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Screw & Plates

Traumas Team
Dept. of Orthopaedic Surgery
Hasan Sadikin General Hospital
Medical School of Padjadjaran University
Bandung

Lag Screw

General Aspects
Screw very efficient tool for fixation of a
fracture by interfragmentary compression or for
fixing a splinting device (e.g : plate, nail or fixator
to bone)
The axial force produced by a screw results from
rotating screw clockwise the inclined surfaces
of its threads glide along a corresponding
surface of the bone.

General Aspects
A.

The undersurface of the


screw head is spherical
allowing a congruent fit to be
maintained while tilting the
screw, e.g., within a plate
hole. The thread is
asymmetrical.
The dimensions shown are
designed to offer a good
relation between axial force
& torque applied

B.

These dimension result in an


inclination of the thread
which is self locking

General Aspects
Two force components are active
one along the circumference of the thread
one along the axis of the screw

The compression applied by a screw


affects a comparatively small area of the
bone by which it is surrounded a single
intert=fragmentary lag screw does not
prevent rotation between two fragments

Types of Bone Screws


Two basic types : cortical & cancellous
Cancellous bone screw
- larger outer diameter
- deeper thread
- larger pitch
- metaphyseal or epiphyseal
Cortical bone screw
- diaphysis

Shaft Screws
Compression of an epimetaphyseal fracture using a
shaft screw
The thread pulls the opposite
bone fragment towards the
head of the screw.
The shaft of the screw does not
transmit any great axial force
between the shaft & the
surrounding bone.
The length of the screw shaft
must be chosen the
threaded part lies fully within
the opposite bone fragment.
Washer is used to prevent the
screw head sinking into cortex

Mode of application of a Fully


Threaded lag Screw
To act as a lag screw the
cortex screw requires a
gliding hole in the
near(cis) and a threaded
hole in the far (trans)
cortex
In diaphyseal bone, shaft
screws or fully threaded
screws are used because
partially threaded
cancellous bone screws
are difficult to remove
after healing

Modes of failure
Screws can fall because of axial pull out,
bending forces, or both.
Screws usually resist axial pull out rather
well.
Most screws are fairly weak in bending
due to their small core diameter

Special Considerations of
Screw Insertion
A screw should not be tightened to the
limits of its strength, but only about 2/3 of
this allow resistance to any additional
functional loading

Positioning of the Screw in


Respect to the fracture Plane
A. A lag screw oriented
perpendicular to the
fracture plane ideal
inclination in the
absence of forces along
the bone axis
B. Inclination half way
between the
perpendiculars to the
fracture plane and to the
long axis of the bone
better suited to resisting
compressive functional
load along the bone
long axis.

Lag screws in metaphyseal and


epiphyseal regions
To obtain anatomical reduction and
absolute stability interfragmentary lag
screws are mandatory in articular
fractures.

New Trends in Screw Application :


Internal Fixator with Locked Screws
The new technology of
using the so-called
internal fixators for
biological internal fixation
takes advantage of short,
unicortical screws.
The head of this screw is
locked within the body of
the fixator (plate) in a
position perpendicular to
the long axis of the
fixator.

New Trends in Screw Application :


Internal Fixator with Locked Screws

A.

B.

Shows the design & force components of a conventional screw as


used for the DCP and LC-DCP. The screw acts by producing
friction between the plate undersurface & the bone surface due to
compression of the interface.
Locked screws as used in newer implants. These are usually
unicortical & work more like bolts than screws; the axial force
produced by the screw is minimal. The screw provides fixation
screw head is locked in a position perpendicular to the plate
body.

Cancellous screw

Cortical Screw

Plates

Introduction
Rigid fixation Vs Biological fixation
Rigid fixation with plates and screws has a
firm place in fracture treatment
Articular fractures require anatomical
reduction and stable fixation as callus
formation is not desired
The potential compromise of cortical blood
supply is a major draw back of
conventional plating

Dynamic compression plate


(DCP) 3.5 & 4.5
Functions :
1. Compression
2. Neutralization
3. Tension band
3 sizes :
1. Broad DCP 4.5 femur & humerus
2. Narrow DCP 4.5 tbia & humerus
3. DCP 3.5 forearm,fibula,pelvis &
clavicle

Dynamic compression plate


(DCP) 3.5 & 4.5

Dynamic compression plate


(DCP) 3.5 & 4.5
When the screw is inserted & tightened

Movement of the bone fragment


relative to the plate

Compression of the fracture

Technique of DCP application


2 DCP drill guide :
with an eccentric (load) hole
with concentric (neutral) hole

Limited Contact Dinamic Compression


Plate (LC-DCP) 3.5 & 4.5
The new LC-DCP
design reduces the
area of contact
between plate & bone
& thereby interferes
less with bone biology

Limited Contact Dinamic Compression


Plate (LC-DCP) 3.5 & 4.5

Technique of LC-DCP application


3 different modes :
1. Compression
2. Neutral
3. Butress
2 LC- DCP drill guides plate 3.5 & 4.5
LC-DCP universal drill guide neutral or
eccentric position relative to the plate
hole.

Technique of LC-DCP application

Tubular plates (4.5/3.5/2.7)


1/3 tubular plate (3.5 version only)
titanium / stainless steel
1.0 mm thick
useful in areas with minimal soft tissue
covering (e.g lat. malleolus, olecranon)
Each hole is surrounded by a small collar
Oval shape of each hole eccentric screw
placement to produce fracture compression
Semitubular plate (4.5 system) less used

Tubular plates (4.5/3.5/2.7)

Reconstruction plate 3.5 & 4.5


Deep notches between the
holes allow accurate
contouring on the flat as well
as standard bending
Oval holes allow dynamic
compression
Useful in fractures of bone
with complex 3-D geomtery
(e.g pelvis & acetabulum,
distal humersu, clavicle)
Special instruments are
available for the contouring of
these plates.

Special plates
Several special plates for
specific locations have
been developed
They are shaped
anatomically
corresponding to the site
where they are to be
applied

Classical Principles of Rigid


Internal Fixation with Plates
Interfragmentary compression provides stability
through friction, but has no direct influence on
bone bridging or fracture healing
4 ways to obtain interfragmentary compression
with a plate :
1. Compression with a tension device
2. Compression with the dynamic
compression principle (DCP / LC-DCP)
3. Compression by contouring (overbending)
the plate
4. Additional lag screws through plate holes

Rigid Fixation by Lag Screw &


Neutralization (Protection) Plate
The traditional & quite effective way to rigidly fix a
simple diaphyseal fracture is to use lag screws
combined with a neutralization (protection) plate.
In metaepiphyseal split fractures lag screw
fixation often needs to be combined with a buttress
plate to protect the screws from shearing forces.

Rigid Fixation by Lag Screw &


Neutralization (Protection) Plate

Compression with the


Tension Device
In transverse or short oblique fractures of
the diaphysis, placement of a lag screw is
not always possible best treated by
intramedullary fixation (except in the
forearm)
Compression plate is used if nailing is
impossible.

Compression with the


Tension Device

Compression by Overbending

Contouring of Plates
Straight plates often need to be contoured
prior to application to fit the anatomy of
the bone.
If this not done reduction will be lost
esp. if no lag screws are placed across
fracture
Repeated bending back & forth should be
avoided

Different functions of plates


The function assigned to a plate does not
depend on its design
Plate may also be used for other
functions: buttressing, bridging, or to act
as a tension band

Buttress Plate
In a metaphyseal /
epiphyseal shear or split
fracture fixation with
lag screws alone may not
be sufficient combined
with a plate with buttress
or antiglide function
In plates with DCP holes,
the screws should
inserted in the buttress
position

Tension Band Plate


Criteria for a plate to act as a tension band:
1. The fractured bone must be
eccentrically loaded, e.g., femur
2. The plate must be placed on the tension
side
3. The plate must be able to withstand the
tensile forces
4. The bone must be able to withstand the
compressive force which results from the
conversion of distraction forces by the plate
There must be a bony buttress opposite to the
plate to prevent cyclic bending

Tension Band Plate

A plate under
tension
is much
stronger
than under
bending
forces

Bridge Plating
Indicated in complex diaphyseal fracture
patterns.
Fixed to the 2 main fragments only, leaving the
fracture zone untouched acts as an
extramedullary splint.
This concept combines adequate mechanical
stability offered by the plate with uncompromised
natural fracture biology to achieve rapid
interfragmentary callus formation & fracture
consolidation

Bridge Plating

Bridge Plating

Bridge Plating