Orthopedic Fixation Devices

Orthopedic fixation devices are used in the treatment of fractures, soft-tissue injuries, and reconstructive surgery. After fracture reduction, internal, external, or intramedullary fixation devices may be used to provide stability and maintain the alignment of bone fragments during the healing process. They must be strong and secure enough to allow early mobilization of the injured part, as well as the entire patient. Indications of Internal and external fixators. Indications for Operative (internal) Fixation When closed method have failed.
1. 2. 3. 4. 5. 6. 7.

Closed methods will probably fail. Displaced intraarticular fractures. Associated neurovascular injury Polytrauma Pathological fracture When it will minimize confinement to bed When it will substantially reduce cost of treatment.

Classification of Orthopedic Fixation Devices Internal Fixation Devices Screws Plates Wires and pins Intramedullary rods and nails Spinal fixation devices 1. External Fixation Devices Fracture Fixation Radius Tibia Pelvis Bone lengthening Ilizarov device Traction Pins 2. Intramedullary Fixation devices Interlocking nails

Advantages of internal fixation: allows shorter hospital stays enables individuals to return to function earlier reduces the incidence of nonunion (improper healing) and malunion (healing in improper position New materials such as stainless steel, cobalt and titanium were not only durable, but also had the strength and the flexibility necessary to support the bone These materials are also compatible with the body rarely cause an allergic reaction or implant failure. The most common types of internal fixation are wires, plates, rods, pins, nails, and screws used inside the body to support the bone directly. Wires Wires are often used as sutures or threads to "sew" the bones back together.

Can be used in conjunction with other forms of internal fixation to hold bones together. Can be used alone to treat fractures of small bones, such as those found in the hand or foot. A variety of wires are used by orthopedic surgeons. One common type is the cerclage wire, in which the wire is placed around the circumference of the bone to pull various fracture fragments together.

Pins

Pins hold pieces of bone together. They are usually used in pieces of bone that are too small to be fixed with screws. These pins are usually removed after a certain amount of time, but may be left in permanently for some fractures. For example, Knowles pins bridge the physeal line in a patient with a slipped femoral capital epiphysis. Another type of pin used currently is the percutaneous pin commonly used to treat humeral neck fractures. These pins have a self- threading screw tip and are placed under C-arm fluoroscopy. Plates Plates are like internal splints that hold the fractured ends of bone together.

Extend along the bone and are screwed in place. If two bones that run parallel to each other both break, such as in the lower leg, plating one bone may provide enough support for the other bone as well. May be left in place or removed (in selected cases) after healing is complete.

Plates come in several flavors, and are named for their function. In general, there are compression neutralization and buttress plates. Compression plates are used for fractures that are stable in compression. They may be used in combination with lag screws, and they may provide dynamic compression when used on the tension side of bone. They dynamic compression plate is one of the most common types of plates, and can be recognized by its special oval screw holes. These holes have a special beveled floor to them with an inclined surface. If desired, this inclined surface can be used to pull the e ds of the bone together as the screws are tightened.

Photograph shows a variety of plates used in internal fixation: tibial condylar plate (A), blade plate (B), reconstruction plate (C), calcaneal plate (D), dynamic compression plate (E), and LISS plate (F). Nails or Rods In some fractures of the long bones, the best way to align the bone ends is by inserting a rod or nail through the hollow center of the bone that normally contains some marrow.

Held in place by screws until the fracture has healed. May be left in the bone after healing is complete. A large variety or devices are placed down the intramedullary canal of bones, ranging from Kirschner wires up to large femoral nails. One can generally classify these devices by wether intramedullary reaming is necessary prior to placement of the device. With the first nails placed down the femoral shaft, the medullary space first had to be reamed out so that the enlarge nail would not shatter the bone as it was hammered down the shaft. However, reaming is an invasive procedure, and can compromise the already tenuous blood supply of the medullary space. Reaming can also lead to thermal osteonecrosis, especially if the medullary canal is small, a tourniquet is used durig reaming, or there is

marked soft tissue injury. If intraosseous pressure becomes elevated during reamimg, fat emboli to the lungs are possible. For these reasons, a variety of unreamed devices have been developed. The Rush rod, had a chisel like tip, and is commonly used for fibular shaft fractures, and occasionally in other tubular bones as well.

Intramedullary nails. (a) Frontal radiograph of the femur shows a comminuted midfemoral shaft fracture that is transfixed with an antegrade intramedullary nail with one proximal and two distal interlocking screws.

Frontal radiograph of the leg shows a tibial shaft fracture that is transfixed with an antegrade intramedullary nail with two proximal and two distal interlocking screws. A fibular shaft fracture is present at the same level Screws Bone screws are used for internal fixation more often than any other type of implant. Although the bone screw is a simple device, there are several designs based on how the screw will be used.

Can be used alone to hold a fracture, as well as with plates, rods, or nails. May be designed for a specific type of fracture. May be left in place, or removed after the bone heals

One of the current tenets of orthopedic fixation is that bone heals better if the fracture fragments are pressed firmly together. Many orthopedic devices are designed to do just that, as well as their primary function of stabilizing the fracture in anatomic alignmet, Fracture compression increases the contact area across the fracture and increases stability of the fracture. It also decreases the fracture gap and decreases stress on the orthopedic implant. This compression can be static, where the compression is produced by the fixation device alone, or dynamic, where body weight or muscle forces are used to produce additional compression. Screws are one of the most ubiquitous hardware devices. They may be used by themselves to provide fixation or in conjunction with other devices. Any screw that is used to achieve interfragmental compressions termed a lag screw. Such screws do not protect fractures from bending, rotation or axial loading forces, and other devices should be used to provide these functions. Cortical and Cancellous Screws The two most common types of screws are cortical and cancellous screws. Cortical screws tend to have fine threads all along their shaft, and are designed to anchor in cortical bone. Cancellous screws tend to have coarser threads, and usually have a smooth, unthreaded portion, which allows it to act as a lag screw. These coarser threads are designed to anchor in the softer medullary bone. Interference Screw Another specialty screw occasionally seen is the interference screw. This screw is sometimes used in the repair of the anterior cruciate ligament. In this type of repair, the surgeon employs a cadaveric allograft ligament which has a block of bone still attached at both ends. A tunnel is drilled through the distal femur and the proximal tibia, and these bony blocks are placed within the tunnels. The interference screws are placed along the side of the bone blocks so that they tightly wedge them into the side of the tunnel and prevent them from moving.

Photograph shows a variety of screws used in internal fixation: the Schanz screw (A), cannulated cancellous screws (B), partially threaded cortical screw (C), and cortical screws (D) (the first two of which are self tapping and the third is non-self tapping).

Diagram illustrates screw anatomy.

Dynamic compression screw. Frontal radiograph of the hip shows a dynamic compression screw device that transfixes the intertrochanteric fracture Washers Washers are generally used in two situations. They are used to distribute the stresses under a screw head so as to prevent thin cortical bone from splitting. Serrated washers are used to affix avulsed ligaments, small avulsion fractures or comminuted fractures to the remainder of the bone. External Fixators: External fixation is a method of immobilizing bones to allow a fracture to heal. External fixation is accomplished by placing pins or screws into the bone on both sides of the fracture. The pins are then secured together outside the skin with clamps and rods. The clamps and rods are known as the "external frame." Some of the advantages of external fixation are that it is quickly and easily applied. The risk of infection at the site of the fracture is minimal, but there is a risk of infection where the pins are inserted from the skin into the bone. Indications for External Fixation 1. Open fracture with massive soft tissue damage. 2. To provide instant fixation in cases of polytrauma.

3. May be the only way to treat fractures with deficient bone stock or infection (external fixation allows easy access to wounds). The weak link in the external fixation system is the threaded pins that are anchored in the bone. These pins should pass through the cortex on either side of the medullary space, and only a few millimeters of the pin tip should ideally protrude through the distal cortex. The usual complications of this fixation system are loosening or infection (or both) of the pins. Lucency developing about a pin as it travels through the cortex is evidence of loosening of that pin. Infection is a much harder diagnosis to make radiographically. Long before signs of radiographic infection develop, the orthopedist will make the diagnosis by seeing pus oozing up along the pins as they exit the skin. Even the presence of periosteal new bone formation about the pin tracts is unhelpful, since these drilled holes are after all fractures of a sort, and fractures do produce callus, even without infection.

Cannulated screw with a washer. Frontal radiograph shows a cannulated, partially threaded cancellous screw and a washer that transfix the distal clavicle and coracoid. The patient had a distal clavicular fracture and reduced acromioclavicular joint subluxation with disruption of the coracoclavicular ligament. Traction: Is a directional force applied to the extremities with transfixing wires or pins attached to the soft tissues or placed through the metaphysis, perpendicular to the long axis of bones. Traction is used for immobilizing and reducing fractures, correcting deformities and elevating extemities for the treatment of soft tissue injuries. Method In this kind of reduction, holes are drilled into uninjured areas of bones around the fracture and special bolts or wires are screwed into the holes. Outside the body, a rod or a curved piece of metal with special ball-and-socket joints joins the bolts to make a rigid support. The fracture can be set in the proper anatomical configuration by adjusting the ball-and-socket joints. Since the bolts pierce the skin, proper cleaning to prevent infection at the site of surgery must be performed.

Installation of the external fixator is performed in an operating room, normally under general anesthesia. Removal of the external frame and bolts usually requires special wrenches and can be done with no anesthesia in an office visit. External fixation is usually used when internal fixation is contraindicated- often to treat open fractures, or as a temporary solution. External fixation is also used in limb lengthening. People with short limbs can have, for example, legs lengthened. In most cases the thigh bone (femur) is cut diagonally in a surgical procedure under anesthesia. External fixator pins or wires (as above) are placed each side of the 'man made fracture' and the external metal apparatus is used to very gradually push the two sides of the bone apart millimeter by millimeter day by day and week by week. Bone will gradually grow into the small gap created by this 'distraction' technique. Such a process can take many months. In most cases it may be necessary for the external fixator to be in place for many weeks or even months. Most fractures heal in between 6 and 12 weeks. However, in complicated fractures and where there are problems with the healing of the fracture this may take longer still. It is known that bearing weight through fracture by walking on it, for example, with the added support of the external fixator frame actually helps fractures to heal.