SMALL BONES AND

Small implant

Agung Sutiyoso
 topik
• Hand and foot
• Cases
• Fracture Treatment
• Instrumentation
Dorsal View

Distal Phalanx

Middle Phalanx
Distal Phalanx
Proximal Phalanx

Proximal Phalanx

5 4 3 2
Metacarpal Hand bones
1
Ankle anatomy
• Tibia
• Medial Malleoli
• Posterior Malleoli
• Fibula
• Lateral Malleolu
• Talus
CASES
Case 1

 36 y.o. male
 Fall on hand
 Swelling
 Tenderness
 Rotational deformities
Metacarpal Shaft Fractures
 Case 2
 48 y.o. actor
 Twisting injury
 Swelling
 Instability
 Angular deformity
 Rotational
deformity
Case 3
 36 y.o. male

 Punched wall

 Swelling

 Tenderness

 Rotational deformity

 BOXER FRACTURE
 Metacarpal Neck Fracture
 Closed reduction

 Percutaneous K-wire
fixation

 Immobilization 3 weeks

 Remove pins at 3 weeks

 Range of motion at 3
weeks

 Strengthening at 6 weeks

 Return to full activity 12

weeks
Middle Phalanx Fracture
Proximal Phalanx Fracture
 Indications for Surgery
 Irreducible

 Unstable

 Excessive rotation or
angulation

 Intra-articular incongruity

 Open fractures

 Segmental bone loss

 Polytrauma
Surgical treatment options
METHOD PRO CONTRA

 Fast  Not rigid

 K-wire  Minimally invasive  Prolonged immobilization
 Less FB load  Infection

 Stable, rigid fixation  Only some fractures

 Lag screws  Can be done percutaneously  Technically difficult
 Early ROM  May require dissection

 Stable, rigid fixation  Devascularizes bone

 Able to contour  Large FB load
 Plates  Early ROM  Restrictive in digits

 Stable fixation  Limits range of motion

 Protects soft-tissues  Bulky
 External fixation  Bridges bony gaps  Infection
 Keeps digit out to length
 Goals of operative treatment
 Align fracture as close to
normal as possible
 Restore ROM
 Limit soft tissue trauma “Stable fixation permits
 Prevent re-displacement with early mobilization”
minimal internal fixation
 Allow early motion and
rehabilitation
 Complications

• Improper hardware placement

• Implant failure
• Malalignment
• Mal union
• Adhesions
Instruments – features and
technique
The future of Upper Extremity…

1 complete system for

Hand Fracture
System

Overview

 Comprehensive Modular System

 5 Interchangeable Modules
– 1.2mm plates and screws
– 1.6mm plates and screws
– 2.0mm plates and screws
– 2.4mm plates and screws
– Cannulated screws

 Instruments laid out in order of use

HPS System – 1.2mm Module

Plate Holding Taks

Drills
• Located in each block
• Color – coded
• 3 connection options: manual, OP, J-latch

Screw size Pilot drill size Over drill size

(Only used for compression with
fully threaded screw)
1.2 1.0 1.3
1.6 1.3 1.6
2.0 1.5 2.0
2.4 2.0 2.4
taks
• Located in every block
• countersink matches tak
• 1.2mm and 1.6mm can be shared
• 2.0mm and 2.4mm can be shared
• .045 guide wire
• Use wire pin driver to insert
• Holds plate in place
• Maintains position
• Frees surgeon and assistant hands
• Surgeons and staff love this!
counstersink
• Located in each block
• 1.2mm and 1.6mm are shared
• 2.0mm and 2.4mm are shared
• Color coded
• Used to create recess in bone in order to minimize the head protruding
• Reduce soft tissue irritation
• Ensures screw head has maximum contact area with bone, distributing the forces
from the screw head more widely
• In the hand only countersink at the diaphysis, the cortex of the metaphysis is very
thin
• Only used with screws outside of plate
Driver stems
 Located in each block
 Color coded
 Self retaining
 Insert 90 degrees onto screw head with force to
engage
 To remove, rock it slightly back and forth and pull
Driver sleeves
• Located in every block
• Color coded
• Used to protect soft tissue in
percutaneous screw insertion
• Used to stabilize insertion of
longer length screws
• Slide over the driver stem
• Should be a press fit that holds
it on driver stem
• if not holding, grab plate benders
and squeeze grooved area to form
 Tray instruments

• Bone and soft tissue management

• Plate altering
• Plate holding
• Screw insertion
 Bone and Soft Tissue Instruments

 Hohmann retractor
 Used to retract soft tissue and lift bone
 Place hook under bone or around soft tissue
 2 size options
 Bone and Soft Tissue Instruments

 Periosteal Elevator
 Used to lift the periosteum off the bone
 Scrape bone with tip
 2 options available

periosteum
 Bone and Soft Tissue Instruments

 Sharp hook
 Aka dental pick
 Used to grab bone fragments and position them in the correct
place
Bone and Soft Tissue Instruments

 Bone clamps
 Termite forceps
 Standard forcep
 Reduction forceps
 Include serated edges to help grab the
bone
 Reduction forceps with k-wire guide
 Used to aid in k-wire insertion
 Reduce fracture, clamp bone, insert
guide wire, remove clamp
 Surgeons find this one insteresting!
 Plate altering instrumentation

Universal Plate Cutter

 Prevents burrs on the surface of the plate
 Plates are cut at a radius to prevent sharp edges
 File available for removal of burs on bottom of
plate if desired
 Silicone inserts retain cut portion of plate
 Multi-purpose jaws can also be used to cut pins
and k-wires
 Do not cut a 2.0mm or 2.4 mm plate in the
1.2mm/1.6mm slot
 Do not cut wires larger than .045 at the tip
Plate cutter
 Place the last hole to be kept in the slot around the post
 Pull slightly
 Hold the plate with one hand and squeeze the handles with the
other
 If it is difficult to cut have surgeon move hands around gold portion
 Cutting around compression holes can be tricky
Plate Altering Instruments

Plate Benders
 Ergonomic bending forceps with spring handles for ease
of use
 Used to contour the plates to match the anatomy
 Use both cutters and be careful not to over bend the plate
Plate Holding Instruments

On Bone Plate Holder

 Facilitates plate positioning
while increasing visibility
 2 sides: 1.2/1.6 and 2.0/2.4
Plate Holding Forceps, swivel foot
 aids in reduction of fracture
and positioning of plate
 Swivel foot goes over plate
Screw Insertion Instruments

Drill guides
 Color coded
 Right side for pilot drill
 Left side for over drill
 Diameter matches drill diameter
 Always use the inserts for the pilot side (1.6, 2.0 and 2.4mm)
 The tip length can be controlled
 The longer the length the better position for ecentric drilling (compresshion
holes) and angles
 The shorter the more stability in neutral drilling
 Surgeon preference
Screw Insertion Instruments

Depth gauges
 Color coded
 1.2/1.6
 2.0/2.4
 Always protect the tips with the tip protector while in the block
 Have them remove this in surgery
 Measurements are located on both sides
 Surgeons like this feature
 Insert into pilot hole until hook catches on other end
 Retract and read measurement
Screw Insertion Instruments

Driver handles
 2 types: ratchet and swivel
 Swivel is prefered by most
hand surgeons
 Ratchet is nice for longer
length screws and larger screws
(2.0 and 2.4)
 Ergonomic handle
 Surgeons love OM handles!

Forceps
 Necessary for removing plats
from block
Forceps
terimakasih