37/38: Internal Fixation - Frush Flashcards Preview

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Flashcards in 37/38: Internal Fixation - Frush Deck (35)

4 AO principles

  1. Anatomical reduction of fx fragments
  2. stable internal fixation designed to fulfill local biomechanical demands
  3. Preservation of blood supply to bone fragments and soft tissue by means of atraumatic surgical technique
  4. Early active pain-free mobilization of m and jt adjacent to fx, to prevent cast dz


review indirect v. direct osseous repair of bone healing

Indirect osseous repair

•Inflammation (1-7 days)

•Soft Callous (~3 weeks)

•Hard Callous (3-4 months)

•Remodeling (months-years)


Direct osseous repair

•Bypasses callous formation

•“cutting cones” form at areas of direct contact

•Gap healing

•Deposition of lamellar bone at 90 degrees to fracture


absolute vs. relative stability - what tools used?

Absolute = no motion at fx site

- use compression plates of screws

- ideal for articular fx

- needs less than 2% strain

Relative stability = varying defrees of motion

- use IM nailing, ex fix, locking plates

- holds fx fragments in place but will likely heal with callous

- needs 2-20% strain


what is strain? how do you decrease strain?

Strain = Deformation of a material when a given force is applied

  • Relative change in fx gap divided by fx gap
  • Strain decreased by increased gap length and decreased motion


Review Strain Model Movie ***

add notes here


key characteristics of ideal implant material (metallurgy)

- biocompatibility

- strength

- resistance to degradation and erosion

- ease of integration

- minimal adverse effects of imaging


titanium v. stainless steel

Stainless steel

  • Corrosion products (Ni, Cr, Mo)
  • Pain
  • Inflammation
  • Allergic rx (nickle allergy very common)


  • Possible foreign body rx --> osteolysis
  • Not as hard as stainless steel


least dense surgically impantable metal


- used for pt with nickel allergy


material of choice for joint implants



screw anatomy


what part of screw broken here?



cortical vs. cancellous surgical screws

(image of cortical)


  • Smaller pitch for grasping cortical bone
  • 1.25 mm thread pitch
  • Fully threaded


  • Larger pitch, 1.75 mm
  • Thin core, deep threads
  • Different tip
  • Fully or partially threaded

(picture of cancellous)


what screw do you use for compression?

Lag screw by screw (overdrill, underdrill, coutnersink, measure, tap)  or by design



glide hole vs. overdrill

synonymous with each other

- larger drill that usually matches screw outer diameter


smaller drill that matches screw core diameter

glide hole, thread hole and underdrill


instruments needed for lag technique


steps of insertion for lag screw by techinique

(video in lecture)

  1. glide hole (larger hole)
  2. thread hole (smaller hole)
  3. countersink
  4. depth gauge
  5. tap
  6. insertion


why is a guide hole necessary?

no guide hole near fragment --> screw distracts fracture instead of compressing it


steps of insertion lag by design

  1. thread hole (small hole only*)
  2. countersink
  3. depth gauge
  4. tap
  5. insertion
  6. compression


what depth is appropriate for by technique and by design?

By technique: Need to insert 1mm past far cortex to increase “pullout” strength

By design: Do not want to pierce far cortex because they are cancellous screws


charnley's fx classification

stable = transverse

unstable = oblique, spiral, comminuted

potentially stable = short oblique


what angle do you place an interfragmentary screw?

- perpendicular to bone: max resistance to shear

- perpendicular to fragemnt: max inter-frag compression



self-tapping v. non-self tapping screw types

Self Tapping

  • Cut own thread path
  • Fluted tip
  • Decrease # of steps of screw insertion
  • Increased torque required for insertion
  • Weakened pull-out strength at fluted areas   (17-30 less)
  • Not recommended for interfrag. fixation (AO/ASIF)

Non-Self Tapping

  • Blunt tip (no flutes)
  • Require thread holes (cortical bone)
  • Less axial load and torque required
  • Ideal for interfrag. compression

Cannulated Screw

  • Reduced thread to core ratio
  • Decreased pull-out strength
  • Simple application
  • Wide variety of sizes


good in areas where screw head promience may be problemativ

herbet screw

- two sets of threads

- decrease pull-out and compressive forces

- ex: STJ arthrodesis


what size K wire would you use?

don't want to use wire larger than 1/3 of the diameter of the bone - could cause fx


same as k-wire but is larger and only comes in smooth variety

steinman pins

- stabilize larger osteotomies or fusion


cerclage =

encircling of a part with a ring or loop

- thin mallelable stainless steel wire


uses k-wire with cerlage wire

tension band wiring

- 1-2 K wires placed across fx in parallel fashion and monofilament wire placed in figure 8 pattern to exert force opposite of fx fragment

- used in fx with stable soft tissue attachment


do staples help with compression?

not traditional

- some newer ones yes ("memory staples")


4 functions you can achieve with traditional plate

- compression (eccentric drilling, prebending, tension device, tension band)

- neutralization (helps protect inter-frag scres, neutralizes forces to prevent rotational forces)

- buttress (stabilizes fx, anchored to main stable fragment, not necessarily to fragment it is supporting, usually metaphyseal or epiphyseal)

- bridge (plate fixated in two main fragments only, used to hold bone out to length due to comminution of surgery with graft placement)


is total bone plate contact a good thing?

no - can create osteonecrosis under plate

- use a limited contact dynamic compression plate to limit trauma


rules of stabilization

Screw Fixation: The length of the fracture should be at least twice the diameter of the bone involved

Plate Stability: Metatarsal plates need 4 cortices, 2 screws on both sides of fracture; Ankle plates need 6-8 cortices, 3-4 screws

Vassals Rule: Reduce the primary fracture and secondary fractures spontaneously reduce

Two Screws are Better than One: 2 points of fixation to resist rotatory forces


which is  better - two small screws or one large screw

two small screws

- resists rotatory force

- 2nd screw perpendicular to cortec: anchor

- 1st screw perpendicualr to fracture line : compression

- if you can only insert one screw - insert is half-way


does a locking plate need to be bicortical?

no - unicortical

- traditional plates need bicortical screws


what should you do pre-op to prevent infection with hardware?

- generally if using hardware, use preop abx to decrease or prevent

- 2 g Ancef IV

- 1 g Vanc IV or 600 mg Clindamycin IV if allergic to penicillin

- leave hardware in if stable with post op infection, take out if unstable

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