eLearning modules for the AO Principles Courses

Surgical screws fixation

AOUK | Prepared by Professor Christopher L Colton, England

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 Surgical Screw Fixation
The purpose of this guide is:
•  Describe the screw as a mechanical device
•  Identify its physical attributes and its functions in surgery
•  Outline the techniques for insertion in bone.
After studying this guide, you should be able to identify the basic screw forms
and sizes of the AO armamentarium and outline the principles underpinning
the surgical techniques of using screws to achieve a variety of outcomes.

What is a screw?
Asked the question “What is a screw?” surprisingly few can describe a generic
screw’s basic function.

All these are screws—aircraft and ship’s propellers, a corkscrew and surgical
screws.
What have they in common as mechanical devices?

A screw is a device for converting rotational forces into linear motion. Due to
the helical morphology of the thread, as it turns in a material, the slope of the
helix causes the screw to move along the longitudinal axis of its shaft.

With the exception of some corkscrews, a generic screw has a solid central
core, about which is wrapped a helical surface. In the surgical context, most
screws have a screw-head, the function of which will be discussed later.

One of the basic attributes of surgical screws is the material of which they are
made. Most are metal—either stainless steel or titanium—their being inert, or
virtually inert, in the body tissues. Of course, biodegradable screws are made of
a variety of materials that are not inert in the body tissues, as they are designed
to be absorbed slowly.

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 Some screws are threaded throughout the length of their cores—fully threaded
screws. Others are only partially threaded over a portion of the core furthest
from the screw-head—so-called partially threaded, or “shaft” screws.
They were also referred to as lag screws in the past, but the term “lag” is now
reserved for describing the function of a screw, not its thread form.

This slide uses, as an example, the thread of a screw designed to gain a hold
in cortical bone—a cortical screw.
A surgical screw is a device manufactured to high specifications and is to be
used with care and precision.
In order to select the correct instruments and technique for insertion of any
screw, the surgeon needs to be familiar with its dimensions.
The symbol ø represents diameter.
The diameter of the core determines the minimal hole size that would permit
the screw to be accommodated in the bone, and so determines the drill used
to create the pilot hole for the screw.
The outside thread diameter, as illustrated, determines the minimal size of any
hole through which the screw will glide, without the threads’ purchasing in the
bone. This is sometimes known as the “nominal” diameter of the screw, as the
screws are often named by this dimension.
For example, the standard cortical screw has an outside diameter of 4.5 mm
and is called a 4.5 cortical screw.
The effective thread depth is the maximum depth of the helix theoretically
available for gaining purchase in the bone and, thereby, driving the screw for-
ward when it is rotated. It is half the difference between the core diameter and
the outside thread diameter.

An appropriate length of screw needs to be chosen. Too long and it may cause
problems by irritating the soft tissues, or protruding subcutaneously. Too short
and it will not gain full purchase in the bone.
The techniques of measuring the correct screw length will be considered short-
ly.
The pitch of the screw is the length travelled by the screw with each 360° turn
of the helix. The shorter that distance, the “finer” the pitch; the longer that dis-
tance, the “coarser” the pitch.

The finer the pitch, the more turns of the helix engage in a given depth of
cortex.

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 The screw head has two functions.
One is to permit the attachment of a driver in order to produce the necessary
rotation. This is achieved either by slotting the head (as in wood screws, but no
longer in surgery), or by producing a shaped recess; this is usually hexagonal,
but may be a cross cut, or star shaped.

The second function of the screw head is to arrest motion when the head
contacts the surface of the bone, or a plate hole (or a washer—effectively a
one-hole plate!). For this reason, the diameter of the head must be greater
than the outside thread diameter.

To introduce a screw into a firm and relatively unyielding material, such as

cortical bone, certain steps are essential.
A core diameter pilot hole is drilled. As already described, this is determined
by the diameter of the core of the screw. For example, the core diameter of
a standard cortical screw is 3.1 mm, and so a 3.2 mm drill bit is used for the
pilot hole.
If the screw is inserted so that the head will directly contact the cortical bone
surface, the bone is countersunk to receive the head (this will be discussed
shortly).
A “female” thread then needs to be created in the cortical bone to accommo-
date the “male” helix of the screw thread. This “female” helix has to be an exact
reciprocal of the screw thread in terms of pitch and outside thread diameter.

The female helix may be created by using a dedicated tap in the pilot hole, or
by using a self-threading (self-tapping) screw.
The self-threading screw has two or more flutes at its tip, specially designed
both to cut an accurate thread, by removing cortical bone, and to avoid jam-
ming of the resultant bone debris in the helix.

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 Screw length?
As indicated, the selection of the correct length of screw is vitally important.

For a standard cortical screw, the tip should just project beyond the far (trans)
cortex, so that the thread bites in the full cortical thickness

For the self-cutting screws, the length must be chosen so that the flutes pass
clear of the trans cortex. If they lie within that cortex, bone can grow into the
flutes and make later removal difficult…so measure the screw hole for length
and add 2 mm.

How does tightening the screw create compression?

When the screw is driven fully in, the head contacts the underlying bone and
resists further longitudinal motion. If the screw is then rotated a fraction further
(tightened), the threaded portion tries to advance and this creates a minute
stretching of the screw, resulting in a tensile force in the core. This is balanced
by an equal compression force at the screw head/bone interface.

Why should we countersink the cortex beneath a cortical screw head (cis cor-
tex)?

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 You will recall that stress is the force applied, divided by the area over which
the force is applied. The smaller the area, the greater the stress on the bone.

If we fail to countersink the cortex, the area of compression is small and the
stress high. This risks failure of the bone.

If we countersink, the area is increased and the stress thereby reduced.

With cancellous screws, which are used largely in metaphyseal and epiphyseal
sites, the underlying cortex is too thin to countersink. If we try to countersink,
the head compresses the cancellous bone beneath and it may fail, being much
less resistant to high stress than thick cortex: what we do in that case is not
to countersink, but to use a washer, which increases the area over which the
screw head compression is borne, thereby reducing the stress.

If we insert a screw across a fracture plane, with a view to closing the fracture
gap and applying a compressive force across the fracture plane, there are cer-
tain preconditions to be met.
If we thread both the near (cis) and far (trans) cortices, the compression will
not pass across the fracture plane.
This can be seen in the polarised light model, where the force lines generated
by the grip of the screw threads in the fragments, plus the compression forces
generated by the screw head in the near fragment, are visible.

In this model, the threads have been prevented from purchasing in the near
fragment by drilling a gliding hole (at least the diameter of the outside thread
diameter). The head then generates compression forces, which can be seen to
pass across the fracture plane.
This is known as the lag screw technique.

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 The standard AO cortical screw has an outside thread diameter of 4.5mm, and
is therefore referred to as the 4.5 cortical screw.
Its dimensions are shown on this slide.
The head diameter is 8 mm.
To accommodate the core, a 3.2 mm pilot hole has to be drilled.
If it is to be used for the lag technique, the gliding hole is made with a 4.5 mm
drill bit.
The thread is cut using a 4.5 cortical tap.
The screws are available in stainless steel or titanium.

The smaller cortical screw has an outside thread diameter of 3.5 mm, and is
therefore referred to as the 3.5 cortical screw. Its dimensions are shown in this
slide.
To accommodate the core, a 2.5 mm pilot hole has to be drilled.
If it is to be used for the lag technique, the gliding hole is made with a 3.5 mm
drill bit.
The thread is cut using a 3.5 cortical tap.
They are available in stainless steel or titanium.

As indicated here, to use a screw for the lag technique, several conditions need
to be fulfilled.
1. The thread must not purchase in the near fragment and so a gliding hole
must be drilled in the near cortex.
2. The thread of the screw must purchase in the far fragment.
3. There must be a screw head to arrest screw progression.
The screw can be a fully threaded cortical screw, or a partially threaded cortical
shaft screw.

The lag screw technique

In the standard lag technique, the gliding hole is drilled first, from outside in,
using a drill equal to the outside thread diameter of the screw.

In certain circumstances, in order to position the gliding hole optimally in the

fracture plane, the gliding hole may need to be drilled from inside outwards,
using a drill equal to the outside thread diameter of the screw. This requires
very careful rotation of the fragment to reach its endosteal surface—the biology
of the fragment should not in any way be compromised by this manoeuvre.

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 Very rarely, if there is a narrow spike at the tip of the far fragment, which would
be difficult to drill optimally through a sleeve in the gliding hole after reduction,
a technique can be used whereby the pilot hole in the far fragment is drilled
first, from inside out.

The post of a special curved drill guide is then engaged in the pilot hole, and
the fracture reduced.
With gentle traction on the curved drill guide, the 4.5 drill sleeve is introduced
through the sleeve of the curved guide and the gliding hole drilled through the
4.5 sleeve co-axially with the pilot hole.
This requires great skill and experience, but is rarely necessary.

Following the drilling of the gliding hole, whether by the outside-in, or in-
side-out technique, the fracture is reduced anatomically, the pilot hole is drilled
in the far cortex, and then the near cortex is countersunk.

The use of the depth gauge is critical for oblique screw tracks.
It is tempting to hook the guide on the acute angle of the far hole, but, as illus-
trated here, this will give a screw length measurement that will be too short.
It is the obtuse angle that must be engaged. If this proves impossible, then
hook onto the acute angled side of the screw hole, and then add 2-4 mm,
depending on the obliquity.

Following depth measurement the correct length of screw is chosen.

The final step is to tap the far cortex. This is a precision manoeuvre and the use
of the tap requires great skill and surgical discipline.

The tap must never be used in a power tool.

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 The tap should only ever be used through a tap sleeve. Not only does this pro-
tect the soft tissues, but it controls the alignment of the tap …

The tap can cut a thread as it is withdrawn, as well as when inserted. There-
fore, if the tap is slightly angled as it is withdrawn, it will cut a second “female”
helix and damage the thread that it cut on insertion. This can compromise the
screw hold.

Such a double helix is avoided by controlling the axis of the tap carefully, using
the tap sleeve, as the tap is gently unscrewed from the pilot hole.

If a screw is inserted by the lag technique, perpendicularly to the long axis of

the bone, it produces maximal resistance to any shear forces generated by axial
loading.

On the other hand, if the screw is inserted perpendicularly to the fracture

plane, it produces maximal interfragmentary compression.

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 These competing objectives can be managed in one of two ways:
Firstly two screws can be inserted, one perpendicularly to the bone’s long axis
and the other perpendicularly to the fracture plane.

The other option is to produce maximal desirable interfragmentary compres-

sion with one, or more, screws perpendicular to the fracture plane, and then
achieve resistance to shear, by using a plate to protect the primary screw fixa-
tion—a so-called protection, or neutralization, function of the plate.

It is clearly important that the holes in the near and far cortices be co-axial.

If the holes are not co-axial, as the screw engages both fragments, the reduc-
tion of the fragments will be affected.

For similar reasons an interfragmentary screw should pass perpendicular to the

fracture plane, with the holes in the centre of each fragment,
in a transverse section

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 So far, we have concentrated largely on cortical screws, which are designed to
gain thread purchase in hard cortical bone.
Cancellous screws are designed to be used where the screw thread must gain
a hold in cancellous bone.

The cancellous screws have a deeper thread and a coarser pitch than their
cortical counterparts. In addition the tip is of a different design, for reasons to
be explained. Note that the spiral of the helix increases from a point, at the tip,
to the full thread diameter over two complete turns.
Those cancellous screws that are not fully threaded have a smooth shaft. The
head design is similar to that of the equivalent cortical screw.

Cancellous screws create their own thread, not by removing bone, but by im-
pacting it aside, rather as a snow plough creates a path through the snow. The
tip design achieves this.

The standard large cancellous screw has a 3.1 mm core, but the unthreaded
shaft has a diameter of 4.5 mm.
The outside thread (nominal) diameter is 6.5 mm—therefore it is referred to as
a 6.5 cancellous screw.
The drill bit used for the pilot hole is 3.2 mm in diameter.

The small cancellous screw has a 1.9 mm core, so a 2 mm drill bit is used for
the pilot hole.
The unthreaded shaft is 2.4 mm diameter.
The outside thread diameter is 3.5 mm—hence the “3.5 cancellous screw”. This
replaced the former 4 mm cancellous screw.

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 Cancellous screws may be fully threaded, for use in attaching plates to intact
metaphyseal areas, or partially threaded for using as lag screws through a
fracture plane.
The 6.5 cancellous partially threaded screws have either a 16 mm, or a 32 mm,
threaded length.

The small cancellous screws also have a fully threaded version, or a partial
thread, the length of which is proportional to the overall screw length.

Let us take a distal femoral unicondylar fracture, such as this 33-B1 fracture,
as a model to demonstrate points of technique of inserting one, or more, 6.5
cancellous lag screws.

The fracture is first reduced and held provisionally with one, or more, Kirschner
wires.

A 3.2 mm pilot hole is then drilled across the fracture plane, and its depth
measured.

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 A 6.5 cancellous tap is used only to open the thin metaphyseal cortex and the
immediately underlying cancellous bone.

The screw of chosen overall length and thread length is then inserted. If the
cortex is anything other than strong, then a washer is used. If in doubt, use a
washer.

As the screw is driven home, the tip creates the thread in the bone by impact-
ing it aside.
There is no need to drill the cortex to 4.5 mm to accommodate the shaft: this
will enter the bone with ease once the 6.5 mm thread has been created.
As the screw is tightened the fracture plane is compressed.
Cannulated cancellous screws are available and can be used—a guide wire
being inserted instead of one of the Kirschner wires at the stage of temporary
stabilisation after reduction.

Summary
A 3.2 mm pilot hole is then drilled across the fracture plane, and its depth
measured.

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