Orthopedic Hardware SCREWS Screws are the most common general purpose fixation devices.

They may be the only hardware used in reparative or reconstruction surgery. More commonly, however, they are used with other hardware devices, particularly plates, to fixate the associated device to bone. For fractures that have large well-defined components, screws are used both to fixate plates and as standalone devices to fixate the fracture fragments. The main features of a screw are shown to the right along with the standard names for its parts. Each of the parts can be modified to produce screws with specific characteristics. The most common variations are differences in spacing between the threads (pitch), core diameter, and tip design. Screws can have hollow (cannulated) or solid central axes and can be fully or partially threaded. Screws tips are designed to be tapping or nontapping (see glossary). Screws are often referred to by the outer diameter of the threaded portion, 3.5, 4.5, and 6.5 mm screws being the most common. Types of Screws Cancellous and cortical screws Although there are a large number of different screws, there are two basic designs: cortical and cancellous screws. As the names imply, cortical and cancellous screws are designed for placement in cortical and cancellous bone respectively. Cortical screws have closely-spaced, shallow threads and larger core-to-outer diameter ratios than cancellous screws. Cortical screws are stronger than cancellous screws of the same outer diameter. They are usually blunt ended. When used to fix plates to long bones, fullythreaded screws are used in order to fixate both cortices so that maximal stability is achieved. The blunt end should extend only a few millimeters into the soft tissues beyond the far cortex to minimize damage to the soft tissue. Cancellous screws are designed for fixation of cancellous bone. They are most commonly used in the metaphyses of long bones where cancellous bone is abundant. They have more deeply cut and more widely spaced threads compared to cortical screw. Since cancellous bone is much less dense than cortical bone, the screw threads cut their path in the bone when the screw is inserted, i.e. cancellous screws are self-tapping. Partialy threaded cancellous screws are often used as lag screws for metaphyseal fractures. Lag Screws Lag screws are used to compress fractures. A lag screw is not a particular type of screw, but rather refers to how a screw is inserted. To function as a lag screw, the proximal part of the screw slides freely in a hole drilled in the bone on the near side of the fracture while the tip is screwed into the bone on the distal side of the fracture. For cortical or cancellous screws, as the screw is tightened, the head forces the two sides of the fracture together. Fully threaded or partially threaded screws can be used as lag screws. Cortical screws are used as lag screws in fractures of long bones and cancellous screws for metaphyseal fractures. These screws produce uniform static fracture compression. Cannulated Screws

Cannulated screws have a hollow central shaft. Both cortical and cancellous screws can be cannulated. Cannulated cancellous screws are used for metaphyseal fractures while cannulated and noncannulated cortical screws are used as lag screws for fixation of diaphyseal fractures. The main advantage of cannulated screws is that they can be inserted over a guide wire or guide pin. The diameter of the guide pin is much smaller than the cannulated screw and can be more accurately placed using fluoroscopy in the operating room. In addition, given its small diameter, the guide pin can be reinserted several times if necessary for accurate placement without excessive damage to bone. One special type of cannulated cancellous screw is the Knowles pin which is a cannulated screw used for fixation of slipped capital femoral epiphysis in children. Dynamic Hip Screw Dynamic hip screws are used for internal fixation of fractures of the femoral neck and intertrochanteric region. The screw is a large cancellous lag screw that glide freely in a metal sleeve. The sleeve is attached to a side plate that is fixed to the lateral femoral cortex with screws. Weight bearing cause the femoral head to becomes impacted on the femoral neck producing dynamic compression of the fracture. The shaft of the lag screw slides down the sleeve maintaining reduction of the fracture as compression occurs. Herbert Screws A Herbert screw is a special purpose screw used to compress small fractures fragments. One end of the screw (upper ends in x-ray and photograph above) has cancellous threads while the other end has larger diameter cortical screw threads. The cancellous screw is inserted first and crosses the proximal fracture, screwing into the bone of the distal fragment. As it is screwed in, the proximal cortical portion engages the proximal bone fragment. Each turn of the screw causes the distal end to travel farther into bone than the proximal end, compressing the fracture. Interference Screws Interference screws are used to secure tendons or bone grafts in place. They are most frequently used for repair of the anterior cruciate ligament. For an ACL repair, bone tunnels are drilled in the tibia and femur as shown above. A tendon autograft is then passed into the holes. The graft may contain attached bone. The interference screws are then inserted which force the tendon or graft again bone fixing it in place. In the above radiograph, two different types of screws are shown. There has been a fracture through the tibial plateau where the screw was placed. A generic type interference screw is shown on the right. PLATES Plates are some of the most common general purpose fixation devices. They contain holes for screws and pins that are used to fix the plate to intact bone and to fractures. Click an entry on the left for viewing a specific category of plates. Properties and function of the more commonly used plates are described below. There are large number of different types of buttress plates. Click the Buttress Plates link in the left panel for an overview of buttress plates and examples of particular types of buttress plates. For simple fractures of long bones, screws are often used to reduce the fractures and apply compression to the fracture site (lag screws). These screws, however, withstand external compressive and bending forces poorly. Plates that span the fracture site and rigidity fixate the reduced fracture are called neutralization plates since they resist or neutralize external forces at the fracture site protecting the lag screw fixation.

A compression plate is most commonly used with diaphyseal fractures of the long bones. The beveled geometry of its screw holes allows compression of a fracture spanned by the plate as the screw head contacts the plate during insertion. Click the Compression Plates link in the left panel for an overview of compression plates. Reconstruction plates are flexible and can be cut to length to fit irregular surfaces. They are used primarily for fractures of the pelvis. Blade plates are used for fractures of the condylar regions of the long bones. They are simpler alternative devices that can be used in place of a plate with a separate condylar screw. The LISS (Less Invasive Stabilization System) plate is a recently introduced type of plate that is a modification of the standard compression plate used for long bone fractures.

Types of Plates Buttress Plates Buttress plates are used to rigidly hold in place fractures at the end of long bones, especially at the knee and ankle, where the fracture site experiences large compressive and other distorting forces. To provide adequate fixation, these plates are broadened and carefully contoured at the joint end of the plate. For this reason, they are often referred to as periarticular plates. The periarticular surfaces of long bone are complex having several surfaces and unique topographic feature at each surface. Buttress plates are contoured to a particular surface (medial, lateral, anterior, etc.), and thus several different plate designs may be necessary for an individual periarticular region. There are a large number of buttress plates. Some of the more common configurations are T-shaped, L-shaped and bulbous end shaped plates. The contoured, periarticular portion of the plate give these plates a three dimensional configuration. Neutralization Plates Neutralization plates are not a specific type of plate. Neutralization refers to how a plate functions in fracture fixation. A neutralization plate removes the loading forces on a fracture by spanning the fracture and transmitting the loading forces through the plate rather than through the fracture site. This allows the primary fracture fixation to be accomplished with other devices such as lag screws. Several different types of plates can function as neutralization plates including compression plates, semitubular plates, and buttress plates. Reconstruction Plates The reconstruction plate is a flexible plate which can be easily contoured to the surface it is attached to. The plate can be cut so that the desired length is achieved. The AP radiograph of the left pelvis shows a reconstruction plate transfixing an acetabular fracture. Blade Plates LISS Plates LISS stands for Less Invasive Stabilization System. A LISS plate is similar to a buttress plate with several modifications. The screw holes in a LISS plate are round and threaded so that the screws are locked onto the plate. This allows adequate stabilization with only unicortical screws rather than the bicortical fixation required with standard compression or buttress plates. The plate does not have to be close to bone and therefore it does not need to be closely contoured to the periarticular surface as with a standard buttress plate (note the simple shape of the distal end of the plate). These modification allow easier insertion and less damage to the bone and its blood supply. Note the specially shaped unicortical screws used with the LISS plate.

PINS AND WIRES Pins and wires can be used as standalone orthopedic hardware or as components of larger hardware constructs. When used for internal fixation, they provide in general much less resistance to external forces than plates, nails, or rods. Therefore, when used alone, they are used for bones which normally experience relatively weak external forces. These devices are used as standalone devices in the upper extremities and as adjunctive hardware in the lower extremities along with hardware that can withstand the larger axial loading forces. Pins used for external fixation are described in an accompanying sections. These pins are thicker and are designed to support greater loads. Kirschner wires, or K-wires, are small diameter rods that are rather easily bent. They are small enough to be used for across the joint fixation without significant damage to articular cartilage. They are frequently used for fracture fixation of the hands and feet and as guide wires for placement of cannulated screws. The function of wires, bands, and cables is usually straightforward. There is one special construct that will be discussed here: tension band wiring. This type of wiring is commonly used for transverse fractures of the patella and olecranon and occasionally for fractures of the greater trochanter. The common factor in these fixations is that rotational forces are exerted on the fracture fragments when the joint is flexed. A tension band is a wire fixation of the fracture placed on the surface of the bone farthest from the joint, e.g. the external aspect of the patella and olecranon. The fracture and the wire create a new pivot point on the external surface when the joint rotates. The inner surface of bone is free to move and the inner parts of the fracture are compressed creating dynamic compression. Types of Pins Kirschners wire Kirschner wires have many uses. They can be used as the primary fixation device for fractures in the hands and feet. They can also be used as adjunctive fixation devices for complex fractures of larger bones. The x-ray on the right shows a bimalleolar fracture. The medial malleolus is fixated with a plate with screws and by two K-wires. There is a Rush rod in the fibula. Cables Cables are used primarily as adjunctive fixation devices for fractures of the long bones. Their use is illustrated in the x-ray at the right. The cables around the proximal femur provide compression to the bone and help improve contact with the femoral prosthesis. This prosthesis is a noncemented, bone ingrowth type and the compression improves bone ingrowth. Tension Band Wiring

INTRAMEDULLARY RODS AND NAILS Intramedullary rods and nails are means of fracture fixation in which a long metallic implant is inserted at one end of a long bone through the medullary canal. The nail itself may traverse a fracture or the nail may be used as a rigid support for screws, pins, or other nails that fixate a fracture. Rods are simple solid cylinders that are thinner and more flexible than nails. They are not fixated with screws or pins. Nails are more rigid implants that usually have proximal and distal holes for the insertion of locking (interlocking) screws and pins that fixate

the implant to bone. Nails can be solid or hollow and can have circular, square, or more complex cross-sections. Large diameter implants require reaming of the medullary cavity before insertion. Nails can also be placed in an antegrade or retrograde manner, i.e. inserted through the proximal or distal end of the medullary canal of a long bone. Retrograde insertion is frequently used to treat fractures of the femoral diaphysis. Nails inserted without locking screws or pins provide splintage, i.e. control of lateral displacement and angulation of a fracture, but no rotational control. Nails at both proximal and distal ends provide rotational and translational control of a fracture and prevent impaction and distraction. This is referred to as static locking. When a fracture of the tibia or femur has healed to a certain degree, the locking devices at one or the other end can be removed so that weight bearing can produce dynamic compression of the fracture. This is referred to as dynamization of the nail. Because of the more complex anatomy of the femur, there is a larger variety of femoral nails. These nails can be inserted in an antegrade or retrograde fashion. The proximal fixation can be transverse through the proximal diaphysis, oblique through the trochanters, or oblique through the femoral head and neck depending on the number and location of fractures. Types of Intramedullary Rods and Nails Short Proximal Femoral Nail This nail is designed for proximal femoral fractures, especially in the intertrochanteric region. Nails for proximal fractures must be thicker to withstand the high stress in the intertrochanteric and subtrochanteric regions. Long Proximal Femoral Nail This nail is designed for combined fractures of the proximal femur and the diaphysis. Nails for proximal fractures must be thicker to withstand the high stress in the intertrochanteric and subtrochanteric regions. Tibial Nail Antibiotic Rods Treatment of infections of intramedullary rods is difficult. The rod must be removed, but standard intravenous antibiotic treatment cannot deliver high concentrations of antibiotics to the affected bone. One method of accomplishing such delivery is with an antibiotic rod as shown on the right. The infected tibial rod was removed. A chest tube was used to contain a slurry of antibiotics and a biocompatible material such as polymethylmethacrylate that quickly hardens. The material is placed in a chest tube with a thin diameter wire. When the material hardens sufficiency, it is extracted and inserted into the tibial medullary space.The antibiotic leaches from the rod achieving higher concentrations than could be obtained with intravenous administration. ANCHORS Suture anchors (also called soft tissue anchors) are small devices placed in bone that have attached sutures or other materials that can be used for repair of soft tissues structures. They are most commonly used in the shoulder and knee regions for reattaching ligaments and tendons. There are several different designs including screws and metal posts with attached barbs.

EXTERNAL FIXATORS Whenever possible, external fixation is the preferred treatment for fractures since internal fixation damages the soft tissues and can compromise blood flow to the injured site. In addition, internal fixation carries the risk of infection. There are several methods of external fixation ranging from bracing and casting to placement of pins through bones distant from the fracture which are attached to external fixators. The latter type of fixation is usually classified into planar fixation, ring fixation, and hybrid. All of these type involve inserting pins through bone on both sides of the fractures and connecting the pins to external fixation devices. The pins used depend on the anatomic site and forces exerted on the pins. Standard pins are olive wires, K-wires, Steinmann pins, and Schanz pins. K-wires and olive wires are used with other stronger constructs. Steinmann pins and the stronger Schanz pins can be used alone to fixate long bone fractures. Planar fixation is performed by passing pins through one (unilateral) or both (bilateral) sides of a bone and connecting the pins to clamps and rods. The pins lie in the same plane. Pins can be smooth, centrally threaded for bilateral fixation or half-threaded for unilateral fixation. Ring fixators consist of circumference rings to which rods are connected. Pins are inserted from the vertical rods and lie in multiple different horiztonal and vertical planes. The most widely used ring fixator is the Ilizarov frame. It uses K-wires, olive wires, and pins for bone fixation. The olive wire is named for the olive shape at the end of the wire. Hybrid fixators are partial rings.

Types Planar Fixators Hoffman Ring Ilizarov fixator