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Screws Plates Pins and Wires Intramedullary rods and nails Anchors
Cortical and Cancellous Screws
Although there are a large number of different screws, there are two basic designs: cortical and cancellous screws. As the names imply, cortical and cancellous screws are designed for placement in cortical and cancellous bone
Cortical screws have closely-spaced, shallow threads and larger core-to-outer diameter ratios than cancellous screws. Cortical screws are stronger than cancellous screws of the same outer diameter. They are usually blunt ended. When used to fix plates to long bones, fully-threaded screws are used in order to fixate both cortices so that maximal stability is achieved. The blunt end should extend only a few millimeters into the soft tissues beyond the far cortex to minimize damage to the soft tissue. Cancellous screws are designed for fixation of cancellous bone. They are most commonly used in the metaphyses of long bones where cancellous bone is abundant. They have more deeply cut and more widely spaced threads compared to cortical screw. Since cancellous bone is much less dense than cortical bone, the screw threads cut their path in the bone when the screw is inserted, i.e. cancellous screws are self-tapping. Partialy threaded cancellous screws are often used as lag screws for metaphyseal fractures. Lag Screws Lag screws are used to compress fractures. A lag screw is not a particular type of screw, but rather refers to how a screw is inserted. To function as a lag screw, the proximal part of the screw slides freely in a hole drilled in the bone on the near side of the fracture while the tip is screwed into the bone on the distal side of the fracture. For cortical or cancellous screws, as the screw is tightened, the head forces the two sides of the fracture together. Fully threaded or partially threaded screws can be used as lag screws. Cortical screws are used as lag screws in fractures of long bones and cancellous screws for metaphyseal fractures. These screws produce uniform static fracture compression. The two illustrations on the right demonstrate how a partially threaded cortical screw functions as a lag screw in a long bone fracture. In the upper image, the jagged white area represents a fracture gap in a long bone. The cortex is dark gray and medullary cavity is light gray. The black area is a hole drilled in the bone across the fracture. In the lower image, a partially threaded cortical screw called a shaft screw was inserted into the threaded distal hole and
compressing the fracture. Both cortical and cancellous screws can be cannulated. Cannulated Screws Cannulated screws have a hollow central shaft. The main advantage of cannulated screws is that they can be inserted over a guide wire or guide pin. it pulled the fragments together. The diameter of the guide pin is much smaller than the cannulated screw and can be more accurately placed using fluoroscopy in the operating room. A lag screw inserted in this fashion is called an interfragmentary screw. it closed the gap as indicated by the arrows. Cannulated cancellous screws are used for metaphyseal fractures while cannulated and noncannulated cortical screws are used as lag screws for fixation of diaphyseal fractures. The screw is a large cancellous lag screw that glide freely in a metal sleeve. Dynamic Hip Screw Dynamic hip screws are used for internal fixation of fractures of the femoral neck and intertrochanteric region. As the screw continued to be tightened. Weight bearing cause the femoral head to becomes impacted on the femoral neck producing dynamic compression of the fracture. Lag screws can also be inserted through the various types of fracture fixation plates. . When the head impacted the near cortex.screwed in. The sleeve is attached to a side plate that is fixed to the lateral femoral cortex with screws. the guide pin can be reinserted several times if necessary for accurate placement without excessive damage to bone. The shaft of the lag screw slides down the sleeve maintaining reduction of the fracture as compression occurs. One special type of cannulated cancellous screw is the Knowles pin which is a cannulated screw used for fixation of slipped capital femoral epiphysis in children. given its small diameter. In addition.
A Herbert screw is a special purpose screw used to compress small fractures fragments. In the above radiograph. Interference Screws: Anterior Cruciate Ligament Reconstruction Interference screws are used to secure tendons or bone grafts in place.Herbert Screw Herbert screws inserted in the trochlea of the humerus. There has been a fracture through the tibial plateau where the screw was placed. The interference screws are then inserted which force the tendon or graft again bone fixing it in place. compressing the fracture. two different types of screws are shown. A tendon autograft is then passed into the holes. screwing into the bone of the distal fragment. The graft may contain attached bone. They are most frequently used for repair of the anterior cruciate ligament. A generic type interference screw is shown on the right. For an ACL repair. bone tunnels are drilled in the tibia and femur as shown above. As it is screwed in. Each turn of the screw causes the distal end to travel farther into bone than the proximal end. the proximal cortical portion engages the proximal bone fragment. One end of the screw (upper ends in x-ray and photograph above) has cancellous threads while the other end has larger diameter cortical screw threads. The cancellous screw is inserted first and crosses the proximal fracture. .
There are large number of different types of buttress plates. Properties and function of the more commonly used plates are described below. Click the Compression Plates link in the left panel for an overview of compression plates. etc. For simple fractures of long bones. Buttress plates are contoured to a particular surface (medial. these plates are broadened and carefully contoured at the joint end of the plate. Buttress Plates Overview Buttress plates are used to rigidly hold in place fractures at the end of long bones. Click an entry on the left for viewing a specific category of plates. withstand external compressive and bending forces poorly. Plates that span the fracture site and rigidity fixate the reduced fracture are called neutralization plates since they resist or neutralize external forces at the fracture site protecting the lag screw fixation. Reconstruction plates are flexible and can be cut to length to fit irregular surfaces. A compression plate is most commonly used with diaphyseal fractures of the long bones. Click the Buttress Plates link in the left panel for an overview of buttress plates and examples of particular types of buttress plates. L-shaped and bulbous end shaped plates. The contoured.). lateral. There are a large number of buttress plates. The beveled geometry of its screw holes allows compression of a fracture spanned by the plate as the screw head contacts the plate during insertion. For this reason. The LISS (Less Invasive Stabilization System) plate is a recently introduced type of plate that is a modification of the standard compression plate used for long bone fractures. and thus several different plate designs may be necessary for an individual periarticular region. they are often referred to as periarticular plates. They are simpler alternative devices that can be used in place of a plate with a separate condylar screw. These screws. To provide adequate fixation. anterior. They contain holes for screws and pins that are used to fix the plate to intact bone and to fractures. especially at the knee and ankle. The periarticular surfaces of long bone are complex having several surfaces and unique topographic feature at each surface. screws are often used to reduce the fractures and apply compression to the fracture site (lag screws). Blade plates are used for fractures of the condylar regions of the long bones.Plates Overview Plates are some of the most common general purpose fixation devices. Some of the more common configurations are T-shaped. They are used primarily for fractures of the pelvis. however. where the fracture site experiences large compressive and other distorting forces. periarticular portion of the plate give these plates a three dimensional configuration. .
Medial Distal Humeral Plate Lateral Distal Humeral Plate Greater Tuberosity Humeral Plate Posterior Ulna/Olecranon Plate Tibial Buttress Plates .
Neutralization refers to how a plate functions in fracture fixation. A neutralization plate removes the loading forces on a fracture by spanning the fracture and transmitting the loading forces through the plate rather than through the fracture site. semitubular plates. The lag screw is inserted separately from the plate and is an interfragmentary screw. . Neutralization plates are not a specific type of plate. This allows the primary fracture fixation to be accomplished with other devices such as lag screws. and buttress plates. The neutralization plate in the above images is a semitubular plate.Neutralization Plate AP and lateral radiographs of a fibular fracture fixated with a neutralization plate and a lag screw. Several different types of plates can function as neutralization plates including compression plates.
The compression holes are oriented away from the center of the plate and locking circular holes are oriented toward the center. Reconstrution Plate Reconstruction Plate: The reconstruction plate is a flexible plate which can be easily contoured to the surface it is attached to. four screws were first inserted as locking screws. Two screws were then inserted on the compression side of the holes in the two most right-sided holes in the plate producing compression at the fracture site.Dynamic Compression Plate Dynamic compression plate fixating a transverse fracture of the proximal ulna. . The fourth hole from the right shows an unoccupied hole over the fracture with the compression side of the hole to the right and locking side to the left. On the left side of the plate. The AP radiograph of the left pelvis shows a reconstruction plate transfixing an acetabular fracture. The plate can be cut so that the desired length is achieved. Lastly a locking screw was inserted in the third hole from the right locking the compressed ends of the fracture together. The plate has specially designed holes that consist of combined standard oval holes used for compression and circular threaded holes used for locking the plate and bone to the screws.
When used for internal fixation. nails. The screw holes in a LISS plate are round and threaded so that the screws are locked onto the plate.LISS Plate LISS stands for Less Invasive Stabilization System. This allows adequate stabilization with only unicortical screws rather than the bicortical fixation required with standard compression or buttress plates. These modification allow easier insertion and less damage to the bone and its blood supply. when used alone. Pins used for external fixation are described in an accompanying sections. The plate does not have to be close to bone and therefore it does not need to be closely contoured to the periarticular surface as with a standard buttress plate (note the simple shape of the distal end of the plate). or K-wires. These pins are thicker and are designed to support greater loads. Therefore. A LISS plate is similar to a buttress plate with several modifications. They are frequently used for fracture fixation of the hands and feet and as guide wires for placement of cannulated screws. This type of wiring is commonly used for transverse fractures of the patella and olecranon and occasionally for fractures of the greater trochanter. they provide in general much less resistance to external forces than plates. There is one special construct that will be discussed here: tension band wiring. Kirschner wires. they are used for bones which normally experience relatively weak external forces. The common factor in these fixations is that . The function of wires. bands. These devices are used as standalone devices in the upper extremities and as adjunctive hardware in the lower extremities along with hardware that can withstand the larger axial loading forces. Note the specially shaped unicortical screws used with the LISS plate. or rods. They are small enough to be used for across the joint fixation without significant damage to articular cartilage. Pins and Wires Overview Pins and wires can be used as standalone orthopedic hardware or as components of larger hardware constructs. and cables is usually straightforward. are small diameter rods that are rather easily bent.
g. The inner surface of bone is free to move and the inner parts of the fracture are compressed creating dynamic compression. They can be used as the primary fixation device for fractures in the hands and feet. bone ingrowth type and the compression improves bone ingrowth. They can also be used as adjunctive fixation devices for complex fractures of larger bones. A tension band is a wire fixation of the fracture placed on the surface of the bone farthest from the joint. There is a Rush rod in the fibula. Kirschner (K) Wires Kirschner wires have many uses. Their use is illustrated in the x-ray at the right.rotational forces are exerted on the fracture fragments when the joint is flexed. This prosthesis is a noncemented. The fracture and the wire create a new pivot point on the external surface when the joint rotates. The x-ray on the right shows a bimalleolar fracture. Cables Cables are used primarily as adjunctive fixation devices for fractures of the long bones. The medial malleolus is fixated with a plate with screws and by two K-wires. . The cables around the proximal femur provide compression to the bone and help improve contact with the femoral prosthesis. the external aspect of the patella and olecranon. e.
Tension Band Wiring Tension band wiring of a patellar fracture. The tension band wire has a characteristic figure of eight appearance and has been reinforced with K-wires. the nail has been placed in a retrograde fashion.Typical femoral nail with one proximal and two distal transverse locking pins. In this example. Note on the lateral view that the wires are placed anteriorly. PROXIMAL FEMORAL NAIL . FEMORAL NAIL Illustration of how a femoral nail is inserted and how the locking pins are placed. lateral and AP views of the knee. Used primarily for diaphyseal fractures.
Intertrochanteric fracture fixated with a proximal femoral intramedullary nail.This nail is designed for combined fractures of the proximal femur and the diaphysis. especially in the intertrochanteric region. TIBIAL INTRAMEDULLARY NAIL . LONG PROXIMAL FEMORAL NAIL Femoral neck and diaphyseal fractures fixated with a long femoral intramedullary nail and proximal locking lag screw.This nail is designed for proximal femoral fractures. Nails for proximal fractures must be thicker to withstand the high stress in the intertrochanteric and subtrochanteric regions. Nails for proximal fractures must be thicker to withstand the high stress in the intertrochanteric and subtrochanteric regions.
Pre-op image of proximal diaphyseal fractures of the tibia and fibula.Intramedullary tibial nail inserted in a static configuration with proximal and distal locking screwsTypical tibial nails with proximal and distal transverse holes for locking pins. Antibiotic Rods .
it is extracted and inserted into the tibial medullary space.The antibiotic leaches from the rod achieving higher concentrations than could be obtained with intravenous administration. . A chest tube was used to contain a slurry of antibiotics and a biocompatible material such as polymethylmethacrylate that quickly hardens. but standard intravenous antibiotic treatment cannot deliver high concentrations of antibiotics to the affected bone. When the material hardens sufficiency.Treatment of infections of intramedullary rods is difficult. The infected tibial rod was removed. The rod must be removed. The material is placed in a chest tube with a thin diameter wire. One method of accomplishing such delivery is with an antibiotic rod as shown on the right.