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Pure Metals: Titanium, Zirconium Uses of wire: Alloys: Stainless steel (Fe, Cr, Ni, C, Mo), Vitallium (Co, Cr, Mo) 20-22 gauge- thick cortical bone, o Mo adds inertness to stainless steel malleolar fractures, tension banding Never mix metals; will get galvanic erosion 24-26 gauge - 1st metatarsal Dorsal Loop technique- loop through cortex dorsally 26-28 gauge - lesser metatarsals, Purchases only 1 cortex phalanges (mostly proximal phalanx Can get dorsiflexed metatarsal because only fixating dorsally of hallux) Intraosseous Loop- dorsal and plantar OR medial and lateral 30 gauge - delicate situations Purchases 2 cortices; more stable 1st & 5th metatarsals = perpendicular to the shaft, 2nd-4th metatarsals = 45 to shaft Circlage Wiring- completely encircles a long bone Good to use in adjunct with other forms of internal fixation Need long oblique fracture in order to work ONLY GIVES SPLINTAGE Staples- indications include triple arthrodesis, fusion, TN/CC joint Types: o Osteoclasps- put perpendicular to fracture with hope they come together and create compression o Memory Compression- made from nickel-titanium alloy At body temperature, the tips of the arms come close to each other to create compression o Oss Staple- similar to memory compression, but an electrical current causes arms to close Kirshner Wires- most common form of internal fixation (offers splintage) Diameter: 0.028, 0.035, 0.045 (2-5 mets; FF sugery), 0.054, 0.062 (1st ray, hallux) Indications: fracture, healing, tendon transfer, maintenance of proper alignment, fusion, arthroplasty, Keller, spaces of joint, maintains length, transverse fracture of metatarsal For K-wire to get compression must be combined with: tension bands, stainless steel wires, wire loops, screws, etc Threaded K-wires: core is NOT the diameter, so they are weaker o Offers mild resistance to distraction Static compression: screw causes the compression Dynamic compression: bodies forces combined with internal fixation, create compression Tension banding- use in 5th metatarsal fracture Tension band + wiring = dynamic compression
Bone Screws
Purpose of fixation device: hold a fracture/ osteotomy stable until sufficient healing has occurred to allow normal loading Compression increases the force of friction between two surfaces, therefore increasing the resistance to movement; enhance stability Screws create compression by: Screw Anatomy: NOT PROPERTIES! Design of the screw Shaft: part that does not have threads Technique of insertion o Fully threaded does not have a shaft Two types of bone Core: Central area between threads Cortical: hard, more compact, may only have 2-3mm cortex o Inner solid area o Screw: NARROW PITCH (3mm), NARROW THREAD Pitch: distance between threads DIAMETER o Different pitches dependent on which Cancellous: spongy bone, more volume type of bone you are inserting it in o Screw: WIDE PITCH, WIDE THREAD PATTERN Thread diameter: outer diameter of screw Holding Power: depends on # of threads imbedded in bone Head of screw Ratio of major to minor diameter (thread surface area) o If you have thread diameter of 1 and core diameter 0.75, you are left with .25 of thread surface to grab into bone Compressive or LAG effect: achieve a compressive effect by with screw being partially threaded or fully threaded Fully threaded- as screw penetrates the bone, you want the head to compress the proximal cortex to the distal cortex o You want the under surface of the head to grab the proximal cortex and pull it toward the distal cortex o Get compressive effect by neutralizing the threads in the proximal cortex Partially threaded- important that all the threads are across the osteotomy Screw Design: under surface of the head should pull the proximal cortex to the distal cortex Bone surface needs to be contoured to the same size and shape as the screw head: COUNTERSINK o Countersinking- reason is to evenly distribute the forces under the head to prevent stress riser Standard Screw Sequence: 1) Temporary Fixate put in anatomic position 2) Dill Pilot Hole 3) Countersink 4) Measure 5) Tap 6) Overdrill 7) Screw insertion New trends: Material: titanium, cobalt chromium (Vitalium) Low contour heads: good for small bone of the foot Cannulation- central core is hollow, allows you to place guide pin across the osteotomy o Cannulated Sequence: 1) Reduce fracture 2) Guide Pin (measure length thats needed) 3) Countersink 4) Screw insertion Self tapping (rare) Self reaming (many new screws are self drilling, no need to drill a pilot hole) Range of screw sizes: 2.0, 2.5, 3.0 = CORTICAL 3.5 = MIXED 4.0, 4.5, 6.5 = CANCELLOUS To get max compression you generally may want 2 screws in an oblique osteotomy 1st screw inserted perpendicular to the fracture to get max compression 2nd screw inserted perpendicular to the long axis of the metatarsal to give you max resistance What if only 1 screw? You split the difference! Lapidus: NOT going cortex-cortex, going from cortex to medullary bone, use a larger screw size (4.0, 4.5, 6.5) for cancellous bone Clinical Applications of Compression Internal Fixation Appleton Page | 2
External Fixation
Purpose: to anchor multiple osseous fragments together through use of wires and rods in order to provide longitudinal support Decrease need for extensive soft tissue dissection Provides post-op adjustment and earlier return to weight bearing and range of motion Mode of Fixation: compression, neutralization, distraction Neutralization- maintain length and alignment of segment as well as resists external deforming forces Distraction- pull segments away from each other slowly (1mm/day), resulting in controlled lengthening of the bone o Fracture reduction through ligamentotaxis Ilizaraov Prinicples: Tension-stress effect- bone could be lengthened through callous distraction, if performed at a proper rate of distraction both osseous and soft tissue will respond o Distraction @ 1mm / day Stages of distraction: o Latency- osteotomy & corticotomy o Distraction- turn at 4X / day o Consolidation- take 2X as long as distraction (4w for distraction, 8w for consolidation) Under optimal conditions during distraction, bone forms via intramembranous ossification Under unstable conditions during distraction, bone forms via enchondral ossification Basic Frame Components: Pins: connects bone to rest of the frame o Stiffness of pin = radius to the 4th power (small diameter increase will greatly increase stiffness) o Thread designs- constant diameter (purchase on near & far cortex; stress focused to these areas), short thread, self drilling, conical taper Conical Taper: obtain purchase on near and far cortex but allow for RADIAL preload Distributes stress in all areas rather than in specific areas like constant diameter Pin Designs: stress highest at pin-bone interface on insertion, thread-shank junction = pins weakest segment Longer thread design = stress riser more distally from bone or away from interface Shorter thread design = stress riser to far cortex External Fixator Types: Monolateral / Half pin- uniplanar correction o Lacks stability in the sagittal plane! Therefore cannot have any weightbearing o Monolateral frame mechanics: Stacking of rods gives more stability and rigidity Delta frame configuration adds resisitance to deformation into 2 planes Need to spread pins apart, otherwise fixation will be deformed Circular (Ilizarov)- circular or partial rings connected by rods o Provide provide compression and distraction o Biplanar correction; allows for sagittal plane stability but allows axial rotation Hybrid- combines circular and monolateral configurations into one frame o Indication: tibial plateau fracture, pilon fractures, ankle fusion Taylor-Spatial frame- for reduction of complex TRIPLANE deformities with utilization of computer programs o Indication: fixation of fractures, limb lengthening, arthrodesis, soft tissue lengthening Complications: infection, edema, hematoma, drainage, pin tract infection, scar, pain, wire breakage, non-union, stress fracture, joint dislocation / subluxation Pin tract infections: Dahls Classification o Grade 0 clear fluid NaCl cleansing with topical abx o Grade 1 slightly red fluid - NaCl cleansing with topical abx o Grade 2 red/tender yellow drainage PO abx with TD pin care o Grade 3 red/painful/purulent definitive PO abx o Grade 4 radiolucency with purulence removal of pin/possible IV abx o Grade 5 sequestrum removal of pin/debridement of pin tract and IV abx
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