INTERNAL FIXATION

Definition
Internal fixation is
an operation in orthopedics
that involves the surgical
implementation
of implants for the purpose
of repairing a bone,
An internal fixator may be
made of stainless
steel or titanium.


Types of internal fixators
include
bone screws and
metal plates,
pins,
rods,
Kirschner wires and
intramedullary devices ;
Kuntscher
nail and interlocking nail.
Principles and I ndications of
Fixation
PRINCIPLES
Rigid fixation
Stress distribution
Fracture stability
Compression
Stability
Primary healing
Membranous bone repair
INDICATION
Displaced intra-articular
fracture
Axial, angular, or rotational
instability that cannot be
controlled by closed
methods
Open fracture
Polytrauma
Associated neurovascular
injury

Advantages of I nternal Fixation
No casts
Prevent skin pressure and
fracture blisters
No scars
No complications of bed
rest
Important for the elderly
Early motion
Avoid stiffness
Enhance fracture healing
Prevent muscle atrophy
Earlier functional
recovery

More predictable fracture
alignment

Potentially faster time to
healing

Functions of Fixation
Interfragmentary
Compression
Lag Screw

Plate Functions
Neutralization
Buttress
Bridge
Tension Band
Compression
Locking


Intramedullary Nails
Internal splint

Bridge plate fixation
Internal splint


Interfragmentary Compression
Interfragmentary compression (N) created
by a lag screw, for example, has to
neutralize external forces and moments to
achieve stability of the fracture.
Lag Screws
Interfragmentary
compression created
by two spongy bone
lag screws in the
epiphyseal fracture of
the distal femur.
Therefore, an internal
fixation of a fracture with
lag screws alone is rarely
stable enough to allow
load bearing of the
operated extremity. In
most cases, a lag screw
is used in combination
with a plate.

Compression Plate
Application of interfragmentary
compression by a tension device pulling
on the plate.
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
Order of fixation:
Articular surface compressed with bone
forceps and provisionally fixed with k-wires
1. Bottom 3 cortical screws placed
Provide buttress effect
2. Top 2 partially-threaded cancellous screws
placed
Lag articular surface together
3. Third screw placed either in lag or normal
fashion since articular surface already
compressed
4. Axial loading causes proximal fragment to
move distal and to the left along fracture
line




Buttress Concepts
Figure from: Schatzker J, Tile M: The
Rationale of Operative Fracture Care.
Springer-Verlag, 1987.
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
Bridge Plates
Bridge/bypass
comminution
Proximal & distal fixation
Goal:
Maintain length, rotation,
& axial alignment
Avoids soft tissue
disruption at fx =
maintain fx blood supply
Intramedullary Nail
Intramedullary nailing
is a generally
accepted internal
splinting technique.
The conventional
Kntscher nail is a
longitudinally slotted
tube that is inserted
into a long bone
under prestress.
The reaming of the bone
can cause a considerable
rise in intramedullary
pressure and temporary
damage to the bone's
blood supply .

Reduction Techniquessome
of the options
Indirect 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

Direct Methods
Incision with direct
fracture exposure and
reduction with reduction
forceps
Open Reduction Internal Fixation
(ORIF)
Open Reduction Internal Fixation (ORIF) involves the implementation of
implants to guide the healing process of a bone ,it is open surgery to
set bones, to enable or facilitate healing.
Rigid fixation prevents micro-motion across lines of fracture to enable
healing and prevent infection.
Open Reduction Internal Fixation techniques are often used in cases
involving serious fractures such as comminuted or displaced fractures or in
cases where the bone would otherwise not heal correctly with casting or
splinting alone.
Risks and complications:
bacterial colonization of the bone, infection, stiffness and loss of range of motion,
non-union, mal-union, damage to the muscles, nerve damage and
palsy, arthritis, tendonitis, chronic pain associated with plates, screws, and
pins, compartment syndrome, deformity, audible popping and snapping, and
possible future surgeries to remove the hardware.

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
Direct Reduction Technique
Closed Reduction Internal Fixation
(CRIF)

Closed Reduction Internal Fixation (CRIF)
is reduction without any open surgery, followed by
internal fixation.
It appears to be an acceptable alternative in unstable
displaced lateral condylar fractures of the humerus in
children, but if fracture displacement after closed
reduction exceeds 2 mm, open reduction and internal
fixation is recommended.


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

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, 1987.
Failure to Apply Concepts