LAG SCREW PRINCIPLES

AND TECHNIQUE

JULIUS C. CARIAZO, MD
MEDICAL OFFICER III
DEPARTMENT OF ORTHOPAEDICS
JOSE B LINGAD MEMORIAL GENERAL HOSPITAL
LAG SCREW PRINCIPLE
• involves placement of one or more screws
across a fracture to achieve
interfragmentary compression
• There are two screw types by which to
achieve this.
• Cancellous bone screw
• Ex. Proximal Tibia (decreased amount of cortical
bone)
• Cortical screw (through a gliding hole)
• Absolute Stability
• Primary Bone Healing
LAG SCREW PRINCIPLE
• Cancellous bone screws have threads only on the
terminal end of the screw.
• Therefore, when inserted across a fracture, the threads
of the tip of the screw engages in the cancellous bone of
the metaphyseal area, causing compression of the
fracture fragments upon tightening.
• Because of the weakness of the cortical bone in this area
washers are used to prevent sinking of the screw head
into the bone.
LAG SCREW PRINCIPLE
• The application of cortical screws involves
overdrilling the near cortex to the external
diameter of the screw.

• When the screw is inserted, it glides

through this hole and the threads only
engage the far cortex. As the screw is
tightened the head of the screw engages
the near cortex and the fracture fragments
are compressed together.
LAG SCREW PRINCIPLE
• Because lag screws compress
the fracture fragments
together, they must be
placed perpendicular to the
plane of the fracture line or
the fracture will displace.

• Malpositionmay contribute
to loss of fracture reduction
Johner R, Joerger K, Cordey J, Perren SM. Rigidity of pure lag-screw fixation as a function of screw inclination in an in vitro
spiral osteotomy. Clin Orthop Relat Res. 1983;(178):74-79.
LAG SCREW PRINCIPLE
• In most cases, a single lag
screw is not sufficient to
stabilize the forces within the
fracture, especially shear and
rotational forces, therefore
additional lag screw(s)
and/or a neutralization plate
may be required
LAG SCREW vs PLATE
• No significant differences in lateral bending
or rotational stiffness were detected
between the osteotomies fixed with 3 lag
screws and a plate.
• Constructs fixed with 1 lag screw were
weaker for both lateral bending and
rotational stiffness. Osteotomies fixed with
2 lag screws were weaker in lateral bending
only.
• No significant differences were found in the
failure torque.
• Compared with lag screw only fixation,
plate fixation requires larger incisions and
increased costs and is more likely to require
follow-up surgery.
CORTICAL LAG SCREW TECHNIQUE
Drill near cortex to external
diameter of screw (gliding hole)
The near cortex is perforated using
a drill that is the same diameter as
the external diameter of the screw.
LAG SCREW TECHNIQUE
Drill far cortex using “centering” drill
guide to inner diameter of screw
It is imperative that the fracture
fragments be properly reduced prior
to drilling through the far cortex.
• The drill guide centers the drill that
will be used to drill the far cortex in
order for the two holes to be in line.
This drill has the diameter that is
similar to the inner diameter or core
of the screw. For instance, when
using a 4.5 mm screw, a 3.2 mm drill
is used to drill the far cortex.
LAG SCREW TECHNIQUE
Drill far cortex using “centering” drill guide to
inner diameter of screw

appropriate sized drill bit is inserted to drill the

far cortex;

• 1.5 mm sized screw requires 1.1 mm drill bit

• 2.0 mm sized screw requires 1.5 mm drill bit

• 2.7 mm sized screw requires 2.0 mm drill bit

• 3.5 mm sized screw requires 2.5 mm drill bit

• 4.5 mm sized screw requires 3.2 mm drill bit

LAG SCREW TECHNIQUE
Countersink near cortex
A countersinking tool is used to
create a platform in the near
cortex.
The hole created by the
countersinking tool provides a
platform for the head of the screw
and ensures full contact.
LAG SCREW TECHNIQUE
• Failure to perform proper countersinking causes an
eccentric loading and lessens the degree of
compression. In very thin cortex it might also lead to
slight displacement of the fragments because of the
eccentric force.

• TOO MUCH COUNTER SINKING

• The medullary canal offers no resistance to the head of the
screw. Therefore, it is imperative that countersinking does
not remove all of the cortical bone around the
circumference of the head of the screw. Otherwise, as the
screw is tightened the head of the screw will enter the
medullary canal and provide no compression of the
fracture fragments.
LAG SCREW TECHNIQUE
Determine screw length
A depth gauge is used to
determine the screw length. It is
important that the tip of the screw
completely exits the far cortex so
that the screw threads engage
completely. Therefore, it is always
better to select a screw that is
slightly longer than slightly shorter
than the measurement recorded
with the depth gauge.
LAG SCREW TECHNIQUE
• Tap far cortex
If conventional screws are used,
tap the far cortex with a 4.5 mm
tap. If self-tapping screws are
used this step can be omitted.
• It is important to push the tap
through the gliding hole without
turning it in order to avoid a false
route of the tap.
LAG SCREW TECHNIQUE
• Screw insertion
The screw of appropriate length is
inserted and tightened. One should
observe the near cortex as the
screw is tightened to assure that
cracking does not occur from
overtightening which might
happen in osteoporotic bone.
• It is important to push the screw
through the gliding hole without
turning it in order to avoid starting
the screw in a false direction