibia and the calcaneus. c The d, e The fracture viewed 4 months later after healing had
fibula was first approached and fixed by a technique taken place. The patient had regained most of his mo-
that will be described. The plate was precontoured and, tion but, because of the original prolonged period of
after an anteromedial approach to the distal tibia, ap- time in a plaster cast, displayed decreased dorsiflexion:
plied to the distal fragment. By means of inserting the this has since improved. There is a slight valgus tilt of
screws in the distal fragment of the tibia, the translation the distal fragment
was overcome, the comminuted fracture was never seen,
65
fragment, by virtue of its soft tissue attachments, will tend to approximate itself into re-
duction. This may be assisted with a fine instrument such as a dental pick. e A soft-tis-
sue-sparing clamp such as the pointed reduction forceps is then used to secure the but-
terfly fragment in its reduced position. The Verbrugge clamp is tightened to maintain
the distraction. The articulating tension device is then loosened and the tab slipped out
from the end of the plate. f The articulating tension device is then placed in the end
hold of the plate and compression is applied. The pointed reduction forceps are tight-
ened to hold the butterfly fragment in its reduced position. Care is taken to apply the
correct amount of tension to the plate in the tibia. This should be in the vicinity of
60 kp, or in the green zone on the collar of the articulating tensioner. Rarely, the Ver-
brugge clamp must be loosened just a little to allow this to occur. Too much tension in
the plate may result in a valgus reduction with this combination of plates and screws.
Alternately, the DC holes may be used and the load guide set eccentric in the second
hole from the end of the plate. g With the plate tensioned and with the plate dynamics
correct, the butterfly fragment may actually be stable without use of the pointed reduc-
tion forceps. This may easily be checked at this time. However, the pointed reduction
forceps should be in place when the definitive lag screws are inserted, in this case
through the plate into the butterfly fragment. The remaining screws are then inserted
through the plate, the number used depending on the quality of the bone and the me-
chanics achieved with the plate. It has been our clinical experience that if a compres-
sion fixation has been accomplished fewer screws are needed
67
Fig. 3.11. Bone spreaders. The AO bone spreader is a Fig. 3.12. Verbrugge clamp. This clamp is used in many
valuable adjunct to fracture reduction., It may be used circumstances to hold the plate to the bone and comes
like the articulating tension device as a distraction de- in various sizes from 0 to 3. The proper size should be
vice. In this case it is placed off the end of a plate and selected in harmony with the size of the bone fragment
against a screw that is placed free in the proximal frag- with which one is dealing. The pointed end of the
ment approximating 1 cm from the end of the plate and clamps may also be used in the end hole of the plate,
is used as a push screw. Opening of the bone spreader and the broad end around the free screw to pull the
between the screw and the end of the plate provides a plate therefore coapting the fragments
distraction force
73
o
o I o
o
o o
o
Fig. 3.14. a, b AP and lateral views of a pilon tached into reduction. d Keying in a diaphy-
fracture with an intact fibula. Note how Cha- seal fragment. e Postoperative X-ray of the re-
put's tubercle has remained at length with the construction. The articular segment has been
intact fibula while the articular fragments are perfectly reconstructed; however, in the ab-
impacted upward. There is articular comminu- sence of lateral dissection, the butterfly frag-
tion as well as comminution in the metaphy- ment in the posterolateral side was never seen
sis; however, the medial malleolar fragment is and remains displaced. Biology was favored
large. There is usually a lesion in the lateral over a perfect X-ray : rather than devitalize the
collateral system and the syndesmotic liga- fragment it was left to heal. f Control at
ments are generally intact. c Intraoperative 8 weeks. g, h AP and lateral views at 1 year.
photo showing the articulating tension device i, j After implant removal 1 Y2 years later. The
in "distraction mode", pushing the plate and patient is functioning normally
therefore the distal fragment to which it is at-
77
78
79
Fig. 3.15. a, b AP and lateral views of a fracture nally fixed to the medial malleolar fragment by a
of the tibial pilon. In the AP view, the medial single screw and length of the joint was regained.
malleolar fragment cannot be well appreciated; It was then fixed with a Kirschner wire and later
however, it is quite large. In this case, the fibula with a 6.5-mm cancellous screw. Bone grafting
is broken. c The swelling was too great to oper- was subsequently carried out. The screw just
ate on the night of admission, so the patient was proximal to the fibular plate is a witness to the
placed on a Bohler-Braun frame in calcaneal indirect reduction carried out on the bone. This
traction. The fracture wants to reduce! This is ex- will be described in a later portion of this chap-
cellent evidence that indirect reduction will be ter (p. 82-84). e, f Follow-up X-rays at 6 weeks
possible. d Intraoperative X-ray showing the re- show the reduction of the joint obtained by this
constructed fibula and the tibia with the articu- method along with early consolidation of the
lating tension device providing distraction on the fracture. The patient unfortunately never came
medial malleolar fragment. The plate was origi- back and could not be found
80
Fig.3.16a-c. Inlaying a plate. A 2- to 3-mm-deep de- bone or in highly comminuted fractures. One must be
pression may be cut into the distal fragment in the opti- careful not to create a situation that compromises the
mal location for plate application. The width should proximal edge of the fracture, destroying the buttressing
match the width of the plate. After preparing grooves effect of the plate. a The grooves are cut. b The precut
matching the outline of the plate, the thin metaphyseal metaphyseal cortex is impacted inward 1-2 mm. c The
cortex is impacted inward 2-3 mm to accept the plate. plate is settled into the groove prepared for it and will
This allows one effectively to debulk the plate, prevent- therefore be less prominent underneath the skin. Inlay-
ing it from being so prominent under the skin. The im- ing the plate allows distraction forces to be transmitted
paction should be made with great care and good judg- directly to the bone. The screw is relieved of bending
ment should be exercised when deciding to use this stress and only holds the plate to the bone
technique, as it could be problematic in osteoporotic
81
Fig. 3.17. a The osseous anatomy of the distal fibula. From the distal tip of the lateral malleolus
proximally there is first a slight pronounced concavity. The concavity ends at a point 8-9 cm
from the tip of the lateral malleolus where the crista fibularis crosses the posterolateral surface as
an oblique linear swell. This crest also imparts a slight external rotation to the shaft of the fibula
as viewed distally to proximally. It continues until just below the midportion of the bone.
b When contouring the plate that will lie on this surface of the bone, these observations must be
considered. Speaking in terms of the surface of the plate that will come in contact with the bone,
we must first flatten the plate in its distal aspect, usually the terminal two holes, with a mallet.
This will make the plate less bulky beneath the skin. Then we should twist the plate so that the
nonflattened end is externally rotated compared to the flattened or distal end. A slight short con-
cavity is created at the distal end, followed by a convexity that is approximately 6 cm long and
starts in the region of the second-to-last hole of the plate. We are assuming here the use of an
eight-hole plate, which is usually required when dealing with the type of fracture necessitating
this special technique. c In special circumstances, e. g., osteoporosis, a short distal fragment, or
buttressing with the plate alone and no screws, a short blade may be constructed by flattening
the end of the plate as described above and bending it at a right angle at the distal hole. Simi-
larly, hooks or fixation spikes may be fashioned by sacrificing the end hole, cutting it out to
leave two sharp spikes after having bent the flat portion to 90°. Depending on what has been
fashioned from the distal portion of the plate, two small drill holes or a slot may be made with
the small osteotome to enhance the seating of this fixation device. Because the blade or hooks
are embedded in the bone, the screw exerts its force only to hold the plate to the bone. As dis-
traction or compression is carried out, the tendency towards valgus or varus deformation is mini-
mized
c
82
83
c
Fig. 3.18. a, b When the plate has been contoured, it is midportion of the bone. A small bone spreader is then
attached to the lateral malleolar fragment with a single placed so that one foot is under the end of the plate, the
screw. Depending on how the end of the plate has been other against the free screw. Distraction of the plate is
used, the screw will normally go in the second hole, as effected by opening the laminar spreader. c When the
there it will have a better buttress effect to resist the length is regained, determined at first by the resistance
forces of distraction. The screw is usually 18 mm in within the laminar spreader, the small intermediary frag-
length. Care is taken not to penetrate the distal talofibu- ments may be squeezed into reduction with a dental
lar joint. A second screw is then placed proximal to the pick. Their reduction in length ultimately determines the
plate about 2 cm from the end and free in the midpor- true length, and the tension may be reduced within the
tion of the bone. A small-fragment Verbrugge clamp is laminar spreader until the fragments are slightly com-
used to fix the plate to the proximal fragment in the pressed by the elastic effect of the soft tissues.
84
o
d If the fracture pattern lends it elf to further compre -
sion, this may be accompli hed at thi point by placing a
small Verbrugge clamp at the end of the plate so that the
pointed end i in the proximal hole and the broader
plate-holding end i around the free screw-head. Clos-
ing the clamp will then apply tension to the plate, fur-
ther stabilizing the fracture. e If the fragments lend
themselve to it, crew fixation , generally with sma ll -
fragment or mini-fragment screws, may be carried out.
Usually no tension is applied to the plate and the frag-
ment are too small for crews. The plate then act in
pure buttres mode
85
oc-=~(~-.-L-
) --:J
a
7______------------~
b
Fig. 3.19 a, b. The ulna is more or less straight along its a very slight amount of concavity to the bone surface of
dorsal surface, which is the surface most amenable to the plate, sufficient to arch the plate away from the
plate fixation. From the olecranon distally it presents a straight surface by about 2-3 mm at the apex (b). This
slight concavity, then it is straight or gently bowed dor- technique is most useful where a segmental fracture or a
sally until the distalmost portion just proximal to the large amount of comminution is present. The plate to be
styloid process. Here again a slight concavity is present. used is usually long : 12-16 holes or longer for the
A straight 3.S-cm mini-DCP is compatible with most ul- 3.S-mm DCP, 8-12 holes for the standard DCP. A very
nas. Occasionally, in a large man, the standard DCP small amount of convexity in its distal most portion
should be used. In cases in which indirect reduction is should be imparted to the bone surface of the plate if it
carried out, the ulnar plate is first contoured to provide extends to the level of the base of the ulnar styloid
86
c
87
o
o
f A "push-pull" screw is placed off the proximal end of the segmental fracture tends to reduce into the gap be-
the plate at a distance of 1 cm from the end of the plate. tween the proximal and distal main fragments. The re-
A medium bone spreader is placed between the push- duction is "fine-tuned" with the dental pick and held in
pull screw head and the end of the plate. Distraction of place with the small pointed reduction forceps.
the plate is carried out. Because of the intact soft tissues
88
[)
g The proximal Verbrugge clamp is tightened. The clamp coapting the fractures and the pointed reduction
spreader is removed and a no.O Verbrugge clamps is forceps stabilizing them, the screws are inserted as
placed with its foot around the push-pull screw and its shown. Interfragmentary compression is applied across
pointed end in the terminal hole of the plate. Because all the fracture lines. i Finally, lag screws are inserted
the distal screw has not been tightened definitely, during "outside" of the plate, ensuring both axial and trans ax-
this action it seeks the "load" position of the plate hole. ial compression. The radius may then be fixed in a simi-
The proximal fracture line may also be controlled with a lar manner
small pointed reduction forceps. h With the Verbrugge
89
Fig. 3.25 a-f. A 46-year-old female who sustained The surgery was carried out through the anterior
a fracture of both columns of the acetabulum in a ilioinguinal approach. The modified one-third tu-
motor vehicle accident. a, b, c AP view of the bular plate hugs the quadrilateral surface and is
pelvis and right and left 45° oblique views. Note underneath the pelvic brim plate. The support of
the medial wall comminution associated with the the intrapelvic plate is concentrated on the quad-
anterior column fractures. d, e, f One-year result. rilateral surface
95
b As the clamp is closed, the plate lifts the displaced to the fracture surface as the relationship of the plate
fragment into the appropriate reduction. Final reduction holes to the location of the joint will allow and proceed-
may be obtained by further manipulation with a large ing proximally. Insertion of the screws in a direction
pointed reduction forceps once the fracture surfaces are away from the fracture serves a dual purpose: they more
opposed. Correct rotation of the column is verified by easily avoid penetrating the joint and also serve to pro-
digital palpation of the quadrilateral surface of the duce tension in the plate whil~ contouring it to the sur-
bone. Additional compression is then added by forcibly face of the retroacetabular portion of the proximal frag-
closing the pointed reduction forceps or the Verbrugge ment. Finally, the pointed reduction or Verbrugge clamp
clamp on the distal hole in the plate. c The screws are may be removed and the remaining screws inserted in
then inserted in the proximal fragment, starting as close the posterior iliac wing
98
size of the distal fragment, but is constant, and making ner wires or definitive lag screws. This reduction may
the window early helps to orient the surgeon as to where sometimes be difficult. Insertion of a Schanz screw, with
to place the other implants for fixation such that they do a T-handle chuck attached, into the medial condylar
not come into conflict with the eventual location of the fragment through a stab wound in a safe location af-
blade plate. e The most difficult aspect of this prelimi- fords a direct handle on the medial condylar fragment
nary location of the window is to attain good orienta- that may be used to correct varus-valgus or flexion-ex-
tion as to the location of the proper axis for the plate in tension orientation. Reduction may then be maintained
the sagittal plane. Three steps may be carried out to at- with a large pointed reduction forceps used intra-articu-
tempt to confirm the correct orientation at surgery. The larly or a new circle-pointed reduction forceps which
first is to imagine a perpendicular from the greatest may be used percutaneously on the medial side and in
transverse diameter of the distal articular fragment that the wound on the lateral side. Temporary fixation may
was used to locate the middle third of the anterior half then be carried out with Kirschner wires. The reduction
of the bone (see c). Second, the window should be paral- is inspected and then definitive lag screw fixation with
lel to and prolonged from the anterior flange of the met- 6.5-mm cancellous screws placed in a relationship to the
aphysis on the lateral fragment as it extends off the arti- window such that they will not come into conflict with
cular segment of the trochlear notch. The third helpful any part of the condylar blade plate. Kirschner wires are
ploy is to visualize the inside of the joint with a mind to then placed intra-articularly on the end of the distal
the orientation of the distal femur in the frontal plane: femur in line with the window in the coronal plane and
the plate portion of the blade plate should be placed so on the anterior aspect of the distal femur in line with the
that the femur is in its normal weight-bearing position. window in the horizontal plane. h, i A summation
This latter observation is best carried out after articular Kirschner wire is then drilled into the bone 5 mm from
reconstruction. Although these determinations are diffi- the joint surface. It is parallel both to the Kirschner wire
cult, they are supported by a good preoperative plan that has been placed through the joint along the end of
and at this step are not critical to the final position, as the distal femur in the coronal plane and to the Kirsch-
the seating chisel can be steered somewhat to correct the ner wire that has been placed along the anterior surface
orientation with the slotted hammer at the time of its in- of the distal femur in the horizontal plane. This summa-
sertion. f, g The illustrations depict front and side views tion wire will serve as a directional guide for the inser-
of the articular reconstruction and fixation with Kirsch- tion of the seating chisel.
102
p Following this preliminary gain in length the no.3 Ver- of the plate in the sagittal plane. With a standard reduc-
brugge clamp is tightened maximally. The articulating tion clamp the rotation of the fracture may be controlled
tension device is then inserted at the proximal end of by placing one jaw of the clamp on the plate and the
the plate. The location of the drill hole that will connect other against the proximal fragment. The tendency of
the articulating tension device to the bone is determined the plate to angulate as distraction is increased may like-
by the amount of residual shortening to be overcome. wise to controlled by this method. In order to prevent
Usually the distance of the drill hole for the articulating straightening of the normal anterior curvatum of the
tension device from the end portion of the plate will be femur the distraction is carried out over a bolster which
about 1-2 cm. This will leave 2-3 em in the device for is placed behind the thigh and kept there during the
further distraction of the fracture. Ahole for anchoring distraction process. When slight overdistraction is
the articulating tension device is made through one or achieved, the butterfly fragment may be teased into re-
two cortices proximal to the plate, depending on the duction by the use of the dental pick, small bone hook,
quality of the bone. In nonosteoporotic bone, it may or large pointed reduction forceps. The butterfly frag-
suffice to penetrate only one cortex. Following the ap- ment should be in a position of approximate reduction
plication of the tensioning device, the hook on its distal from the distraction process alone as it is usually con-
end is turned into a position which will allow it to push nected to the soft tissues that will be elongated during
on the proximal end of the plate. The tightened Ver- the distraction.
brugge clamp maintains the correct proximal alignment
105
q A large pointed reduction forceps is then placed on time orient it such that it is impacted between the two
the butterfly fragment and tightened to impact it into the major fragments and therefore capable of taking load.
defect on the medial aspect of the femur. This instru- With this accomplished, the distraction exerted by the
ment is preferred as it is extremely sparing to the soft articulating tension device is removed. When the device
tissues, slipping through them rather than pushing them is loose, its hook is placed in compression mode and
away. The butterfly fragment mayor may not slip imme- tension is applied to the plate. Depending on the quality
diately into a completely anatomic reduction; however, of the bone and the fracture morphology, maximal pre-
it should be possible to jam it into the defect such that load is then applied. In healthy non porotic bone, ten-
with the aid of the pointed reduction clamp it is stable sion to the end of the red zone on the device may nor-
in that position. The object here is to maintain the com- mally be applied safely.
plete viability of the medial butterfly and yet at the same
106
r As an optional step, when the fracture configuration that allows the butterlly fragment, once reduced, to be
appears suitable, stability of the medial butterfly frag- stabilized by the introduction of axial compression. This
ment can be checked by the effect of axial compression would not be the case if the compression forces were lo-
alone. This is not necessary but will demonstrate that cated exclusively underneath the plate, as would occur
the preload obtained by axial compression is well dis- in a valgus reduction of the fracture. Because as yet no
tributed. In our experience, because of the stability ob- screws have been inserted in the fracture zone, the bone
tained through axial compression, with simple fracture fragments are free to impact, eliminating significant
patterns the limb may be actually taken through a vigo- fracture gaps and producing a true medial buttress. This
rous range of motion even at this stage, with complete sets up the tension-compression cycle in the plate-bone
stability of the fractures before the insertion of a single construct. Lag screw fixation through the plate, which is
screw. The beneficial feature of the angled blade plate is possible under these circumstances, or outside the plate
that since the angle between the blade plate and the is carried out in the usual manner. A general rule of
plate is 95° , application of it in perfect alignment to the thumb is that lag screws may be inserted successfully in
anatomic axis of the femur in the frontal plane should the areas previously occupied by the clamps which have
automatically result in significant preload once the plate effectively temporarily stabilized the fracture.
is reduced to the proximal fragment. It is this preload
107
s, t The remainder of the plate screws are then added angled blade plate further suggests that the impaction of
according to the preoperative plan and the articulating bone has occurred on the side opposite the plate, which
tensioner is removed. When one accomplishes the fixa- is mechanically optimal. A further advantage of this ap-
tion in this order, one knows that a buttress of bone has proach is that the reduction is carried out by means of
been restored, as only in its presence may the axial pre- the soft tissue attachments, not in spite of them. Finally,
load with the tensioner be applied and maintained. This the reduction maneuvers are mechanically effective and
cannot always be determined when lag screw fixation smooth, without the usual struggle attendant on manual
precedes plate application. Proper application of the reduction
108
os
o
g
d Kirschner wires are inserted in the same areas in the the lateral side. The area of the fracture will usually
joint as shown in Fig. 3.30. e A summation Kirschner have some disruption of the musculature which will re-
wire is then inserted parallel to the Kirschner wires in quire only a small amount of further development in or-
the frontal and horizontal planes to act as a definitive der to allow the plate to come underneath the vastus lat-
guide for the insertion of the seating chisel, which is eralis. A nO.3 Verbrugge clamp is then placed carefully
then carried out.. f, g The lateral approach is then ex- on the proximal fragment and tightened to hold the
tended proximally, taking care to bypass the fractured plate to the shaft.
area, dissecting to bone only proximal to the fracture on
111
h, i The articulating tension device is then placed as into compression mode, and an attempt made to load
close as possible to the end of the plate and the tab the fracture. It may be surprising, but using pointed re-
turned to the distraction mode. The device is fastened to duction clamps in a couple of key places a comminuted
the bone by means of a uni- or bicortical screw, depend- fracture can be impacted and preloaded so that
ing on the quality of the bone. Distraction is then car- both mechanical stability and biological viability are
ried out according to how much elongation of the seg- achieved. Lag screws are inserted in the location previ-
ment is needed, determined in the preoperative plan. If ously occuppied by clamps. However, in highly commi-
the fracture morphology allows, the Verbrugge clamp nuted fractures this will be impossible and a pure but-
may be tightened, the articulating tension device turned tress function of the plate is all that can be realized.
112
m
113
,
t
o
the flange of the proximal fragment to be interdigitated. slightly out of, rather than in anatomic reduction. With
In fact, one of the most difficult fractures to reduce is compression load, the fracture shortens. However, when
one in which there is a long spiral fracture without com- there is a slight malrotation of the butterfly fragment it
minution of the supracondylar or subtrochanteric re- is impacted proximally and distally by its offset into the
gions, for these reasons. Having the plate not fully seat- intermedullary canal and therefore accepts a load, be-
ed until after reduction is made presents no real coming wedged, as it were, between the two major frag-
problem. In fact, seating the blade and plate in this se- ments. This situation frequently occurs in an indirect re-
quence causes the plate to exhibit an "antiglide effect" duction of a comminuted fracture when load is applied
which will secure the reduction of the fracture and give after distraction and after reduction forceps are careful-
a variable amount of compression across the oblique ly placed on comminutions to bring them into the frac-
fracture surfaces. 0 Some fractures, because they are ture gap. It is surprising under these circumstances how
oblique and because the shearing surfaces are smooth many of these fractures may actually accept load
without interdigitations, may actually be more stable
114
Fig. 3.33. a, b A 19-year-old male with polytrauma from bone graft was applied. The condylar plate was used to
a motorcycle accident. The patient sustained an open reduce the fracture and to act as a splint for the commi-
grade 1 comminuted femoral fracture along with inju- nuted fracture zone. e, f At 8 weeks the patient began
ries to his right ankle, pancreas, kidney and spleen. The full weight bearing. The X-ray at 16 weeks shows conso-
patient also had a pneumothorax and a cardiac contu- lidation of new bone along the medial cortex. g, h X-
sion. c, d Open reduction and internal fixation was car- rays at 1 year show healing and remodeling of the frac-
ried out with a condylar blade plate. Several fragments ture zone. The patient has normal function of his knee
were without soft tissue, and therefore a cancellous joint and is working full time
115
2'racin
g or good side
k
118
I On a second sheet of tracing paper the distal fragments points are definable at surgery from a lateral approach
are traced as a separate block. m The illustrations are to the hip. With an anterior capsulotomy, the neck of
then manipulated so as to reduce the plate portion of the femur will be fully exposed safely and the inferior
the blade plate to the lateral cortex of the distal frag- quadrant of the head directly visualized with no en-
ment tracing. One can see at this point whether the re- dangering of the blood supply to the femoral head. One
duction with a 95° implant in the position selected re- Hohmann retractor will be placed on the anterior rim of
sults in an anatomic valgus or varus position. If it results the acetabulum and one along the inferior neck, and a
in too much valgus or varus, a second tracing may be wide Hohmann posterior to the greater trochanter. With
made, changing the orientation of the blade in the prox- these retractors in place, the point of entry for the seat-
imal fragment. The final drawing in the coronal plane ing chisel and the depth at which it is to be introduced
should tell the surgeon the following: first, the location are seen directly at surgery and can be measured with a
of the entry point from the tip of the trochanteric or the ruler from the landmarks previously described. These
vastus tubercle; second, the direction of the end of the may be correlated with the values obtained from the
blade to direct it toward the inferior quadrant of the drawing.
femoral head; third, the length of the blade. All of these
119
q r
t u
00. 23/'~
123
e
d
Fig. 3.35 a-i. A comminuted intertrochanteric fracture ment; 5 the fractures distracted for reduction of the
associated with a transforaminal fracture in a 30-year- comminuted metaphysis; 6 with compression applied to
old man. a, b, c Preoperative X-rays: AP and lateral the articular block. f, g The immediate postoperative X-
views of the hip, AP view of the pelvis. d, e Preopera- rays. Note the small amount of flexion residual in the
tive drawings: 1 fractured side; 2 the fractures drawn in- proximal fragment. This occurred because the amount
to the outline of the sound side with the seating chisel in of flexion of the proximal fragment was not fully appre-
place; 3 perspective drawing of where the seating chisel ciated. It creates a mild extension osteotomy. h, i The fi-
will be placed relative to the original displacement of nal X-rays after 55 weeks
the fracture; 4 drawing of the plate in the proximal frag-
124
125
Fig.3.36a-f. A 27-year-old male with a sub- quence of operative events was as described in
trochanteric fracture with trochanteric and Fig. 3.34, the plate being used as a means of re-
proximal shaft components. a, b, c AP and duction. The articulating tensioner was used
lateral films of the original fracture. d, e The just in distraction and then in compression.
postoperative montage. In this case, the se- f Healing of the fracture at 26 weeks
126
127
Fig. 3.37. a A 16-year-old Caucasian female who was 5 days. Because of the nerve repair the patient was
struck by the propeller of a motorboat when she feel in- placed in a spica cast with the hip in extension for
to the water. She sustained open iliac wing, SI joint, in- 6 weeks. c, d Radiographic control at 8 weeks. Already
tertrochanteric, subtrochanteric, and proximal femoral we see a "softening" of the fracture lines indicative of
shaft fractures on the right. The sciatic nerve was lacer- early healing of stable, vascular fracture fragments. The
ated at the level of the tendon of the internal obdurator blade was inserted without a capsulotomy of the hip be-
muscle. b Initial treatment consisted of irrigation and cause of the open fractures. The blade is just out anteri-
debridement of the fractures followed by internal fixa- orly. e 6 months post injury all fractures are healed. The
tion of the pelvis and femur. The femur was reduced in- patient has return of sciatic nerve function to the level of
directly as has been described. The sciatic nerve was re- the knee joint. f Montage at 9 months
paired and the wounds were closed secondarily at
129
The femoral distractor (Fig.4.3), first modified in 1969 by~. E. Muller Fig.4.3, page 146
(personal communication, 1988) from the distractor used in spinal surgery
by Harrington [8], is still undergoing evolution at the time of writing. The
current model consists of two arms that may be connected to the proximal
and distal fragments of a fracture by bolts or Schanz screws. These arms
are connected to a threaded spindle; one arm is fixed, and the other is
moved along the spindle by means of two collar screws and a carriage. An
excursion of up to 27 cm is built into the device, and an additional 3 cm is
possible if the compression collar screw is removed. Even more excursion
is possible; however, kinking of the threaded spindle within the sleeve may
cause angular malposition of the end of the device and loss of mobility in
distraction or compression.
The connecting bolts are designed to permit fixation to the bone through
either one or two cortices. The drill bit used with the connecting bolts has
a diameter of 4.5 mm. Sometimes, when high forces are to be overcome or
the distractor will be placed well away from the bone, 6.0-mm Schanz
screws are preferable, as they are more rigid and resist bending. They may
be inserted with the same drill bit.
When applying the connecting bolts to the bone, it is useful to drill the
hole perpendicular to the shaft axis. This is facilitated by the use of the
90° angle guide which is found in the angled blade plate set of instru-
ments. The femoral distractor has a swivel in the socket which holds the
connecting bolt in the fixed arm, thereby allowing certain corrections to be
carried out in rotation.
In the future additional distractors will become available, such as the ex-
tra-long one seen in Fig.4.4. Some of these will allow corrections not pos- Fig.4.4, page 146
sible with the current models. For example, currently there is no adjust-
ment with the device in the frontal plane; placing the connecting bolts or
Schanz screws parallel to one another is a relative necessity. In some cases,
correction of the deformity in the frontal plane is accomplished by placing
the connecting bolts at such an angle to one another that they become par-
allel after the deformity is corrected. Attachments of various types for the
distractor are being developed by AD and will be useful to all of us.
The use of the femoral distractor in femoral shaft fractures is well covered
in the Manual of Internal Fixation [25]. Although we will address it briefly
here, the reader is referred to this original description.
Through the appropriate incision, the fracture of the femur is exposed. In
most cases, there will have been considerable dissection of the deep layers
secondary to the injury itself. Initially, the major fragment ends are
cleaned of interposed soft tissue, granulation tissue, or, if the fracture is
old, callus. If nailing is to be carried out, reaming of the bone ends from
the fracture site retrograde for a short distance allows for better control of
the centralization of the reaming. Similarly, if plating is to be carried out
and lag screw fixation performed, the opportunity afforded by the relaxed
132
soft tissues in their state before reduction should be taken to anticipate fix-
ation by setting up inside-outside gliding or threaded holes. These can be
utilized for fixation once reduction and axial compression have been ac-
complished.
Following this, the linea aspera is identified on the proximal and distal
fragments. Using this structure as a guide to correct axial alignment, the
location for the connecting bolts (which may be planned beforehand with
the tracing) is found. The connecting bolts should be proximal and distal
enough from the fracture to allow an appropriate implant to be placed in
Fig.4.5, page 147 between, in front of them or behind them (Fig. 4.5).
With the two connecting bolts in position, the femoral distractor is applied
and, using the collar screw on the inside of the arm, distraction is carried
out. As with distraction-reduction using plates, there is a tendency with
distraction to straighten out the normal anterior bow of the femur. This
must be anticipated, as loss of the normal contour of the femur results not
only in a gap posteriorly in the reduction, but also a thigh that appears
Fig. 4.6, page 148 conical, less muscular, and cosmetically abnormal (Fig.4.6 a- b).
Distracting the major fragments facilitates the incorporation of the commi-
nuted bone fragments into the reduction. They are then stabilized with re-
duction forceps, and following this the distraction force is removed by re-
versing the screw collar on the inside. Further impaction and compression
of the bone fragments may be accomplished by turning the screw collar
tight on the outside. A contoured plate may be applied at this point. This
plate may be employed as a definitive fixation of the femoral fracture, if
that is the plan, or as a temporary splint to allow antegrade reaming and
open intramedullary nailing of the fracture to be carried out once the fem-
oral distractor has been removed. In this case, the plate may be much
Fig.4.7, page 149 shorter (Fig.4.7). If the plating is to be definitve, compression from the
Fig.4.8, page 150 femoral distractor is not enough (Fig.4.8), and the articulating tension de-
Fig.4.9, page 151 vice should be applied to tension the implant as the fixation is accom-
Fig. 4.1 0, page 152 plished. A clinical example is given in Fig. 4.9 with sequential films, show-
ing the radiographic appearance of fracture healing under these condi-
tions. Fig.4.10 illustrates the problem of a femoral neck fracture combined
with a comminuted shaft fracture.
The operation may be carried out with the patient in the supine or the lat-
eral postion. When possible, the lateral position is used, as it affords easier
access to the trochanter, less interference with the soft tissues, and better
deployment of the image intensifier.
Knee rolls or bolsters are needed to support the operated leg during the
procedure. The upper trunk is stabilized by means of a total hip bean bag,
or built-in table supports. The image intensifier is situated so that AP and
lateral control of the fracture zone is possible. Monitoring of the trochan-
teric area is quite easily accomplished by swinging the arm obliquely.
Depending on the forces of distraction required, various combinations of
proximal control may be obtained, but normally one or two unicortical
connecting bolts are sufficient. These are inserted under the image intensi-
fier control through a short 25-mm incision overlying the thickened por-
tion of the proximal lateral femoral cortex. With the intensifier positioned
to give an AP view, a 2.0-mm Kirschner wire is used as a probe to feel the
sagittal diameter of the bone beneath. Next, a 4.5-mm drill sleeve with a
trocar is inserted at the desired location and checked to be at right angles
to the lateral femoral cortex. The trocar is removed and a hole is drilled
through a single cortex with a 4.5-mm drill. Without removing the guide, a
2.0-mm Kirschner wire is placed into the drill sleeve and into the hole as a
marker. This Kirschner wire is removed and the connecting bolt is inserted
into the hole with a T-handled chuck. If necessary, a second unicortical
connecting bolt may be inserted in a similar fashion, using the carriage
clamp as a guide (Fig. 4.4).
The distal connection is likewise placed through a 25-mm incision. This is
located over the lateral femoral condyle and based on a 2.0-mm Kirschner
wire that is placed transversely to the femoral shaft axis. Again verifying
with the image intensifier, the 4.5-mm drill hole is made at as close as pos-
sible to right angles with the shaft of the distal femur, or approximately 5°
varus in relation to the Kirschner wire placed across the end of the distal
femur through the joint. A 6.0-mm Schanz screw is then inserted in the
hole following use of a marker in the same manner as at the proximal end.
The position of the Schanz screw is shown in Fig.4.17 j.
The long femoral distractor is then placed over the connecting bolt proxi-
mally and the Schanz screw distally. Using the inside collar screw, distrac-
tion is carried out. Rotation can be adjusted at the distal end by means of
the set screw, and when the alignment is correct the other set screws are
tightened as well. Alignment in the coronal plane may be facilitated by the
use of bolsters, as has been mentioned above. Manipulation in the sagittal
plane is possible, and the correction achieved may be fixed somewhat by
the addition of a second connecting bolt proximally. If there is more resist-
ance' this correction may be delayed until the actual procedure has begun,
the reduction in this plane being controlled by means of a 9-mm nail in-
serted into the proximal fragment after initial reaming. This nail serves as
a lever arm for manipulating the proximal fragment. When this method is
used, the approach is made, the proximal fragment is reamed to 10 mm,
and the 9-mm nail is inserted. For the purpose of gaining more leverage,
the nail may be lengthened by adding the proper-sized conical bolt and
the ram guide. Usually the proximal fragment needs to be manipulated in-
to extension, and this is easily accomplished with the improved leverage
134
In most distal femur fractures the articulating tension device may be used
to regain length. In fractures comminuted over a large segment or in the
presence of osteoporotic bone, the distractor is perhaps more suitable. The
distractor is also exceedingly useful in fractures which must be treated
with a condylar buttress plate. Because of the amount of communition as-
sociated with these fractures and the lack of a fixed relationship of the dis-
tal portion of the condylar buttress plate to the bone, the distractor with
Fig.4.15, connecting bolts proximal and distal controls the reduction more reliably
pages 162-164 than the articulating tension device, as has been described in Chap. 3
Fig.4.16, page 165 (Figs.4.15-4.17). The femoral distractor may be employed to achieve re-
Fig. 4.17, pages 166, 167 duction with the proper anatomic axis of the femur restored as well.
135
The technique used in the operative reduction and fixation of medial pla-
teau fractures is similar to that for lateral plateau fractures, with the fol-
lowing exceptions:
The medial surgical approach may be a straight and parapatellar or may
be of the "hockey stick" type, in which case the transverse limb runs paral-
lel to the joint line. This latter approach has the advantage of proximal ex-
tension, if necessary posteromedially, to obtain a better view of the posteri-
or medial joint line.
137
Close attention should again be paid to the soft tissues medially. The osse-
ous insertion of the medial ligament attachment allows little if any soft tis-
sue stripping. It is preferable to place the plate over the medial collateral
ligament instead of deep to it (Fig. 4.20). Fig. 4.20, page 171
There are times when patients present with fractures of such a nature that
conventional approaches are doomed to failure. These are usually high-
energy fractures with severe comminution, extensive soft tissue injury, or
lacerations of the skin overlying ligamentous or tendinous structures. In
138
In the tibia, as in diaphyseal fractures of the femur (see p.131), the femoral
distractor acts as an indirect reduction aid, allowing simultaneous realign-
ment of the tibial shaft and the restoration of length in an atraumatic way.
The distractor has been particularly helpful in the reduction and fixation
Fig. 4.26, page 178 of comminuted shaft fractures (Figs. 4.26, 4.27). It may be used acutely or
Fig. 4.27, page 179 to correct longstanding malunion or nonunion. It is equally helpful in
plate fixation and in cases suited for intramedullary nail fixation. In the
latter, application of the distractor in the proper manner may allow closed
nailing to be carried out (Figs.4.26, 4.27).
Open and Closed Nailing: The steps in using the distractor as an aid to in-
tramedullary nailing of the tibia are essentially the same as described for
the femur (p.132), with a few exceptions. The distractor may be applied
medially or laterally, depending on the dominant displacement of the frac-
ture. It must be applied in the metaphyseal bone far away from the frac-
ture. Because of this, Schanz screws should be used and their position con-
trolled by placing them parallel to the knee and ankle joint axis in the
coronal plane. This is assured by placing 2.0-mm Kirschner wires transcu-
taneously through the joint of the knee and the ankle. The exact location,
if in doubt, may be verified with the use of the image intensifier. The
6.0-mm Schanz screws are then inserted 1-2 cm below the joint proximally
and above the joint distally, parallel to these guide wires. It is important
that in the proximal tibia the Schanz screw is inserted in the posterior half
of the metaphysis close to the joint, enabling it to be used for distraction
and temporary stabilization without conflicting with the reaming or defini-
tive nailing of the tibia.
139
With fractures of the tibial shaft, the advantage of the femoral distractor
over a fracture table as a reduction aid is that the knee may be flexed to
120°, which facilitates the reaming and the nail insertion by lessening the
chances of conflict with the posterior tibial cortex during the procedure.
The joints are free to move, and the leg itself is free on the operating
table.
Distraction is then carried out until the fracture is stabilized by the in-
creased soft tissue tensions. Manual manipulation may be required to re-
duce the fracture in the sagittal plane, and when flexing the knee assis-
tance may be required to pull backward on the proximal portion of the leg
to counteract the tendency for the proximal fragment to extend because of
the pull of the quadriceps as the knee is flexed.
The "pacemaker board" is utilized in order that the image intensifier may
be used as needed during operation. The AP view is obtained by extend-
ing the knee during surgery and placing the leg on the table; the lateral
view may also be obtained in this position by changing the orientation of
the C-arm. The lateral view can be monitored during surgery if the C-arm
is elevated in a horizontal orientation and focused on the fracture site as
reaming or nailing is carried out. This, however, is sometimes difficult and
requires an experienced radiology technician, and represents one of the Fig. 4.28, pages 180,
few compromises made in utilizing the technique (Fig.4.28). 181
The lateral surgical approach has been utilized for the following reasons:
First, there is a pronation deformity of the os calcis which can be dealt
with more easily from the lateral side. Second, the "separation fragment",
the sustentaculum tali, usually stays reduced to the talus because of its
strong intraosseous ligamentous connections. Most commonly the main
fracture dislocation takes place in the dorsolateral part of the posterior
facet of the os calcis. Third, the lateral approach is technically easier with
no need to deal directly with the neurovascular bundle.
The incision is liberal and curvilinear, one finger breadth distal to the infe-
rior tip of the lateral malleolus, parallel to the peroneal tendons proximal-
ly, and extending to the base of the cuboid distally. The peroneal tendon
sheath is incised longitudinally along with its distal retinaculum. The fibu-
localcaneal ligament, which forms the medial wall of the tunnel for the
peroneal tendons, is opened if necessary to deal with the fracture, if it is
not already ruptured. All of the structures are loosely repaired at the time
Fig.4.31, of wound closure (Fig. 4.31).
pages 185-188 In addition to the adjustment of the frame to regain the external appear-
ance of a normal heel, an intraoperative X-ray may be made to assess the
progress of the overall reduction.
The fixation of the Steinmann pin in the tuberosity of the os calcis may be
compromised because of extra-articular extensions of the fracture into this
area; surprisingly, however, even small fragments suffice to achieve
enough stability to allow the Steinmann pin to fulfill its function of regain-
ing the length of the body of the os ca1cis and rotating the posterior tuber-
osity downward.
In central depression fractures, after the subtalar area is inspected, the lat-
eral wall of the os calcis is checked along with the calcaneocuboid articu-
lation. In the easiest type of case, the lateral half of the subtalar articular
surface is impacted. In more difficult cases, a third or even a fourth central
fragment may be present. Usually we are dealing with sagittal, longitudi-
nal fracture lines which, when reduced, maintain the convexity of the pos-
terior subtalar facet. The articular fragments are disimpacted and lifted up
against the intact joint surface belonging to the talus. They may be held
with a small elevator and fixed with Kirschner wires to the medial separa-
tion fragment of the sustentaculum tali, which, as has been mentioned, is
in its proper reduced position. If comminution is present and central arti-
cular fragments must be fixed, they are elevated and transfixed with small
subchondral Kirschner wires to the sustentaculum. These wires are driven
through the sustentaculum, emerging through the skin on the medial side.
They are next retrieved with a drill on the medial side and withdrawn until
they are flush with the fracture surface on the lateral side. Only now is the
lateral articular comminution (usually in conjunction with the exploded
lateral cortex) united, thus completing the reduction of the subtalar joint.
The Kirschner wires are now driven back from the medial side into the re-
duced lateral fragment. This completes the temporary fixation.
When the lateral wall fragment is significant, its reduction usually obviates
the need for cancellous bone grafts, as the residual defects are insignifi-
cant. This has been the experience of ourselves and others. In rare cases,
cancellous bone grafts may be required to support the reduced articular
surface.
141
Defintive fixation is carried out with screws buttressing the lateral wall
across the area of comminuted joint to the good-quality bone of the medi-
al separation fragment. Generally, small 3.S-mm cortical screws, placed
subchondrally, are used. When comminution of the lateral cortex of the os
calcis is present, small-fragment plates, such as the AO 3.S-mm recon-
struction plates or the 3.S-mm Y plate of Letournel, are used to buttress
the fractured cortex. Additionally, when comminution is significant, these
plates are needed to maintain length with regard to the tuberosity frag-
ment and the fragment of the anterior articular process.
In tongue type fractures a similar approach is employed. The technique
differs somewhat in that when constructing the triangular frame, care must
be taken to avoid transfixing the articular fragment which extends posteri-
orly into the posterior os calcis, as this would prevent its later manipula-
tion. This could conceivably happen if the pin through the tuberosity was
placed in the tongue fragment itself. The reduction of the tongue fracture
is facilitated by using a small Hohmann retractor or a periosteal elevator
as a lever.
When the os calcis is multifragmented, reconstruction of the joint between
the os calcis and the cuboid may prove to be difficult. In these circum-
stances small Kirschner wires inserted from posterior through the tuberos-
ity and thus through the anterior process, transfixing the cuboid, help to
maintain the reduction. These Kirschner wires may be removed 3-4 weeks
after surgery.
After removal of the external fixation frame, stability and mobility of the
joint is verified and final X-rays are obtained. To the extent possible, the
dissected soft tissue structures are sutured. Loose closure of the peroneal
tendon sheath and the skin is carried out over small suction-drainage
tubes. A soft compression dressing is added. The leg and foot are elevated
for 72 h. Active and passive exercises are begun after 24 h. If stability is
not assured at surgery, a removable posterior split is used. The foot, how-
ever, is removed from the splint several times a day for the same exercises.
Partial weight bearing to 10 kg is instituted following the period of eleva-
tion to help prevent post-traumatic osteoporosis and Sudek's atrophy.
Although this technique has been used since 1983, no formal reports on its
long-term effectiveness have yet been published. It is our opinion that the Fig.4.32, page 189
shape of the hindfoot can be restored to normal and maintained. Although Fig. 4.33, page 190
some motion is preserved, loss of greater than SO% of the mobility of the Fig. 4.34, pages 191,
subtalar joint is to be expected (Figs. 4.32-4.34). 192
The Minidistractor
Other Applications
radius and ulna. This technique is effective in this area because of the
strong capsular ligaments, and is indicated in unstable fractures of the dis-
tal radius with comminution and impaction. The standard technique em-
ploys distraction over the wrist joint with the wrist in a neutral position, al-
though montages may sometimes be made which do not span the wrist
joint. The fixation is made with 2.5-mm terminally threaded Schanz pins,
employed together with universal clamps which have holding sleeves for
the 4.0-mm bars and the 2.S-mm pins. In addition there are "bar-to-bar"
4.0-mm clamps with spring-loaded nuts. The connecting bars are 4.0 mm
in diameter and range from 60 to 200 mm in length. The technique in the
usual situation is to make 5-mm incisions in the skin overlying safe areas
for insertion of the pins. The 2.S-mm threaded wires are then inserted with
a small air drill using a 3.S-mm tissue sleeve to protect the soft tissues. Two
threaded Schanz screws are inserted proximal to the fracture in the radius
and two are inserted distally in the shaft of the second metacarpal. Main-
taining the forearm and hand in neutral rotation, the wires are inserted at
an angle of 4So to both the transverse and the sagittal plane, avoiding the
extensor tendons. In the forearm the first wire is placed proximal to the
palpable wad of the extensor pollicis brevis muscle. The distal wire is in-
serted between the tendons of the abductor pollicis longus and extensor
carpi radialis brevis and longus muscles. When inserting the wires in the
metacarpal, the metacarpophalangeal joint is flexed to a right angle to
avoid the extensor hood. The thumb is held in abduction to avoid the first
web space. In the metacarpal the two Kirschner wires must be inserted
converging at an angle of Soo -60° in the bone, the points not touching
each other. This allows a longer passage in the bone and thus more stable
fixation. The two outer wires are drilled first and the connecting rod is
temporarily fixed. Placement of the two inner wires is then facilitated by
using the two inner clamps as aiming devices. After the rod is attached to
the pins and adjacent to the bone, the two distal metacarpal clamps are
fixed. Pulling on the fingers directly or by use of "chinese finger traps"
provides distraction. If reduction under the image intensifier is satisfacto-
ry, the proximal clamps with the spring-loaded nuts are tightened manual-
ly. During this phase any desired change of position can easily be accom-
plished. When adequate distraction and manipulation have resulted in the
desired reduction and maintenance of the fracture, a second rod is applied
2-3 em further along the threaded wires, to increase stability. Finally, the
special proximal manual clamps can be replaced by the definitve clamps.
The advantages of this method are a simple frame, easy application, eco-
nomical use of materials, and stable fixation. A clinical example can be
seen in Fig. 4.40. Fig. 4.40, page 200
Summary
and held in their place by tissue sparing forceps. Fragments that profit
from slight "over-reduction", such as central tibial plateau fractures, can
be managed more easily.
Regardless of whether or not the definitive implant for fixation of the frac-
ture is a nail, plate, or a lag screw, it is best to plan where and how to
mount the distractor. In this way, conflicts between distractor and implant
or unforeseen problems of angulation caused by the distractor can be an-
ticipated and therefore eliminated.
At present there are two distractors, the so-called femoral distractor which
was specifically designed for the femur and the minidistractor designed
for the hand and foot. There are also prototypes of models with modifica-
tions in length, clamp adjustability, and size. As the use of these instru-
ments increases, other models will surely appear with further develop-
ments that will make them even more valuable.
This chapter has described only some of the situations in which the dis-
tractors are useful; there are many other occasions on which they have
been of service. The purpose here has been to acquaint the reader with the
principles of their use and their major applications. Having done that,
when those other occasions arise, the distractor will be available on the
back table.
145
o o
Fig. 4.5. The placement of the connecting bolts should blade plate set. If one has correctly assessed the rela-
be such that they are out of the way of the definitive im- tionship of the linea aspera along the general shape of
plant to be used. In an open femoral nailing, unicortical the bone (the pronounced curve of the femur along its
connecting bolts may allow the maintenance of reduc- anterior lateral border), there will be only minor, if any,
tion while reaming is carried out. In a plate fixation, rotational corrections to make once the distractor is ap-
connecting bolts should be placed wide enough apart to plied. If the patient is osteoporotic or if a lot of distrac-
allow the plate to be placed inside of them, or anterior tion is to be carried out, it is best to penetrate both cor-
or posterior enough so that the plates can be placed be- tices with the connecting bolts. This tends to minimize
hind or in front of them. The 4.5-mm drill hole is then the deformity produced when tension is increased in the
made with the help of the right-angled template guides soft tissues by distraction (with a lateral application a
so that it will run perpendicular to the femoral shaft varus deformity occurs). Penetrating both cortices with
axis. The right-angled guides are found in the angled the connecting bolts also helps to prevent pullout
148
c
149
<II Fig.4.6. a As the forces in distraction become higher ture malunion, it is sometimes necessary. Using the
there is a tendency to straighten out the femur at the bending press, a concavity is produced in a narrow 8- to
fracture site. This will lead to a less than pleasing ap- 10-hole DCP with a curve distributed along its entire
pearance of the thigh and also leave a posterior gap at length. With careful dissection, the plate is slid onto the
the fracture site. There are two ways in which the nor- anterior surface of the femur and held in place proxi-
mal anterior bow of the femur may be preserved during mally and distally with large self-centering Verbrugge
distraction. b The first and preferable way is to place a clamps. Distraction is then carried out. The plate in this
bolster posterior to the thigh during distraction, allow- case acts as a tract along which the fragments glide as
ing gravity to produce a slight anterior angulation while the distraction forces are applied, and the anterior bow
distraction is carried out. c The second way is less ac- of the femur is preserved. Obviously, the price for such a
ceptable as it requires more dissection. When forces are tactic is high as more soft tissue dissection is required
high, however, such as in the lengthening of an old frac-
Fig. 4.8. a If plating is to be definitive, and the fracture been removed, or if it is still in situ it should be maxi-
pattern is simple, compression from the femoral distrac- mally compressing the reduced fracture so that it is tak-
tor is not enough. The bone fragments may be com- ing no load. The plate is maximally tensioned with the
pressed in this circumstance, but the implant has not tensioner, and lag screws and plate screws may be in-
been preloaded. Fixation of the plate should be ob- serted. A lag screw across a fracture is extremely impor-
tained by means of a screw or screws to one side of the tant to increase stability. b In this case the fourth screw
fracture, and the articulating tensioner should be ap- hole from the left has been used for a lag screw to cross
plied to the other end of the fracture 2-3 cm from the the fracture. If there has been bone loss opposite the
end of the plate. The adjustable hook in the device is plate or a significant devitalization of the fracture zone
then placed into compression mode and tension is from the original injury or surgical technique has been
placed on the plate until appropriate load (in or beyond faulty, a cancellous bone graft should be added. It may
the red zone in the femur) has been reached. Before this be applied to the opposite side through the fracture dur-
is accomplished, the femoral distractor should have ing the distraction stage
151
Fig. 4.12. The current model of the femoral distractor. and manipulation of the proximal and distal fragment
This new prototype will allow distraction, interlocking, of the femur in all planes
Fig. 4.13. a Drawing of a comminuted fracture of the tached to the shaft and "tensioned" proximal to the dis- ~
subtrochanter region of the femur, extension into the tal connecting bolt. f The proximal fragment and the
proximal shaft. b A tracing of the good side. c The distal fragment are then adjusted in length in the same
good side with the fracture lines drawn in. This was ac- way as would occur with the femoral distractor during
complished in the same manner illustrated in Fig. 3.34. surgery. At this time incorporation of the comminution
d The drawing must include the reduced head, neck, of the segment may be carried out. Because the femoral
and trochanteric aspects of the proximal fragment. The distractor is being used, the level of the second hole of
implant overlay is then adjusted such that the entry the plate should be scrutinized closely to see if there is
point is on the surface of the lateral aspect of the greater good bone opposite it. The second screw-hole of the
trochanter about 1.5 cm from the tip and the blade is di- plate is the ideal location for the connecting bolt, as the
rected into the inferior quadrant of the head. The sec- first screw-hole then remains open for a fixation screw.
ond hole of the plate will be used for the insertion of the The first screw is a very important screw that engages
connecting bolt or Schanz screw in order to attach the the calcar in the proximal fragment. If the proximal
femoral distractor. This is drawn in place with the fragment is too short medially, however, the first screw-
Schanz screw perpendicular to the long axis of the hole in the plate may be the only possible place to fix
plate. e The distal fragment is also drawn, with the con- the proximal connecting bolt. If that is the case, a new
necting bolt at right angles to the femoral shaft and well direction of the fixation screw or 6.5-mm cancellous
away from the fracture focus so that the plate can be at- screw will be needed. When a 6.5-mm cancellous screw
157
"
1\
II
I , ; , .... __ -
I J '
I , \
" \I
I
I
I
I
I,
" I \
-
"i..' ...1, \
a b c
d e
is inserted in the hole after the femoral distractor is re- redrawn until the final position is satisfactory. This new
moved, good fixation can still be obtained in the calcar. data must be incorporated. The case itself differs from
It is reiterated that during planning, if, in reducing the the description in the previous chapter (Fig.3.34) only
plate portion of the blade plate to the shaft, varus or too insofar as the distractor is used as the reduction instru-
much valgus appears in the drawing in the frontal plane, ment.
then the step for location of the seating chisel must be
158
g The fracture is exposed and an anterior caps ulotomy the length of the fracture, one or more extra clamps may
of the hip is carried out, exposing the femoral head and be necessary and are inserted in a smiliar manner. At the
neck. The seating chisel is inserted, guided as usual by level of the subtrochanteric fracture, it is usually helpful
Kirschner wires. Control of the three planes of reference to place a standard reduction clamp straddling the plate,
is obtained as has been described earlier (Fig. 3.34). The with one jaw on the anterior surface of the femur and
95° condylar plate is then introduced, and, using the one on the posterior cortex. This clamp may be adjusted
drill guide, a 4.5-mm drill hole is made in the lateral cor- as distraction is carried out by placing one of the jaws
tex at right angles to the second hole of the plate. The on the edge of the plate and the other against the re-
connecting bolt is inserted. If it is too short, a 5.0-mm or spective anterior or posterior cortex. This allows a little
6.0-mm Schanz screw may be substituted. Usually, be- adjustment of rotation as reduction is carried out with
cause of the forces required, both cortices are engaged, distraction. The rotation can then be fixed by the wing
although this is not always necessary. The full extent of nut on the femoral distractor. When the fragments have
the lateral mailbox approach is then developed to allow been inserted and the rotation is correct, a pointed re-
the plate portion of the blade plate to be brought along duction clamp is carefully inserted through the soft tis-
the lateral cortex of the unreduced fracture and applied sue and closed against the medial fragment. The clamps
to the main distal fragment. The distal hole for the con- are fully tightened to restore and maintain the align-
necting bolt is next made in the location determined by ment. The plate in this case acts as a splint to restore the
the preoperative plan. The bolt is inserted and the dis- alignment in the frontal and sagittal planes. The distrac-
tractor attached. h A large Verbrugge clamp is placed tion is slowly released by spinning the collar screw in
on the plate, making a small opening in the medial soft the reverse direction. When it is loose the col\ar screw
tissues for the bone-holding arm of the clamp. The on the other side may be tightened to compress the bone
broader plate-holding portion is placed on the plate and fragments together. As this is accomplished, the commi-
the clamp is snugged up until it is stable. Depending on nuted fragments previously reduced are impinged upon
159
the other fragments, compressed, and stabilized. If the femur that in the normal case enough preload should be
clamps cannot control these fragments at this point, the applied to allow the red ring to be completely covered
fracture may be redistracted, reduction regained, and by the collar, i.e., over 100 kp of load. A little time
cerclage wires placed very carefully around the plate should be allowed to pass while general wound care is
and comminuted fragments in the area where clamps attended to. This will show whether the force generated
were previously unsuccessful. The compression stage is by tensioning will dissipate. If it does, the compression
once more carried out and, as noted earlier, the external should be regained with an open-end wrench until it is
tensioner is placed off the end of the plate. Preload is maintained over a period of time. If it is impossible to
then added to the plate. The femoral distractor must re- preload the plate, this indicates that the deficiency exists
main in compression during this time so that it allows in the bone buttress and the plate can only be used as a
the load to be taken by the bone and does not itself buttress plate. In this instance success depends on the
share the load. It is our experience in fractures of the viability of the fragments.
z
"co
I
cr
QI)
o
161
NK 5-28-81
Fig. 4.14. a, b Preoperative X-rays of a closed commi- tion aid. c, d Postoperative control at 6 months showing
nuted subtrochanteric femoral fracture with trochanteric all fractures healed. Note use of 6.5-mm screw in site oc-
extension in a 28-year-old Caucasian male. The fracture cupied by connecting bolt. e, f The patient subsequently
was operated on very shortly after admission. The femo- had his plate removed and returned to his previous em-
ral distractor was used along with the plate as a reduc- ployment as a laborer
162
Fig. 4.15. a A severely comminuted fracture of the distal tractor has spanned the comminuted area and portion
femoral shaft extending into the supracondylar and in- of the femoral shaft to be plated. The plate is attached
tracondylar area. The articular segment has been recon- to the proximal fragment by means of a Verbrugge
structed and fixed. The blade plate has been inserted as clamp. b Using a small instrument, such as a dental
described in Fig. 3.32. The connecting bolt has been pick, comminuted fragments with their soft tissues at-
placed in the first hole of the plate, and the femoral dis- tached are gently teased into approximate reduction.
163
c As the comminutions are brought into the plate, they low the application of preload. If the pattern is such that
are fixed by means of a large pointed reduction forceps . preload may be applied, the articulating tension device
Rotation of the plate is controlled by a standard recon- must next be attached to the end of the plate and ten-
struction clamp as shown. d As the fragments are as- sioning of the plate carried out. Following this, lag
sembled using the plate as a scaffolding, a decision must screws may be inserted.
be made as to whether or not the fracture pattern will al-
164
Fig. 4.18. a The placement of the femoral distractor on bility. Distally, a point on the lateral surface of the tibial
the lateral side of the femur for a lateral plateau frac- diaphysis is selected that is sufficiently beyond the dis-
ture. It is placed approximately a finger breadth in front talmost aspect of the fracture to allow the definitive im-
of the lateral epicondyle on the distal femur and any- plant to be applied without fear of conflict. A right-
where below the implant and the midline of the sagittal angled guide is oriented to the surface of the bone and a
plane at right angles to the tibial shaft. Proximally, a drill hole of 4.5 mm is made through the cortex. In most
2.0-mm guide wire is placed intra-articularly so that it cases, the drill hole need not be continued completely
rests against the ends of the femoral condyles in the through the opposite cortex, but should be made such
frontal plane. Using this as a guide and reference, a that the end of the Schanz screw will have a fixation
4.5-mm drill hole is made just anterior to the lateral point on the intramedullary surface of the internal tibial
femoral epicondyle. b Using the T-handled chuck from cortex. It is helpful when placing the Schanz screws to
the external fixator set, a 6.0-mm Schanz screw is insert- keep them as parallel as possible in the horizontal plane,
ed into the lateral femoral epiphysis. The more porotic as less correction in rotation will then be needed. If the
the bone, the deeper into the condyle the screw must be bone stock is good, a connecting bolt through only one
inserted. The Schanz screw is checked manually for sta- cortex is used.
169
Fig. 4.19. a Four views of the knee joint showing a lateral tibial
plateau fracture with central articular impaction. The injury was
sustained while skiing. b Surgery was carried out the same day.
Through a lateral approach the fracture was exposed and a
femoral distractor applied. This intraoperative view shows dis-
traction on the lateral side of the joint. The articular reduction
has been carried out and provisionally fixed with a Kirschner
wire. I will be supported by bone graft and buttressed by a
plate. c Immediate postoperative X-ray illustrating the reduc-
tion obtained. The fracture is buttressed by a one-half tubular
plate. d X-ray control 1'l1 years later show maintenance of the
reduction along with an excellent joint space. The patient's re-
covery has been complete and she functions normally
171
is carried out by means of reduction forceps and a small is replaced by definitive stable internal fixation by
instrument. Provisional fixation of Kirschner wires may means of lag and plate screws. Recently we have at-
be helpful in order to sequentially stabilize the commi- tempted more and more often to replace a buttress plate
nuted joint surface. c Undercontouring of a half-tubular on the medial side of the fracture with an external fixa-
plate allows its application inferiorly on the distal frag- tor: shown here is a three-hole one-half tubular plate
ment as shown in the drawing. It can be seen that the substituting for the broken medial cortex. We try to
plate functions purely as a buttress, helping to stabilize avoid the use of bulky implants on both sides of the
the joint surfaces. A figure 8 tension band wire over the proximal tibia. e The fixator located on the medial side
anterior tibial tubercle fragment and the distal tibial has the advantage of providing a buttress without im-
metaphysis is frequently helpful in order to counteract pinging on the medial ligamentous structures. In a few
the extension moment produced by the quadriceps ten- cases it may be applied without a formal medial expo-
don on this fragment. This has been a mechanically ef- sure. It is placed in the subcondylar bone proximally
fective yet economical way to increase the stability of and at right angles to the shaft distally. The fixator itself
the fixation. d The provisional Kirschner wire fixation is locked in buttress mode
174
a b
Fig. 4.22 a, b. Alternative anterior method of montage of lized to reduce the fracture, which may be approached
the femoral distractor in bicondylar tibial plateau frac- medially or laterally as demanded by the circumstances.
tures. A proximal Schanz screw is placed in the midline This montage allows distraction without the production
in the distal femur proximal to the patella. Distally the of a varus or valgus deformity; however, the knee obvi-
connecting bolt is placed at right angles to the tibial ously cannot be flexed during the procedure, which is
shaft axis away from the fracture. Distraction is then uti- sometimes a disadvantage
175
Fig.4.23 a-f. A 44-year-old man involved in a motorcy- joint. Note that regaining the correct length reduced the
cle accident sustaining bilateral tibial injuries. That on fracture. The underbent one-half tubular plate is in a
the right was a bicondylar tibial plateau fracture, load position. d Intraoperative control with definitive
closed. a, b Before operation. c Intraoperative control fixation. e, f Follow-up 18 months later. Full use of ex-
with two distractors and a Kirschner wire across the tremity with full motion
176
a b c
Fig. 4.24. a An example of a type of injury requiring a fracture focus, so as not to limit possible more definitive
special approach because of compromised bone and fixation in the future. An additional advantage of such a
soft tissues. It is a comminuted proximal tibial plateau construct is to allow elevation of the limb, as the frame
fracture extending into the tibial diaphysis. b, c The ap- may be utilized to support the injured extremity in a po-
proach is one of articular reconstruction and fixation sition higher than chest level. When the soft tissues have
with a simple lag screw followed by spanning the knee healed, in 2-3 weeks, either the frame may be broken
with moderate distraction provided by an anterior uni- down and reapplied beneath the knee joint so as to al-
lateral frame in order to stabilize the soft tissues by Jiga- low motion, or internal fixation may be employed as a
mentotaxis. Half-pins are utilized away from the tibial delayed secondary procedure
177
Fig.4.25a-j. A 26-year-old man with an open grade 2 nal fixator as a buttress. He was then started on physical
comminuted tibial plateau fracture with extension dis- therapy with an active knee range of motion exercises.
tally into the diaphysis. a, b Before operation. c, d The g, h At 4 months the medial fixator has been removed,
initial treatment consisted of irrigation and debridement the patient's range of knee motion is 130° to full exten-
of the open wounds, articular reduction, and fixation sion, and there is consolidation of the comminuted
with two lag screws and a Kirschner wire, followed by fracture area. i, j Final radiographs at approximately
the application of a half pin frame external fixator ante- 1112 years after the accident. Healing in complete knee
riorly. e, f At 6 weeks the patient was taken back to sur- motion is full
gery, where the anterior frame was disassembled and the
patient had a lateral plate fixation with a medial exter-
178
Fig. 4.26. a Example of a comminuted diaphyseal frac- for the distraction bolts. As described an extra-long fem-
ture of the tibia with displacement and shortening. In oral distractor is available which allows one to insert the
such a comminuted fracture the distractor is extremely connecting bolts with a greater span between them.
helpful. b The connecting bolts are inserted proximal General principles for distraction, reduction, and plate
and distal to the fracture, or to the fracture zone when fixation are similar to those presented in discussing the
comminution is present. The bolts are placed into the application of the distractor in fractures of the femur
shaft at right angles to the shaft axis with the help of the (Figs. 4.3 -4.9) except that the distraction need not be
right-angled guide. Rotation is controlled with an at- carried out over a bolster as the tibia is a straight bone.
tempt to make the connecting bolts as parallel as possi- These steps will not be reiterated here. Medial applica-
ble in a horizontal plane. Although correction of rota- tion of the plate is desirable, as no important blood ves-
tion is possible with the distractor after the bolts have sels enter the medial face of the tibia along its subcu-
been inserted, major corrections demand that the dis- taneous border and the anteromedial counter of the
tractor become skewed, which make it a little more diffi- tibia is much more accessible and easier to fit with a
cult to work around during the subsequent reduction plate. However, the condition of the soft tissues and the
and fixation steps. The distractor is best applied medial- nature of the fracture pattern and displacement also
ly, anteromedially, or anteriorly, thereby circumventing playa role in this decision. Only those screws necessary
penetration of the muscle compartments. Displacement for interfragmentary fixation or implant fixation should
of the fracture, choice of surgical approach, and method be utilized
of fixation all playa role in deciding the best location
179
Fig. 4.28. a, b Front and side views of a tibia in which come its tendency to extend with knee flexion. Note that
the femoral distractor is applied to regain length in a re- the proximal position of the pin allows medullary ream-
duction. Note that the Schanz screws are placed at right ing and subsequent nailing to be carried out without in-
angles to the tibial shaft axis and proximally in the mid- terference. Distally the Schanz screw must be removed
portion of the bone. The operation is performed on a ra- before final impaction of the nail. e Completed nailing
diotranslucent table with "pacemaker" extension, moni- is illustrated. The advantage of this approach is the in-
toring the procedure with image intensification. creased knee flexion that may be obtained when using
c, d Length and alignment are restored by use of the the distractor. The disadvantage is that image intensifi-
femoral distractor in the sagittal plane. Pressure on the cation control is difficult to obtain in the lateral view
proximal fragment is exerted by the assistant to over-
181
e
182
Fig. 4.29. a Front and side views of a comminuted pilon of the talus and just in front of the medial malleolus and
fracture in which the fibula is intact. b The connecting slightly proximal to the neurovascular bundle, a 4.S-mm
bolt is applied proximal to the fracture in a location drill hole is made in the talus parallel to its articular sur-
where it will not interfere with the definitive fixation. face. The drill hole is made to the other side of the talus
An attempt is made to place it at right angles to the tib- but not through the opposite cortex. Into this drill hole
ial shaft axis utilizing the right-angled template from the the long end of the connecting bolt or S.D-mm Schanz
angled blade plate set. It may be placed through one or screw is inserted. The distractor is then connected and
two cortices, depending on the situation. Distally, after distraction is carried out. Usually it is best to place the
the standard operative approach is extended 1 cm and leg on a bolster so that the distal tibia is supported up to
taking care to protect the posterior tibial tendon and the the prominence of the heel. c, d The talus is distracted
neurovascular bundle, a careful anterior capsulotomy of below the exposed articular surface, which may then be
the ankle joint is performed so that the talus at the end explored from below as well as from above, proceeding
of the distal tibia is visualizable. Just behind the rim of through the fracture gaps. Distraction is obtained or re-
cartilage that extends medially from the articular surface leased as needed so that in the end the articular reduc-
183
e
d
tion may be obtained and temporarily maintained with finitive fixation may be carried out after cancellous
Kirschner wires. Use of the large as well as the circular bone grafting of the defect. Because of the intact soft tis-
pointed reduction forceps facilitates the repositioning of sues in the area of the metaphysis, a relatively light me-
these articular fragments. e With preliminary Kirschner dial buttress plate is being used by us more and more as
wire fixation holding the fracture, the distraction force an "artificial cortex" to support a comminuted area of
can be increased so that the articular reconstruction can the metaphysis. Depending on how far the fracture lines
be viewed directly, fracture faults being probed for step- extend proximally from the metaphysis, a cloverleaf
offs with a dental pick. If the reduction is less than de- plate or a one-third or one-half tubular plate flattened in
sirable, the distraction may be released and an attempt its distal aspect has been used with good success. If
made to improve the situation, using the top of the talus there is a significant diaphyseal extension with short ob-
as a template. These steps may be repeated as neces- lique or transverse fracture lines, the 4.5-mm narrow
sary. f Once the articular reconstruction is correct, de- DCP, as described earlier (Figs. 3.2-3.5), is indicated
184
Fig. 4.30 a-g. A distal intra-articular tibial fracture in a finitive implant. This implant was chosen because the
28-year-old metal worker who fell while at work. upper portion of the fracture consisted of a torsional
a-c AP, oblique, and lateral views before operation. fracture line amenable to leg screw fixation, while the
Note the proximal extension of the fracture lines from crushing of the metaphysis would be well supported by
the tibial crest to the articular surface. d, e AP and later- an implant of this dimension. f, g The fracture a little
al views following reduction and fixation of the fracture. more than 1Vz years after the accident. The patient has
The femoral distractor was utilized and a one-half tubu- occasional lateral ankle pain, but motion is excellent
lar plate extending proximally was employed as the de-
185
Fig. 4.31. a A central depression fracture of the os calcis for the peroneal tendons is incised and tagged, if it is
with loss of joint congruency and Bohler's angle. b The not already ruptured. The fat pad is dissected from the
goal will be to reestablish the three poles of the os calcis, sinus tarsi, hinging it anteriorly along with the short toe
as described by Emile Letournel, and Bohler's angle by extensors so that the anterior process and calcaneocu-
use of a triangular frame. c Illustration of the foot and boid joint can be visualized. All of the structures are
ankle from the lateral side. The incision is liberal and loosely repaired at the time of wound closure. The au-
curvilinear one finger breadth distal to the inferior tip of thors have used two types of frames over the evolution
the lateral malleolus, parallel to the peroneal tendons, of this technique; however, the principles of their effec-
and extending to the base of the fifth metacarpal. The tiveness are similar. d An external fixator is mounted in
sural nerve is protected. The peroneal tendon sheath is a triangular configuration. This illustration shows a
incised longitudinally along with its distal retinaculum standard external fixator which is available in most hos-
and the tendons subluxed anteriorly. The fibular calca- pitals.
neal ligament which forms a medial wall of the tunnel
186
through the navicular and exiting superior to the neuro- recognizable with almost normal anatomic landmarks
vascular bundle. Two adjustable clamps are placed on except for the hole underneath the talus. The subtalar
each pin, and matching bars of the appropriate length region will still need reduction, as centrally the articular
are passed through each of the tube-holding ends of the surface is markedly impacted into the underlying bone
clamps. The clamps are snugged but not tightened. By below the posterior facet of the talus. Before reducing
manual traction or, if a standard external fixator is used, this by digging it out of its impacted position, it is good
with the tension device, each of the limbs of the triangu- to check on the location of the sustentaculum tali frag-
lar structure is lengthened and the triangle is made sym- ment, which will be the medialmost fragment in the re-
metrical. When length has been regained, the assistant gion and, as the joint is further distracted, will move
tightens the clamps definitively. At this stage, the proce- with the underlying joint surface of the opposing facet
dure usually restores two poles of the os calcis. A dis- of the talus. This is the important landmark to which
turbing disorganization of fracture fragments becomes other fragments must be reduced.
anterior
facet
middle .......--initial
facet Fx-line
b : blo ws-out
lateral wall
joint depression
posterior Fx-line
facet
k Aligning the pins in the frame and lengthening the portion of the bone it is easy to see the sustentacular
axis of the triangle corrects the alignment and reesta- fragment. 1, m After elevating the subtalar articular sur-
blishes length. The third pole of the os calcis (thalamic face, the lateral wall fragment is closed and definitive
pole) is reduced by elevating the depressed subtalar fixation is carried out. The small Y plate of Letoumel is
fragment. In this drawing the subtalar fragment and the perfect for such a fracture, but in this case with a large
lateral wall fragment are still displaced. One observes medial separation fragment (sustentaculum tali frag-
that looking from lateral over the depressed thalamic ment) a 3.5-mm reconstruction plate is used
Fig. 4.32 a-g. A comminuted, central, depression type Bohler's angle, as depicted in Fig.4.31 a. There is also ~
os calcis fracture in a 30-year-old man. a-e AP, lateral, comminution of the lateral wall and a fracture into the
oblique, and axial views before operation. The fracture anterior process. The fracture of the tuberosity is more
involves the lateral half of the subtalar joint with the pri- extensive in this actual case than in the diagrammatic il-
mary fracture line continuing through the anterior pro- lustration (Fig.4.31).
cess to the calcaneocuboid joint. There is loss of
189
Fig.4.33a-k. A 48-year-old man sustained an interesting two- and Fig.6.15, p.244) if necessary the distalmost hole may be
part fracture of the os calcis with lateral extrusion of the poste- fashioned into small hooks, and in this case additional tension
rior fragment and comminution of the fibula. a-d AP, oblique, band fixation was carried out. A little concavity, just enough to
lateral, and axial views of the ankle and foot before operation. start the deformation, is bent into the plate before its applica-
Notice the medial separation fracture line. It runs through the tion to the fracture. f-h AP, lateral, and axial views of the foot
posterior facet and leaves the sustentaculum intact for both re- and ankle postoperatively, showing restoration of the os calcis,
duction and fixation. The fibula has been crushed by the ex- including the subtalar joint, the length of the os calcis, and the
tended calcaneal fragment. e This illustration shows the indi- calcaneocuboid joint. i-k X-rays 2 years after the accident.
rect reduction of the comminuted fibula fracture done from Subtalar motion is slightly limited
anterior with a spring plate. As noted earlier (Fig.3.17, p.81
191
0910" BH
27.4.14
091068 BH
13.7.87
Fig. 4.34 a-m. Bilateral closed os calcis fractures in a gular configuration as a reduction aid. In these in-
24-year-old farmer who fell 6 m onto a concrete floor. traoperative views we see the reduction with prelimi-
The patient had surgery on the day of the accident. nary fixation with Kirschner wires. These were subse-
a Lateral and axial views of the left heel demonstrate a quently replaced by screws. c Lateral and axial views
joint depression fracture. b Surgery was carried out the day following surgery. The joint has been restored
via a lateral approach using the minifixator in a trian- along with Boehler's angle.
192
d The right heel was fractured as well. Lateral and axial views show
a similar joint depression fracture with a fracture line extending in-
to the tuberosity of the os caIcis. e A similar lateral approach was
employed on the right side. Illustrated is the preliminary reduction
and fixation. f One day after the operation, the reduction and fixa-
tion of the right side is seen. g, h Final radiographic results seen in
lateral and axial views at a little over 3 years. The joint spaces are
well maintained. The trabecular pattern of the bone has been re-
stored. i-I Clinical photographs of the left and right feet. The pat-
ient is working full time as a farmer. He has full ankle motion, but
the left subtalar motion is decreased. He can walk 10 km but com-
plains of some heel pain afterwards. m Footprints taken at the time
of the 3-year follow-up
193
c d
Fig. 4.36. a A comminuted fracture of the fibula in the created, allowing the intermediary fragments to be re-
transitional cortex between metaphysis and diaphysis duced. d The reduction of the intermediary fragments
associated with a fracture of the medial malleolus and then ensues or is "fine-tuned" with a dental pick, fol-
ankle instability. b Application of the minidistractor to lowed by application of a one-third tubular plate to the
the proximal and distal fragments with 2.S-mm termi- posterior or posterolateral surface and removal of the
nally threaded Schanz screws. c Slight overdistraction is tracti(;n force on the minidistractor (not shown)
195
e
Fig. 4.38. a Illustration of a comminuted distal most pin is driven across the epiphyseal
fracture of the distal end of the radius: AP fragment. This may be accomplished simply
view. b The first 2.5·mm Schanz screw is in- by loosening the knurled pin collar sleeve.
serted at 15° from the plane of the distal ra- d Reduction carried out with "tissue-spar-
diocarpal joint determined by image intensi- ing" pointed reduction forceps. e Buttress-
fication or through a Kirschner wire inserted ing of the fracture zone with a smaIl-frag-
into the joint space at surgery. The second ment T plate. f The lateral view of such a
Schanz screw is placed at right angles to the plate with volar displacement will exert an
shaft of the radius proximal to the fracture. excellent buttress effect and can be made
c The minidistractor is applied and distrac- more stable by the insertion of screws
tion is carried out. As length is regained on through the distal holes in the plate
the fragment containing the radial styloid the
199
Fig. 4.40 a-h. A comminuted fracture of the distal radi- Articular reduction and fixation with Kirschner wires is
us in a 48-year-old man. a, b Note the intra-articular ex- followed by supplementary autogenous bone graft. A
tension of the metaphyseal fracture along with a sepa- transfixing Kirschner wire temporarily maintains the
rate dorsoulnar fragment which still bears a loose distal radioulnar relationship. e, f The Kirschner wire
relationship to the ulnar styloid. c, d The problem has through the distal radioulnar joint has been removed
been solved by combining ligamentotaxis for reduction and early consolidation of the fracture is seen 7 weeks
with internal fixation by means of lag screws and post operation. g, h Six-month follow-up showing
Kirschner wires. The minifixator in this case has been union of the distal radius, maintenance of the relation-
used both to gain reduction and to maintain length of ship between the distal radius and ulna, and restoration
the comminuted distal radius. Fracture reduction from of a healthy trabecular pattern. Functionally, this patient
proximal to distal using 3.5 mm lag screws for fixation. has only minor limitations of pronation and supination
201
Chapter 5: Substitution
Composite Fixation
plate, usually contoured to the shape of a "bishop's staff," takes over the
support function of the subchondral bone. The plate is used to buttress the
very thin contours of the remaining uninvolved cartilage surface. The asso-
ciated defect is filled with autogenous cancellous bone. Removal of such
an implant is possible with an small curved chisel that is used to undercut Fig.5.15,
the bone around the plate (Fig. 5.15). pages 225-227
A 3.5-mm reconstruction plate may be used to substitute for the bony at-
tachments of important muscles. In such cases, for instance when part of
the body of the scapula or the iliac wing must be resected, the recon-
struction plate can be fixed to either end of the remaining bone after con-
touring to allow the reattachment of the muscles in near-anatomic loca-
tions (serratus anterior and subscapularis on the scapula, gluteus medius
and minimus on the iliac wing). In both locations the frame provided by
the reconstruction plate substitutes for the bony attachments, and after
scar tissue formation has taken place almost normal function can be ex-
pected.
Summary
Fig. 5.1. a "Substitution" using plate fixation the fact that the comminuted segment is
and an external fixator is indicated in severely straight) in combination with the articulating
comminuted fractures such as that in the tibia tension device, reduction is carried out. c As
illustrated. Hypothetically speaking the soft an alternative, the external fixator applied as a
tissue injuries of the leg consist of a grade 2 femoral distractor may be used for reduction
open wound with a 6 cm laceration on the me- and maintained afterward (Figs. 4.26, 4.27).
dial aspect of the leg. b A lateral plate is ap- The fracture is reduced. Pointed reduction
plied using the methods discussed in Chap. 3 forceps applied through the soft tissues may
(Figs. 3.6-3.10). Extreme care must be exer- be used to improve the reduction (not shown).
cised with the soft tissues and the deep expo- d Along with proximal and distal fixation
sure of the bone must be limited to the region screws, lag screws are inserted in the areas pre-
of the intact proximal and distal main frag- viously occupied by clamps. If reduction was
ments. In this way the comminuted fragments made with the plate, Schanz screws are insert-
remain attached to soft tissue. Using the plate, ed proximally and distally on the medial side
which must be "contoured" for the lateral side of the tibia perpendicular to the tibial shaft
of the bone (this task may be facilitated preop- axis. A simple meoial frame is then construct·
eratively by using a bone model and exploiting ed with the tubular fixator system.
207
Fig.5.5a-f,
legend see
page 212
212
Fig. 5.5. a, b A 28-year-old male who had a motor vehi- e, f The bone and montage at 10 days. At this time de-
cle accident and sustained a grade 2 open fracture of the layed primary closure had been carried out. g, h A
tibia. The wound, 4 cm long, was located medialIy. 2\1 months the fixator was removed. i, j The treated
c, d The plate was applied lateralIy as described in fracture is viewed at approximately 6 months post injury
Fig.5.2 and a medial fixator was placed in tension.
213
Fig.5.9a-h. A 23-year-old male was the only survivor the initial surgical procedure, as its ease of application
of a high-speed automobile accident. The patient was in the supine position and its independence from image
polytraumatized including a closed head injury, a com- intensification allow all injuries to be handled simulta-
minuted femur fracture and ipsilateral open tibia frac- neously in a speedy and efficient way. c, d The postop-
ture, an ipsilateral forearm fracture and a contralateral erative montage is illustrated in AP and lateral projec-
open ankle fracture. a, b AP and lateral views of the left tions. The fracture was reduced indirectly by the use of
femur fracture. Certainly using a plate fixation in this the articulating tension device proximally after the plate
circumstance has its advantages to the patient during was fixed to the distal fragment. The lateral cortex of
219
... the bone proximal and distal to the fracture zone was all e, f Five weeks post injury there is softening of the frac-
that was directly visualized. An external fixator was then ture lines with some early bone formation in welds seen
mounted through open plate holes proximally and dis- proximally and distally. The fixator has been removed.
tally and loaded in tension, "protecting" the plate from g, h The healed fracture 4 months later. In this case the
cyclic loading until the viable medial cortical comminu- lateral fixator in combination with a lateral plate pro-
tion consolidates. The correct axis of the shaft along vided a solution to a difficult fracture that was both bio-
with the correct length has been achieved, but individual logically and mechanically sound
diaphyseal fragments are not anatomically reduced.
Fig. 5.10. The use of DCP as a medial ing it medial. The other screws are insert-
buttress, combined with a 95° angled ed through the holes in both plates. To
blade plate. The 95° angled blade plate accomplish this, a 3.2-mm drill is used to
may be used either with the articulating drill the lateral cortex with the appropri-
tension device or with the femoral dis- ate drill guide. A 1.6-mm Kirschner wire
tractor to distract the fracture. While the is then passed through the hole and used
fracture is distracted a gouge and curette to feel the hole of the medullary plate.
are used to make a trough in the distal When the direction is known, the drill is
metaphysis on the medial aspect to allow directed in the same path toward the me-
the intramedullary plate to be seated dial cortex, which is penetrated. Insertion
against the blade. The plate is fed into the of these screws is frequently skewed so
intramedullary canal retrograde and then, that the screws actually thread the hole in
using the curved impactor, driven into the the plate as they pass into the medial cor-
prepared trough to abut against the blade. tex. This ensures the blocking action of
The fracture is now reduced by diminish- the plate. In the drawing the fifth screw
ing the distraction force and allowing the from the top would have this effect. The
fracture surfaces to oppose. Two or three medial plate is thus locked between the
screws should thread the lateral cortex blade and the screws
only and impact against the plate, push-
220
c d
222
.'ig.5.13a-h. A 90-year-old female was involved in a views note the comminution existing in both of these
motor vehicle accident. She sustained bilateral, highly fractures. There was no evidence of loosening of the
comminuted condylar and supracondylar femoral frac- prosthetic components. e-h X-rays of the patient's
tures above bilateral total knee prostheses. She was orig- composite fixations approximately 1 week post sur-
inally treated in traction and transferred to our facility gery. With this fixation the patient's distal femurs
10 days after the accident. The patient was uncontrol- were stable and she could be mobilized. Unfortu-
lable in traction - hysterical and unable to tolerate this nately, the patient died of a stroke 2 months later in a
form of treatment. a-d Preoperative AP and lateral nursing home
224
~ f, g The cavity was then filled with au- joint in the clinical photos. j, k Radio-
togenous cancellous bone and the graphs at 8 weeks. There is no loss of
wound was closed. h, i The postoper- reduction of the reconstructed joint
ative AP and lateral views show the surface. I, m Radiographs at 5 years:
joint contours to be restored and but- no recurrence, improved trabecular
tressed by the one-half tubular plate structure of the bone. n, 0 The right
used in this manner. The subchondral knee lacks 10° of flexion, but other-
screw fixes the fracture seen on the wise is stable and painless
228
Chapter 6: Tricks
3-mm guide wire to act as a handle to manipulate the guide wire across
Fig. 6.7, page 237 fracture fragments (Fig. 6.7). The same instrument is also valuable in com-
bination with a Schanz screw to provide increased leverage for rotating
fragments into reduction, as in a posterior approach to a transverse or po-
sterior column fracture (Letournel). In such a case it is placed into the is-
chium and with the handle the ischium is rotated in order to reduce the is-
Fig. 6.8, page 238 chiopubic fragment (Fig. 6.8).
A similar ploy may advantageous in a T type supracondylar fracture of the
distal femur. In the case of difficulty in reducing the medial condyle
through the lateral approach, a small stab wound is made medially over
the fractured medial condyle. A 6.0-mm Schanz screw is inserted into the
medial fragment through a 4.S-mm drill hole made in the side of the frag-
ment. With a handle on the medial condyle, rotation and varus/valgus
maneuvers can be carried out while the intra-articular reduction is viewed
Fig. 6.9, page 239 through the lateral operative incision (Fig. 6.9).
The aiming device from the external fixator set may also be of value be-
yond its recognized role. The pointed end of the device may be used for
lag screw fixation of small fragments in the vicinity of a joint or of larger
fragments in, for example, the femoral neck, or in certain instances for lag
screw fixation in the pelvis and acetabulum.
shape from a square knot into half-hitches and slide along the tensioned
end, slipping on the loop and approximating the soft tissues. It may help
to slide the half-hitches along with the tip of the needle holder. When the
desired approximation is reached, the free end is grasped and firmly ten-
sioned. This squares the knot once more. A final throw is then made to
Fig. 6.19, page 250 lock the knot (Fig. 6.19).
a b
233
Fig.6.2a-k. A valgus-impacted
proximal humeral fracture with in-
volvement of the greater tuberosi-
ty. a, b AP and axillary views be-
fore operation. c, d Via a small
deltoid splitting incision, a perio-
steal elevator is introduced through
the fracture cleft in the greater tu-
berosity. Through the same small
incision a bone spreader is inserted
in the opening made by the eleva-
tor and opened, disimpacting and
correcting the valgus position of
the articular component. Control at
this point in the procedure is ob-
tained with image intensification.
e, f With the components in a re-
duced position. A terminally
threaded Schanz screw is utilized
for final reduction and fixation, de-
finitively backed up by a second.
g, h Following metal removal ap-
proximately 4 months after opera-
tion. i-k Final result almost
2Yz years post injury showing full
restoration of the anatomy of the
proximal humerus. The patient has
absolutely full function
234
2
---'-L____
Fig. 6.5 a-d. The reduction of translation of a flat bone. The clamp should be opened such that interference be-
a The pelvic reduction forceps is first placed securely on tween the two fragments is eliminated. Further turning
one fragment with a screw. Using the 3.2-mm drill a of the screw will then completely eliminate the transla-
hole is made in the bone in alignment with the screw- tion. d The forceps is closed and the reduction may be
holding end of the forceps. b An extra-long screw is in- provisionally stabilized by closing the collar nut on the
serted through the hole in the clamp and into the bone. spindle
c By tightening the screw the translation is overcome.
237
lfig.6.6. A 2.7-mm guide pin from the AO entation is correct the third stage of the
DHS set is inserted into the piriform fo - DHS reamer is used to open up the cor-
: a and controlled with an AP and oblique tex and ream the cancellous bone to
'or lateral view using the image intensifier. make a passage for the 3-mm guide wire
'When it has been ascertained that the ori-
Fig.6.10a-c. The technique and ad- shown. Through the drill sleeve the
vantage of setting up gliding holes be- 3.2-mm drill is inserted and the
fore reduction. a The figure illustrates threaded hole is drilled. The surgeon
a distal tibia fracture with a large pos- may gain an appreciation of how good
terior malleolus comprising over half the lag screw will be by how long the
the articular surface. It is approached 3.2-mm drill stays in bone before it
surgically, and before reduction a reaches the other cortex and goes
4.5-mm gliding hole is made just prox- through. c With the reduction main-
imal to the joint line. Through the ex- tained by the reduction forceps, the
posure frequently the drill may be hole is tapped, measured, and the ap-
seen coming out of the cancellous sep- propriately sized 4.5-mm cortical
aration of the fracture fragments. screw is inserted as a lag screw. By
b Next, the drill sleeve is placed in the carrying out the steps of lag screw fix-
4.5-mm gliding hole and the reduction ation in this order it is certain that the
is carried out in the usual manner and threads exist only in the far fragment
held provisionally, either with Kirsch- and that the maximal lag effect is
ner wires or with reduction forceps as therefore achieved
241
-
a b
Fig. 6.12 a-c. Screws and wires are useful for temporary
fixation when the location is inaccessible to standard
clamps. This technique is helpful in the anterior fixation
of the sacroiliac joint or with large incarcerated bone
fragments, sometimes in conjunction with a bone
spreader. a A place is selected on the sacral ala and a
hole may be drilled to the depth of 30-40 mm. A
4.5-mm screw of 32-34 mm in length is inserted and left
proud. A similar screw is inserted in the posterior thick-
ening of the iliac bone next to the joint and in an appro-
priate position in relation to the screw in the sacrum.
The head of this screw is also left proud and a 1.2-mm
wire is placed around the two screws. b, c By twisting
the wire or by using the standard AO wire tightener, the
two plates of bone are brought together. Sometimes it is
necessary to place a second set of similar screws slightly
more proximal (or distal) to give a second point of re-
duction. In this way rotation may be eliminated as well.
Tightening the wires on the two sets of screws stepwise
c shares the load so that neither set is overloaded. In addi-
tion, on the concave side of the sacroiliac joint, the
straight pull of the wires between the two screws helps
to hold the rotational alignment of the ilium relative to
the sacrum. With the two screws then held in approxi-
mation by tightened wire the reduction is temporarily
fixed. Final fixation is then accomplished with an ante-
rior plate or plates. Alternatively, the screw fixation set
up prior to reduction may be employed for definitive
fixation. In such a case the screw is inserted through a
stab wound from the outside through the iliac wing into
the ala of the sacrum or the body
243
Fig.6.14a-e. The same principle may be used in the ceps. With the screws tensioning the plate, it acts as a
proximal tibia in conjunction with a femoral distractor tension band. d The same principle may be exploited
when a proximal articular tibial plateau fragment resists with less of an implant. For example, the wire shown in
reduction in the sagittal plane. a The femoral distractor this illustration crosses over the tip of the proximal frag-
is used in distraction mode and the small four- or five- ment and as the wire is tightened the translation may be
hole one-third tubular plate is applied to the distal frag- overcome. e This figure-of-eight wire acts as well as a
ment on the crest of the tibia. b As the screws are insert- tension band wire, as it neutralizes very well the effect
ed the plate impinges upon the proximal fragment, of the quadriceps on the proximal fragment, yet is a very
reducing the translation. c With the translation reduced, economical implant. It is also of value used in the same
the proximal screws may be inserted which fixes this manner to secure stability in the sagittal plane when a
proximal transverse fracture more securely; an anterior high tibial osteotomy is carried out
plate tends to block the deforming force of the quadri-
244
10 0 0 0 1
1000 01
lo ooC:
a b
Fig. 6.15. a A "spring plate" is helpful to stabilize thin tion there is a small shale fracture of a thin but impor-
fragments of an articular surface such as seen frequently tant portion of the articular surface of the back of the
in fractures of the posterior wall of the acetabulum. For acetabulum. Because of its peripheral location it is diffi-
this technique a three-hole one-third tubular plate is cult to fix with screws. The technique shown here has
usually selected. It is flattened and the end hole is cut been of value at this location and others where there are
out, leaving two sharp spikes projecting. These spikes small shale fractures of the posterior wall. The end hole
are then bent at 90° to the flattened plate. A spring ef- of the plate is filled with a screw and the prongs are ro-
fect which pushes the prongs into the underlining shales tated over the unstable shale fragment. Placement of the
of bone, stabilizing them securely, can be produced in a second screw is such that this malleable plate is forced
number of ways: by applying the plate over a concavity into the concavity of the bone springs the plate against
or hollow in the bone, or by bending the plate into a the shale fracture, which is stabilized by the prongs. The
slight concavity as viewed from the bone surface and in- small plate can also be contoured into a concavity and
serting screws through the holes into the bone, as seen placed underneath the buttress plate running up to the
here, or by sliding the plate underneath a previously ap- posterior retroacetabular surface. Tightening of the butt-
plied buttress plate, as seen in Fig.3.24a-f. b Illustra- ress plate pushes the hooked spring plate into the shale
tion of the principle of a hooked spring plate, using the fractures or comminuted fractures of the posterior rim,
example of the posterior inferior wall of the acetabulum stabilizing them securely
in the region of the tuberosity. Frequently in this loca-
245
Fig.6.16a-h. Use of the plate described in Fig.6.15 in a e CT scan. f-h Postoperative X-rays of the internal fixa-
transverse and posterior wall acetabular fracture in tion. Note the small hooked spring plate stabilizing the
which the posterior wall was comminuted and the frag- posterior inferior wall, which was thin and in which no
ments peripheral and thin. a-d Preoperative X-rays. screw could be placed
246
247
.... Fig.6.18a-k. A 15-year-old girl involved in a motor ve- which was extremely short and porotic. The defect in
hicle accident sustained a grade III open tibia and fibu- the tibia was filled with PMMA and gentamycin beads.
la fracture. a AP view of the involved right leg. Note the In the same session of surgery a free vascularized tra-
severe soft tissue injury apparent on this plain X-ray. pezius muscle flap was transferred into the large defect
b Although the middle segment of the fracture was com- and grafted with split-thickness skin. g Clinical photo-
pletely stripped of its soft tissue an attempt was made to graph showing the condition of the soft tissue after this
use it. After thorough irrigation and debridement mini- intervention. There was no drainage. The soft tissue
mal internal-external fixation was attempted. c The pat- sleeve of the tibia had been reconstructed. h, i At
ient became infected and was transferred to the care of 21;2 months post accident and 19 days post stabilization,
Dr. Thomas Greene, a microvascular hand surgeon. The another free graft was carried out, this time of the fibula
avascular segmented fragment had sequestrated and from the opposite side (shown above). It was fixed with
was removed. The clinical photograph shows the condi- screws passing through the small plate. Note that there
tion of the leg at this point in time. d The Hoffmann ap- has been early consolidation of the fibula. j At
paratus was removed and the leg kept at length with cal- 3V2 months post free fibula transfer. All fracture inter-
caneal pin traction. The wound was serially debrided. phases have healed, and a synostosis between the tibia
Drainage ceased. e, r Internal stabilization was and fibula has developed. k Just short of 11;2 years post
achieved by fixing the fibula with a 3.5-mm DCP and a accident the leg is healed. There is no shortening. The
one-third tubular hook plate with a tension band; and function of the knee and ankle are excellent. The trans-
the tibia with a narrow 4.5-mm DCP bent to a right ferred fibula is hypertrophic
angle and inserted directly into the distal fragment,
250
j
r
6
"-.- 1"";
~
I
Fig. 6.19. The Maurice Muller controlled square knot. the knot to half-hitches which slide easily along the
The suture is inserted in the usual manner. 1 The first pulled portion. 5 The desired approximation is
throw is accomplished. 2 The second throw is made to achieved. 6 The free end is then pulled, which resquares
form a loose square knot. 3 The held end is then pulled the knot. 7 Finally, a further throw is made to lock the
while the free end is not set. 4 This changes the shape of square knot
251
References
1. Allgower M, Ruedi T (1979) The operative treat- ation of calcaneus fractures. Topics in Orthop
ment of intraarticular fractures of the lower end of Trauma 1: 173-192
the tibia. Clin Orthop 138: 105 16. Maquet PGJ (1980) Osteotomy. In: Freeman MAR
2. Bell SN, Dooley BJ, O'Brien McC, Bright NF (ed) Arthritis of the knee. Springer, Berlin Heidel-
(1985) Cortical bone grafts with muscle pedicles. J berg New York, pp 148-183
Bone Joint Surg [Br] 67B: 804-808 17. Mast J (1983) Preoperative planning in the surgical
3. Canale ST, Harper M (1981) Biotrigonometric correction of tibial nonunions and mal unions. Clin
analysis and practical applications of osteotomies Orthop 178: 26-30
of the tibia in children, vol 30. AAOS Instruction 18. Mast J (1987) Techniques of reduction of distal in-
Course Lectures, pp 85-101 traarticular fractures of the tibia. Techniques Or-
4. Danis R (1949) Theorie et pratique de l'osteosyn- thop Surg 2: 29-36
these. Masson, Paris 19. Mast J, Spiegel PG (1984) Complex ankle frac-
5. Essex-Lopresti P (1952) The mechanism, reduction tures. In: Meyers M (ed) The multiply injured pat-
technique and results in fractures of the os calcis. ient with complex fractures. Lea & Febiger, Phila-
Br J Surg 39: 395-419 delphia
6. Ganz R, Isler B, Mast J (1984) Internal fixation 20. Mears D, Rubash H (1986) Pelvic and acetabular
technique in pathological fractures of the extremi- fractures. Slack Inc, Thorofare, New Jersey
ties. Arch Orthop Trauma 103: 73-80 21. Meek R, Boyle M (1986) Technique for the opera-
7. Gotzen L, Tscherne H, Allgower M (1985) Correc- tive management of supracondylar and intracon-
tive osteotomies of the femoral shaft. In: Hierhol- dylar fractures of the distal femur. Techniques
zer G, Muller KH (eds) Corrective osteotomies of Orthop Surg 1: 39-43
the lower extremities after trauma. Springer, Berlin 22. Milch H (1947) Osteotomy of the long bone. Tho-
Heidelberg New York, pp 117-125 mas, Springfield
8. Harrington PR (1964) Spine instrumentation. Am J 23. Muller ME (1971) Die huftnahen Femurosteoto-
Orthop 8: 228-231 mien. Thieme, Stuttgart, p 9
9. Heitemeyer V, Hierholzer G (1985) Die uber- 24. Muller ME (1984) Intertrochanteric osteotomy: in-
briickende Osteosynthese bei geschlossenen dication, preoperative planning, technique. In:
Stuckfrakturen des Femurschaftes. Aktuel Trauma- Schatzker J (ed) The intertrochanteric osteotomy.
to115: 205-209 Springer, Berlin Heidelberg New York, pp 25-66
10. Jakob R (1984) The use of the small external fixa- 25. Muller ME, Allgower M, Schneider R, Willenegger
tors on fractures of the wrist. Topics in Orthop H (1979) Manual of internal fixation, 2nd edn.
Trauma 1: 35-36 Springer, Berlin Heidelberg New York
11. Jakob R, Wagner H (1986) Zur Problematik der 26.0est 0 (1985) Special diagnosis and preoperative
Plattenosteosynthese bei den bikondylaren Tibial- planning. In: Hierholzer G, Muller KH (eds) Cor-
kopffrakturen. Unfall Chirurg 89: 304-311 rective osteotomies of the lower extremities after
12. Kinast C, Bolhofner B, Mast J, Ganz R (1988) Sub- trauma. Springer, Berlin Heidelberg New York,
trochanteric fractures of the femur: results of treat- pp 29-37
ment with the 95 degree condylar blade-plate. Clin 27. Perren SM (1979) Physical and biological aspects
Orthop (in press) of fracture healing with special reference to inter-
13. Kinast C, Ganz R (1988) Biomechanische und kli- nal fixation. Clin Orthop 138: 175-196
nische Untersuchung der erweiterten Verbund- 28. Ross SK (1987) The operative treatment of complex
osteosynthese des proximalen Femur (in press) os cal cis fractures. Techniques Orthop Surg 2: 55 - 70
14. Letoumel E (1981) Fractures of the acetabulum. 29. Ruedi T, von Hochstetter AHC, Schlumpf R (1984)
Springer, Berlin Heidelberg New York Surgical approaches for internal fixation. Springer,
15. Letournel E (1984) The open reduction internal fix- Berlin Heidelberg New York
252
30. Vandershilden J, Spiegel PG (1983) Minimal inter- Femurendes. In: Breitners Operationslehre, vol IV,
nal and external fixation in the treatment of open 33rd revision. Thieme, Stuttgart
tibial fractures. Clin Orthop 178: 96 33. Weber BG (1981) Special techniques in internal
31. Vidal J (1979) Treatment of articular fractures by fixation. Springer, Berlin Heidelberg New York
"ligamentotaxis" with external fixation. In: Broo- 34. Weber BG, Cech 0 (1976) Pseudoarthrosis. Huber,
ker AS, Edwards CC (eds) External fixation: cur- Bern
rent state of the art. Williams & Wilkins, Baltimore 35. Weber BG, Simpson L (1985) Fibular lengthening
32. Weber BG (1979) Die Verletzungen des proximalen in internal fixation. Clin Orthop 199: 61
253
Subject Index
tibia, shaft reduction with distractor 138, 178 wire tighteners, use in reduction 225
tibial plateau, reduction with distractor 135-138,
168-177 X-rays, appreciating deformity 20
-, errors in planning 12
Verbrugge clamp as a plate tensioner 51 -, magnification 16