Basic Principles and Techniques of Internal Fixation of Fractures Brett D. Crist, MD Original Author: Dan Horwitz, MD; March 2004 Revision Author: Michael Archdeacon, MD, MSE; January 2006 New Author: Brett D. Crist, MD; October 2009 General References Schatzker J, Tile M: The Rationale of Operative Fracture Care. Springer-Verlag, New York, 1987.    Hein U, Pfeiffer KM: Internal Fixation of Small Fractures. Springer-Verlag, New York, 1988.  

“Common” Definitions of Fracture Healing Union Bone’s mechanical stability restored to withstand normal loads Clinically: no pain at fracture site Radiographically: 3 out of 4 cortices with bridging callus Delayed Union Fx not consolidated at 3 months, but progressive callus Non Union No improvement clinically or radiographically over 3 consecutive months A fibrocartilaginous interface From: OTA Resident Course – Russel, T

High Energy vs. Low Energy Direct axial load or bending force Fall from height/Motor vehicle crash Soft tissue envelope significantly damaged Comminuted fracture patterns Open fractures “Low Energy“ Twisting mechanism or direct load on weak bone Fall from standing Less soft tissue injury Simple fracture pattern “High Energy" “Low Energy"

Fracture Patterns Fracture patterns occur based on mode, magnitude and rate of force application to bone Bending Load → transverse fx with wedge segment 3-point Bend →Wedge fragment 4-point Bend → Segmental fragment Torsional Load → oblique or spiral fx Axial Load → Articular impaction (Plateau, Pilon, etc.) Figure from: Schatzker J, Tile M: The Rationale of Operative Fracture Care. Springer-Verlag, New York, p. 3, 1987.

Fracture Patterns Understanding these patterns and the inherent stability of each type is important in choosing the most appropriate method of fixation and surgical approach Figure from: Schatzker J, Tile M: The Rationale of Operative Fracture Care. Springer-Verlag, New York, p. 3, 1987.

Biology of Bone Healing THE SIMPLE VERSION... High Rate of Healing Absolute Stability = 10 Bone Healing Relative Stability = 20 Bone Healing Fibrous Matrix > Cartilage > Calcified Cartilage > Woven Bone > Lamellar Bone Haversian Remodeling Minimal Callus Callus Spectrum of Healing

Biology of Bone Healing Direct/Primary bone healing Requires rigid internal fixation and intimate cortical contact –absolute stability Minimal callus formation Cannot tolerate fracture gap Interfragmental compression will minimize fracture motion Relies on Haversian remodeling with bridging of small gaps by osteocytes (cutting cones) Figure from: OTA Resident Course - Russel

Biology of Bone Healing Indirect/Secondary Bone Healing = CALLUS Divided into stages Inflammatory Stage Repair Stage Soft Callus Stage Hard Callus Stage Remodeling Stage 3-24 mo Relative stability Figures from: OTA Resident Course - Russel

Primary/Direct Bone Healing Secondary/Indirect Bone Healing Practically speaking... Primary/Direct Bone Healing Secondary/Indirect Bone Healing Simple fracture patterns See the fx during surgery and directly reduce and fix with: Lag screws Plates and screws Complex fracture patterns Don’t directly see the fracture during surgery (use fluoro) Indirectly reduce the fx and fix with: IM Rods Bridge plate fixation External fixation Cast

Fixation Stability Relative Stability Absolute Stability IM nailing Ex fix Bridge plating Cast Lag screw/ plate Compression plate

Compression Plating/ Lag screw Spectrum of Stability IM Nail Ex Fix Bridge Plating Cast Compression Plating/ Lag screw Relative (Flexible) Absolute (Rigid)

Practically speaking…. Most fixation probably involves components of both types of healing. Even in situations of excellent rigid internal fixation one often sees a small degree of callus formation...

Fixation Stability Absolute Relative (Rigid) (Flexible) No callus Reality No callus Callus Absolute (Flexible) Relative (Rigid)

Functions of Fixation Interfragmentary Compression Lag Screw Plate Functions Neutralization Buttress Bridge Tension Band Compression Locking Intramedullary Nails Internal splint Bridge plate fixation External fixation External splint Cast *Not internal fixation

Indications for Internal Fixation Displaced intra-articular fracture Axial, angular, or rotational instability that cannot be controlled by closed methods Open fracture Polytrauma Associated neurovascular injury MULTIPLE REASONS EXIST BEYOND THESE...

Benefits of Internal Fixation Earlier functional recovery More predictable fracture alignment Potentially faster time to healing

Screws Cortical screws: Cancellous screws: Greater number of threads Threads spaced closer together (pitch is (smaller pitch) Outer thread diameter to core diameter ratio is less Better hold in cortical bone Cancellous screws: Larger thread to core diameter ratio Threads are spaced farther apart (pitch is greater) Lag effect with partially-threaded screws Theoretically allows better fixation in cancellous bone   Figure from: Rockwood and Green’s, 5th ed.

Lag Screw Fixation Screw compresses both sides of fx together Best form of compression Poor shear, bending, and rotational force resistance Partially-threaded screw (lag by design) Fully-threaded screw (lag by technique)

Lag Screws “Lag by technique” Using fully-threaded screw Step One: Gliding hole = drill outer thread diameter of screw & perpendicular to fx Step Two: Pilot hole= Guide sleeve in gliding hole & drill far cortex = to the core diameter of the screw 1 2 Figure from: Schatzker J, Tile M: The Rationale of Operative Fracture Care. Springer-Verlag, New York, p. 8, 1987. Figure from: Schatzker J, Tile M: The Rationale of Operative Fracture Care. Springer-Verlag, 1987.

Lag Screws Step Three: counter sink near cortex so screw head will sit flush Step Four: screw inserted and glides through the near cortex & engages the far cortex which compresses the fx when the screw head engages the near cortex Use as sole technique of fixation is limited and advocated only in the fibula and femoral neck and unicondylar fractures. Figure from: Schatzker J, Tile M: The Rationale of Operative Fracture Care. Springer-Verlag, New York, p. 8, 1987. Figure from: Schatzker J, Tile M: The Rationale of Operative Fracture Care. Springer-Verlag, 1987.

Lag Screws Functional Lag Screw - note the near cortex has been drilled to the outer diameter = compression Position Screw - note the near cortex has not been drilled to the outer diameter = lack of compression & fx gap maintained

Lag Screws Malposition of screw, or neglecting to countersink can lead to a loss of reduction Ideally lag screw should pass perpendicular to fx Figure from: Schatzker J, Tile M: The Rationale of Operative Fracture Care. Springer-Verlag, New York, p. 8, 1987. Figure from: OTA Resident Course - Olsen

Neutralization Plates Neutralizes/protects lag screws from shear, bending, and torsional forces across fx “Protection Plate" Figure from: Schatzker J, Tile M: The Rationale of Operative Fracture Care. Springer-Verlag, 1987.

Buttress / Antiglide Plates “Hold” the bone up Resist shear forces during axial loading Used in metaphyseal areas to support intra-articular fragments Plate must match contour of bone to truly provide buttress effect

Buttress Concepts Order of fixation: Articular surface compressed with bone forceps and provisionally fixed with k-wires Bottom 3 cortical screws placed Provide buttress effect Top 2 partially-threaded cancellous screws placed Lag articular surface together Third screw placed either in lag or normal fashion since articular surface already compressed Figure from: Schatzker J, Tile M: The Rationale of Operative Fracture Care. Springer-Verlag, New York, p. 8, 1987. Figure from: Schatzker J, Tile M: The Rationale of Operative Fracture Care. Springer-Verlag, 1987.

Antiglide/Buttress Concepts Plate is secured by three black screws distal to the red fracture line Axial loading causes proximal fragment to move distal and to the left along fracture line Plate buttresses the proximal fragment Prevents it from “sliding” Buttress Plate When applied to an intra-articular fractures Antiglide Plate When applied to diaphyseal fractures

Bridge Plates “Bridge”/bypass comminution Proximal & distal fixation Goal: Maintain length, rotation, & axial alignment Avoids soft tissue disruption at fx = maintain fx blood supply

Tension Band Plates Plate counteracts natural bending moment seen w/ physiologic loading of bone Applied to tension side to prevent “gapping” Plate converts bending force to compression Examples: Proximal Femur & Olecranon

Tension Band Theory The fixation on the opposite side from the articular surface provides reduction and compressive forces at the joint by converting bending forces into compression The fracture has tension forces applied by the muscles or load bearing JOINT SURFACE Tension band Load applied to bone

The tension band prevents distraction and the force is converted to compression at the joint The tension band functions like a door hinge, converting displacing forces into beneficial compressive forces at the joint JOINT SURFACE Tension band Load applied to bone

Classic Tension Band of the Olecranon Wires can be used for tension band as well Ex: Olecranon and patella 2 K-wires from tip of olecranon across fx site into anterior cortex to maintain initial reduction and anchor for the tension wire Tension wire brought through a drill hole in the ulna Both sides of the tension wire tightened to ensure even compression Bend down and impact wires   Figure from: Rockwood and Green’s, 4th ed.

Compression Plating Reduce & Compress transverse or oblique fx’s Unable to use lag screw Exert compression across fracture Pre-bending plate External compression devices (tensioner) Dynamic compression w/ oval holes & eccentric screw placement in plate

Examples- 3.5 mm Plates LC-Dynamic Compression Plate: stronger and stiffer more difficult to contour. usually used in the treatment radius and ulna fractures Semitubular plates: very pliable limited strength most often used in the treatment of fibula fractures   Figure from: Rockwood and Green’s, 5th ed. Figure from: Rockwood and Green’s, 5th ed.

Compression Fundamental concept critical for primary bone healing Compressing bone fragments decreases the gap and maintains the bone position even when physiologic loads are applied to the bone. Thus, the narrow gap and the stability assist in bone healing. Achieved through lag screw or plating techniques.

Plate Pre-Bending Compression Prebent plate A small angle is bent into the plate centered at the fracture The plate is applied As the prebent plate compresses to the bone, the plate wants to straighten and forces opposite cortex into compression Near cortex is compressed via standard methods External devices as shown Plate hole design Alternatively a Verbrugge clamp over a screw can be similarly used to promote compression. Figure from: Schatzker J, Tile M: The Rationale of Operative Fracture Care. Springer-Verlag, New York, p. 9, 1987.

Plate Pre-Bending Compression Alternatively a Verbrugge clamp over a screw can be similarly used to promote compression. Figure from: Schatzker J, Tile M: The Rationale of Operative Fracture Care. Springer-Verlag, New York, p. 9, 1987.

Screw Driven Compression Device Requires a separate drill/screw hole beyond the plate Concept of anatomic reduction with added stability by compression to promote primary bone healing has not changed Currently, more commonly used with indirect fracture reduction techniques Alternatively a Verbrugge clamp over a screw can be similarly used to promote compression. Figure from: Schatzker J, Tile M: The Rationale of Operative Fracture Care. Springer-Verlag, New York, p. 9, 1987. Figure from: Schatzker J, Tile M: The Rationale of Operative Fracture Care. Springer-Verlag, 1987.

Dynamic Compression Plates Note the screw holes in the plate have a slope built into one side. The drill hole can be purposely placed eccentrically so that when the head of the screw engages the plate, the screw and the bone beneath are driven or compressed towards the fracture site one millimeter. Figure from: Schatzker J, Tile M: The Rationale of Operative Fracture Care. Springer-Verlag, New York, p.9, 1987. This maneuver can be performed twice before compression is maximized. Figure from: Schatzker J, Tile M: The Rationale of Operative Fracture Care. Springer-Verlag, 1987.

Dynamic Compression Plating Compression applied via oval holes and eccentric drilling Plate forces bone to move as screw tightened = compression

Lag screw placement through the plate Compression can be achieved and rigidity obtained all with one construct Compression plate first Then lag screw placed through plate if fx allows   Figure from: Rockwood and Green’s, 5th ed.

Locking Plates Screw head has threads that lock into threaded hole in the plate Creates a “fixed angle” at each hole Theoretically eliminates individual screw failure Plate-bone contact not critical Courtesy AO Archives

Locking Plates Must have reduction and compression done prior to using locking screws CANNOT PUT CORTICAL SCREW OR LAG SCREW AFTER LOCKING SCREW

Locking Plates Increased axial stability It is much less likely that an individual screw will fail But, plates can still break

Locking Plates Indications: Osteopenic bone Metaphyseal fractures with short articular block Bridge plating

Intramedullary Nails Relative stability Intramedullary splint Less likely to break with repetitive loading than plate More likely to be load sharing (i.e. allow axial loading of fracture with weight bearing). Secondary bone healing Diaphyseal and some metaphyseal fractures

Intramedullary Fixation Generally utilizes closed/indirect or minimally open reduction techniques Greater preservation of soft tissues as compared to ORIF IM reaming has been shown to stimulate fracture healing Expanded indications i.e. Reamed IM nail is acceptable in many open fractures

Intramedullary Fixation Rotational and axial stability provided by interlocking bolts Reduction can be technically difficult in segmental and comminuted fractures Maintaining reduction of fractures in close proximity to metaphyseal flare may be difficult

Open segmental tibia fracture treated with a reamed, locked IM Nail. Note the use of multiple proximal interlocks where angular control is more difficult to maintain due to the metaphyseal flare.

Intertrochanteric/ Subtrochanteric fracture treated with closed IM Nail The goal: Restore length, alignment, and rotation NOT anatomic reduction Without extensive exposure this fracture formed abundant callus by 6 weeks Valgus is restored...

Reduction Techniques…some of the options Indirect Methods Direct Methods Traction-assistant, fx table, intraop skeletal traction Direct external force i.e. push on it Percutaneous clamps Percutaneous K wires/Schantz pins—”Joysticks” External fixator or distractor Incision with direct fracture exposure and reduction with reduction forceps

Reduction Techniques Over the last 25 years the biggest change regarding ORIF of fractures has probably been the increased respect for soft tissues. Whatever reduction or fixation technique is chosen, the surgeon must minimize periosteal stripping and soft tissue damage. EXAMPLE: supraperiosteal plating techniques

Direct Reduction Technique Pointed reduction clamps used to reduce a complex distal femur fracture Open surgical approach Excellent access to the fracture to place lag screws with the clamp in place Remember, displaced articular fractures require direct exposure and reduction because anatomic reduction is essential  

Reduction Technique - Clamp and Plate Place clamp over bone and the plate Maintain fracture reduction Ensure appropriate plate position proximally and distally with respect to the bone, adjacent joints, and neurovascular structures Ensure that the clamp does not scratch the plate, otherwise the created stress riser will weaken the plate   Figure from: Rockwood and Green’s, 5th ed.

Percutaneous Plating Plating through modified incisions Indirect reduction techniques Limited incision for: Passing and positioning the plate Individual screw placement Soft tissue “friendly”

Failure to Apply Concepts Classic example of inadequate fixation & stability Narrow, weak plate that is too short Insufficient cortices engaged with screws through plate Gaps left at the fx site Unavoidable result = Nonunion Figure from: Schatzker J, Tile M: The Rationale of Operative Fracture Care. Springer-Verlag, New York, p. 320, 1987. Figure from: Schatzker J, Tile M: The Rationale of Operative Fracture Care. Springer-Verlag, 1987.

Summary Respect soft tissues Choose appropriate fixation method Achieve length, alignment, and rotational control to permit motion as soon as possible Understand the requirements and limitations of each method of internal fixation If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an e-mail to ota@aaos.org E-mail OTA about Questions/Comments Return to General/Principles Index