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Principles of Internal Fixation

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

Principles of Internal Fixation


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

Principles of Internal Fixation


Open reduction
Surgically exposure of the fracture site Implants placed internally

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

Principles of Internal Fixation


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

Internally placed implants are hidden


No extensive care

Principles of Internal Fixation


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

Principles of Internal Fixation


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

Extent of soft-tissue damage Duration of the fracture

Principles of Internal Fixation


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

Tension

Fracture Forces

Bending

Rotation

Compression

Orthopedic Wire

Flexible Made of stainless

steel Generally used in conjunction with other forms of fixation

Full Cerclage

Hemicerclage

Interfragmentary

Tension

band

Tension band
Opposes tensile forces
muscle / ligament

converts tensile forces to compressive forces

Wires

Principles of full cerclage wire placement


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

Wires

Principles of full cerclage wire placement


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

Wires

Securing full cerclage


Twisted wires
Wire holders/pliers Wire tighteners

Single and double loop wires


Special tensioning device required

Good

Bad

Wires

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

Intramedullary (IM) Pins

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

IM pins do not counteract


rotational forces
External fixator Plate Cerclage wires

Use additional fixation

Provide endosteal contact


Fill 70% of the bone diameter

Stacked pins
Do not provide appreciable stability

IM pins alone are

poorly suited for comminuted fractures

They cant withstand


axial forces

Collapse and

instability will result

Steinmann pins are

most commonly used

They pins vary in


diameter
Proportional to strength

Vary in point
morphology
Chisel Trocar Threaded

IM pin insertion
Jacobs chuck Low speed drill Retrograde Normograde

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

Normograde insertion
Pin inserted at epiphysis and driven across fracture line

Femur
Retro or Normograde Extend hip

Intertrochanteric fossa
Direct laterally Over reduce

Tibia
Always Normograde
Countersink or cut short

Intra-articular

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

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

Kirschner Wires

Small and elastic Usually used as:


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

Interlocking Nails

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

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

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

Screws

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

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

Screws

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

Screws

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

Screws

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

Screws

Screws

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

Screws

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

Bone Plates

Necessary for many fractures Requires specialized equipment and

training Not readily available in many practices More expensive than pinning

Bone Plates

Counteract
Tension Compression Shear Bending Rotational forces

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

Tension side of the bone

Femur
Craniolateral

Radius
Cranial

Tibia*
Craniolateral

Unla*
Caudal

Humerus
Craniolateral

Mandible*
dorsal

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

Plates are stronger if load sharing with the bone occurs

Plates come in a wide variety of shapes and sizes

Plates

Functions
Neutralization Compression Buttress

Neutralization

Plate protects primary

repair from weight-bearing forces

The weight-bearing load is


shared by both the plate and the bone

Compression

Mechanical compression

added to the fracture site

The weight-bearing load is


shared by both the plate and the bone

Primary bone healing


results

Buttress

Spans a gap to prevent


collapse of a fracture

All of the weight-bearing


forces are transmitted through the plate

Plates

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

Plates

Dynamic compression plates


Allows compression of major bone fragments
External compression

Screws must be LOADED in order to get compression


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

1) Load Drill Guide: Provides 1 mm compression,


screws are placed eccentrically
little displacement is provided.

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

Loading a screw in the DCP for compression

Applying compression to a fracture

Plates-Rod constructs

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

Removing Implants

In general, it is recommended that all


orthopedic implants be removed

In practice, however, we rarely remove


orthopedic implants

Removing Implants

Why dont we remove them


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

Removing Implants

When to recommend removal


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

Removing Implants

Radiographs should document healing


prior to removal
Unless implant failure

Warn owners about potential for bone


breakage
Cage rest required after plate removal

Good idea to culture implants

Removing Implants

IM pins are easier to remove than plates


Must leave pins long enough Not the same refracture worry

Young dogs tend to over-grow the

implants and they are hard to remove

Plates on the pelvis and humerus should


be left in place if not causing a problem

Advantages of one over another

IM pins are cheaper than plates and


interfere with blood supply less

Little equipment is required for pin


placement

IM pins can migrate, especially if motion


is present

Advantages of one over another

IM pins must be combined with another


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

IM pins are not ideal for comminuted or

transverse fractures (limits to amendable fractures)

Advantages of one over another

Interlocking nails counteract all fracture


forces and may do it better than plates

Interlocking nails do require a lot of

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

Interlocking nails are limited by the type

of fracture you can repair and the size of the animal

Advantages of one over another

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

Plating requires some expertise and


expensive equipment

Advantages of one over another

Plating requires an aggressive surgical


approach in most instances

Plates may interfere with blood supply


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

Advantages of one over another

Open approaches may delay fracture


healing and predispose to infection
Plates/screws Interlocking nails

Closed approaches can be used with


IM pins
External fixator

Interlocking nails require a limited approach

Advantages of one over another

Hidden implants allow early function with


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

Articular fractures generally require open


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