Fracture Fixation

Published Online:https://doi.org/10.1148/rg.236035159

Abstract

The basic goal of fracture fixation is to stabilize the fractured bone, to enable fast healing of the injured bone, and to return early mobility and full function of the injured extremity. Fractures can be treated conservatively or with external and internal fixation. Conservative fracture treatment consists of closed reduction to restore the bone alignment. Subsequent stabilization is then achieved with traction or external splinting by slings, splints, or casts. Braces are used to limit range of motion of a joint. External fixators provide fracture fixation based on the principle of splinting. There are three basic types of external fixators: standard uniplanar fixator, ring fixator, and hybrid fixator. The numerous devices used for internal fixation are roughly divided into a few major categories: wires, pins and screws, plates, and intramedullary nails or rods. Staples and clamps are also used occasionally for osteotomy or fracture fixation. Autogenous bone grafts, allografts, and bone graft substitutes are frequently used for the treatment of bone defects of various causes. For infected fractures as well as for treatment of bone infections, antibiotic beads are frequently used.

© RSNA, 2003

Introduction

Bone fractures can be complete or incomplete, simple or comminuted, closed or open. Comminuted fractures comprise more than two bone fragments, and open fractures are associated with an open skin wound (,1).

Many fractures are treated nonoperatively. Still, a large number of fractures require operative treatment. If a fracture that requires operative treatment is not treated, nature tries to stabilize the mobile fragments by pain-induced contraction of the surrounding muscles, which may lead to bone shortening. The end result of this process frequently is the lack of proper bone alignment and impaired function (,1,6).

The basic goal of fracture fixation is to stabilize the fractured bone, to enable fast healing of the injured bone, and to return early mobility and full function of the injured extremity. For lower extremity fractures, stability for weight bearing is the main goal. In the upper extremity, restoration of functional hand and arm motion is most important. For diaphyseal fractures, proper alignment of the fracture fragments is all that is needed for adequate function and prompt healing of the fracture, whereas intraarticular fractures require precise anatomic reduction with articular congruency being very important.

There are two main types of fracture fixation: internal and external. All internal and external fixation methods that allow appreciable interfragmentary movement under functional weight bearing are considered flexible fixation. Techniques that use compression are considered rigid fixation (,1,6).

The article describes current approaches, techniques, instrumentation and complications related to fracture fixation, with discussions of conservative fracture treatment, external and internal fixations, and bone grafting.

Conservative Fracture Treatment

Conservative treatment of a fracture consists of closed reduction to restore the alignment and subsequent stabilization. Conservative treatment is achieved by traction or by external splinting (,1,6).

Traction devices are temporarily applied along the long axis of the bone. They align the bone fragments and provide some stability (,Fig 1). Traction devices work only when the fragments are still connected to some soft tissues. Skeletal traction entails the insertion of either a Kirschner (K) wire or Steinman pin through the bone. The Kirschner wire has a smaller diameter and produces less injury to the soft tissues than does the Steinman pin, but it requires the use of a tensioned traction bow. Steinman pins come in a variety of sizes. Both Kirschner wires and Steinman pins can be smooth, partially threaded, or fully threaded. The threaded pins are associated with a more traumatic insertion than smooth pins, but they are less likely to loosen over time. The most common indication for skeletal traction is a femoral fracture. Less commonly, skeletal traction is used for humeral fractures as well as some lower extremity fractures and dislocations. Sometimes, intraoperative skeletal traction is used for the reduction of a distal radius fracture (,1,,3).

Traction pins for the lower extremity are placed in one of three sites: supracondylar femur, proximal tibia, and calcaneus. Possible complications with supracondylar traction are quadriceps injury, neurovascular injury, and infection. Calcaneal traction should be avoided because it has a high infection rate. The indications, technique, and complications with lower extremity traction pins are nicely summarized by Althausen and Hak (,7). Controversy over usefulness of preoperative traction for fractures of the proximal femur is summarized by Parker and Handoll (,8) based on review of the results of seven randomized trials. The reviewers concluded that use of preoperative traction for hip fractures has no benefit. However, they suggested that the information is insufficient and that additional trials are needed to evaluate for possible benefits of preoperative traction (,1,,3,,7,,8).

External slings, splints, and casts are made mainly of plaster of paris, synthetic casting material, plastic, or metal. They can be used for the temporary immobilization of the injured extremity or for definitive fracture treatment. They may be used in combination with internal fixation to provide additional support. Use of an adequate length of one of these devices in a given situation is very important for providing proper fracture stabilization (,,,,Fig 2). Externally applied splints and casts result in restoration of gross anatomy and maintenance of reduction under conditions of relative mobility. Braces are also commonly used for limiting range of motion of a joint after a surgical procedure or trauma (,1,,2,,5,,6).

External Fixation

External fixators provide fracture fixation based on the principle of splinting. They are the only system that allows the surgeon to control the flexibility of the fixation. External fixators are the standard in treating open fractures with substantial soft-tissue injuries that require vascular procedures, fasciotomy, soft-tissue flaps, or multiple débridements, to avoid additional damage to an already compromised limb. The other indications for the application of an external fixator are polytrauma; fractures in children to avoid pin fixation through the growth plate; temporary joint bridging before later open reduction internal fixation (ORIF); and arthrodesis of the ankle, elbow, or knee. In these latter cases, external fixators are especially indicated in acute or chronic infections, in limb-lengthening procedures, and occasionally after corrective osteotomies (,1,6).

External fixators are made of pins or wires (Schanz screws, Steinman pins, Kirschner wires) that are placed percutaneously into the bone above and below the fracture site. These pins or wires are connected by various clamps to external fixation rods (stainless steel or carbon fiber roads). There are three basic types of external fixators: standard pin fixator (,,,Fig 3), ring fixator (,Fig 4), and hybrid fixator (,,,Fig 5). Standard uniplanar external fixators consist of percutaneously placed pins that are connected to an external rod. Proper pin or screw placement is very important. These pins or screws should penetrate the near cortex and medullary canal and engage the far cortex without penetrating the muscle compartment. Joint penetration by any of these pins must be avoided. Standard uniplanar fixators can be used for almost every long bone fracture except those involving the proximal femur or humerus. They are commonly used for the stabilization of complex distal radius fractures. The pins are placed in the distal radius and second metacarpal shaft. This technique uses the surrounding soft tissues or ligamentotaxis to provide indirect stabilization of the fracture. Uniplanar external fixators have a limited use in temporary stabilization of pelvic fractures (,1,6).

Ring fixators are made of thin wires under tension that are attached to circular or semicircular rings or frames. This technique was introduced by the Russian surgeon Ilizarov for limb-lengthening procedures. Currently, it has broader applications. The term Ilizarov fixator is frequently used for any type of ring fixator (,1,,2,,4,6).

The third type of external fixator is called a hybrid fixator. It represents the combination of ring and standard uniplanar fixators. It is commonly used for treatment of the proximal and distal tibial fractures that are close to the joint. This fixator is made of a ¾ ring proximally, which is attached to the bone by Kirschner wires. The ring is connected to a unilateral external rod, which is attached to the distal bone shaft by Schanz screws (,1,6).

The adequate care of pin-track sites is important and starts at the day of placement. Daily cleansing and disinfection is necessary to minimize pin-track infection. Radiography is used to evaluate for pin loosening, breakage, and infection. Visualization of the entire device is frequently limited because of the overlapping frame, and additional views and even fluoroscopic evaluation may be needed for adequate assessment of possible complications (,1,6).

Pinless fixators are sometimes used for tibial fractures but they are less stable. With these fixators, the medullary canal is not penetrated because the clamps (forceps) are anchored into the cortex only. This type of fixation allows later safe intramedullary nailing (,1).

Internal Fixation

Since the late 1950s, open reduction and internal fixation (ORIF) has been used to restore bone anatomy and enable early mobilization and to overcome the limitations encountered when fractures are treated with skeletal traction or cast immobilization (,1,,2,,5,,6). The main goal of internal fixation is the achievement of prompt and, if possible, full function of the injured limb, with rapid rehabilitation of the patient. The majority of internal fixation implants are currently made of stainless steel. Occasionally, less strong but biologically superior and more elastic titanium implants are favored. Numerous devices are available for internal fixation. These devices can be roughly divided into a few major categories: wires, pins and screws, plates, and intramedullary nails or rods. Staples and clamps are also used occasionally for osteotomy or fracture fixation (,Fig 6) (,1,6,,9,11).

Pins

There are a variety of fixation pins used in orthopedic practice. Fixation pins can be smooth or threaded and are made in a large number of sizes. Among the most commonly used are Kirschner (K) wires and Steinman pins (,Fig 7). These devices are used for temporary fixation of the fracture fragments during fracture reduction, to attach skeletal traction devices, and as guides for the accurate placement of larger cannulated screws. The percutaneously placed Kirschner wires commonly protrude through the skin for ease of later removal. Occasionally, the pins are used for definitive fracture treatment and should be watched for migration. The Steinman pin is also occasionally used for wrist arthrodesis (,1,6,,12).

Wires

Wires are used alone or more commonly in combination with other orthopedic fixation devices. They are of various diameters and can be braided. Wires are frequently used to reattach osteotomized bone fragments (ie, greater trochanter or olecranon). In combination with pins or screws, the wires are used to create a tension band, which uses distractive muscular forces to create compression at the fracture site (,,,Fig 8). Wires are used to suture bone and soft tissue, and they can break. However, if there is no loss of bone fragment position, breakage of wires is usually of little significance. Circumferential cerclage wires are commonly used in conjunction with intramedullary fixation to stabilize long bone fragments (,Fig 9). One of the potential complications with cerclage wires is interruption of the periosteal blood supply with subsequent osteonecrosis or fracture nonunion (,1,6).

Screws

A variety of screws are used in orthopedic practice (,Fig 10). The main parts of a screw are the screw head, which is its bulbous end and the part engaged by the screwdriver, and the shank or core, which can be of variable diameter and can be partially or fully threaded. The distance between the threads is called “pitch” (,Fig 11). Screws are of different sizes and can be self-tapping (which have cutting ends) or non-self-tapping. Non-self-tapping screws are easier to insert and remove, but they are not the best choice for fixing fractures in regions with a thin cortex. Some screws have a “standard” point and others a “trocar” point. Screws are commonly used in combination with plates and nails or rods. The use of different types and designs of screws depends on the surgeon’s preference (,1,6).

There are two basic types of fixation screws according to the Arbeitsgemeinschaft fur Osteosythesefragen known to English-speaking countries as the Association for the Study of Internal Fixation [ASIF]): cortical and cancellous. Cortical screws are often fully threaded and usually have a smaller thread diameter and pitch (,Fig 10). Cortical screws are designed to be used in the diaphysis. Cancellous screws are intended to cross long segments of cancellous bone. They typically have deeper threads, larger thread diameter, and a greater pitch than cortical screws, and they are usually partially threaded, with threads only on their ends (,Fig 10). Occasionally, cancellous screws can be fully threaded (,1,,13).

Newly designed Schanz screws have a larger core diameter and less deep self-cutting threads, which provide better buttressing against forces that act perpendicular to the long axis of the screw (,Fig 10). There are other types of recently designed diaphyseal unicortical locked screws that are used with plates, which provide better anchorage with a minimally invasive technique and which can function as a fixed angle device (,1).

A screw that crosses the fracture line (ideally, perpendicular to the fracture line) is called an “interfragmentary” screw (,,,Fig 12). This screw is supposed to provide compression between the fracture fragments to enhance fracture stability and promote healing. To act as a lag screw, the interfragmentary screw requires a gliding hole in the near (cis) cortex and a threaded hole in the far (trans) cortex. Fully threaded interfragmentary screws are used in the diaphysis because they are easier to remove than partially threaded cancellous screws. Sometimes, the interfragmentary screw is placed through the fixation plate. Interfragmentary screws are preferred in the fixation of articular fractures to obtain anatomic reduction and adequate stability. Interfragmentary screws are also preferred for treating juxtaarticular fractures. Self-tapping screws, which have cutting ends, are not recommended for use as lag screws because removal and reapplication of the screw may be needed. Interfragmentary screws are used occasionally to treat open fractures (ie, in case of very long oblique spiral fractures or in the presence of a large well-vascularized third fragment that requires fixation) (,1,,2,,4,6).

In certain situations, a washer (metallic ring) is used with the screw to prevent the screw head from sinking into the bone (,Fig 13). Washers enhance the compressive area of a screw in regions of thin cortex, and they prevent fractures under the screw (,1,,4,,6).

Loosening of well-placed screws is induced by micro motion at the interface between the thread and bone. From a radiologic standpoint, it is important to observe and report possible complications including screw breakage, loosening, or change in position (,1,,2,,6).

A screw that is used to stabilize the distal tibiofibular syndesmosis is called a syndesmotic screw. This screw is placed across the distal tibiofibular joint parallel and 1–2 cm proximal to the joint line. The syndesmotic screw can also be placed through one of the holes of a fibular fixation plate. Syndesmotic screws are usually removed 6–12 weeks after placement, after the interosseous membrane has healed (,1,,4,6).

Cannulated screws have a hollow shank, which allows them to be placed more exactly over a guide pin. They are commonly used for fixation of subcapital hip fractures and may be inserted percutaneously with fluoroscopic guidance (,Figs 10, ,14). This surgery is commonly performed by using a fracture table to provide traction and maintain reduction during the fixation (,1,,2,,4,6).

A special type of screw that is used in the treatment of intertrochanteric proximal femur fractures is called a dynamic compression screw device (,Fig 15). It consists of a large lag screw with distal threads that is inserted into the femoral head and neck. This screw fits into the barrel of a side plate, which is secured to the femoral shaft with multiple cortical screws. The lag screw can slide within the barrel, which results in compression of the fracture site as the patient ambulates (,1,,2,,4,6).

Another “special” type is a Herbert screw, which was originally designed for the fixation of scaphoid fractures. Currently, this screw has a more broad application (,Fig 16). The Herbert screw has threads of different pitch at both ends, with an unthreaded central shank, and does not have a head. It acts as a countersink, allowing different threads at its ends to draw the fracture fragments together (,1,,2,,6,,14).

For capsular, tendinous, and ligamentous repairs, a variety of anchor screws are used (,Fig 17). These screws have barbs and hooks for soft-tissue or bone attachment and allow for suturing of ligaments to the anchor, which is then placed in the bone (,1,,2,,6).

Fixation techniques for anterior cruciate ligament (ACL) grafts continue to evolve. The Kurosaka screw, which is a type of interference screw, is designed to anchor the ACL graft into the lateral femoral condyle and proximal medial tibial metaphysis. This screw is headless, short, and broad. There are a variety of designs for interference screws that act as anchors for the fixation of ACL grafts. These screws can be metallic or bioabsorbable and radiolucent (,,,Figs 18, ,,,19). The integrity and possible complications of the ACL graft are evaluated frequently with magnetic resonance imaging (,1,,2,,4,6,,15,20).

The radiographic appearance of the knee after ACL reconstruction was summarized by Manaster and colleagues (,15). On the lateral radiograph, the tibial osseous tunnel should begin distally near the tibial tuberosity, course posteriorly, and exit the tibial articular surface immediately anterior to the anterior tibial spine. On the frontal radiograph, the tibial tunnel begins in the medial tibial side, courses laterally and proximally, and exits the articular surface at the intercondylar eminence of the tibial plateau. The appropriately placed ACL graft has an oblique orientation and on sagittal oblique magnetic resonance images is posterior to the intercondylar roof line (Blumensaat line). On the lateral radiograph, the femoral osseous tunnel extends from the intersection of two lines, which represent the posterior femoral cortex and the intercondylar roof. On the frontal radiograph, the femoral tunnel begins laterally, just superior to the lateral femoral condyle, and emerges on the superolateral aspect of the intercondylar notch.

Aside from interference screws, there are other devices used for the fixation of the ACL graft, including buttons, washers, staples, cross pins, polyester titanium buttons, and suture posts (,1,,2,,4,6,,15,20).

Plates

ASIF has developed a variety of plates, most of which can be used for both rigid and flexible fracture fixation (,Fig 20). The majority of these plates are made of stainless steel or titanium. With flexible fixation, the fracture fragments displace in relation to each other when the load is applied across the fracture site. Fracture fixation is considered flexible if it allows appreciable interfragmentary movement under functional load. All fracture fixation methods, with the exception of compression techniques, may be described as flexible or biologic fixation. Fracture healing under flexible fixation typically occurs by means of callus formation. However, despite wide use of flexible fracture fixation, rigid fracture fixation with plates and screws still has an important place and is desirable for fractures that involve an articular surface. Bridging of the fracture with a stiff splint reduces mobility of the fracture fragments, which allows minimal displacement under functional load. Although rigidity of the fracture fixation contributes to reducing fracture mobility, the only technique that can effectively abolish motion at the fracture site is interfragmentary compression. With a plate and screws, complete stability diminishes the strain at the fracture site to such extent that it allows for direct healing without formation of visible callus. Articular fractures require exact anatomic reduction and stable fixation to avoid development of abundant callus. This is important because unevenness of the joint surface and presence of callus formation at the articular surface lead to patient discomfort and often development of early and progressive osteoarthritis (,1).

The terminology that is commonly used with fracture plating is “compression plating” and “neutralization plating.” Compression plating applies compression to the fracture ends. In cases of severely comminuted fractures, bone loss, or other situations that prevent compression, the plate is applied in neutral mode to hold the fracture fragments in place during healing. Frequently, not all the screw holes in the plate are filled. When diaphyseal fractures in the long bones are treated with a plate, a minimum of six cortices should be engaged at each fracture site, except for the femur, which requires eight. Plates are most commonly used for fixation of long bones, but they also are used in the spine and for arthrodesis of the wrist (,Fig 21) (,1,,2).

The dynamic compression plate (DCP) was introduced in 1969 and has since been modified. This plate has holes designed for axial compression, which is achieved by means of eccentric screw insertion (,,,Figs 12, ,20). The DCP functions in different modes: compression, neutralization, tension band, or as a buttress. It is available in three different sizes to accommodate fracture fixation in bones of different sizes. The screw holes in the DCP are oval and are best described as a portion of an inclined and angled cylinder. The plate can be used with different types of screws. In the DCP, the areas about the plate holes are less stiff than the areas between them, and during bending the plate tends to bend only at the hole sites (,1,,2,,4,6).

The newer design of the DCP is the low-contact DCP, which reduces the area of contact “footprint” between the plate and bone. This design produces less compromise to the capillary network of the periosteum, which leads to a relative improvement in cortical perfusion (,Fig 21). The distribution of the holes and even stiffness of this plate allow gentle and elastic deformation of the entire plate without stress concentration at one of the screw holes, as occurs with the DCP. The footprint of the low-contact DCP has a trapezoidal shape, and the screws can be inserted in the plate in different modes: compression, neutral, and buttress (,1,,2,,4,6).

One-third tubular plates are thinner than DCPs. Tubular plates are called “tubular” because they form part of the circumference of a tube, that is, one-third, one-fourth, and so forth of the circumference of a tube or cylinder. Tubular plates have a radiographic appearance similar to that of DCPs. These plates are only 1 mm thick and are used for fracture fixation in regions with a small amount of overlying soft tissue, such as the distal fibula, distal ulna, and olecranon. The holes in tubular plates are oval and are surrounded by small collars, which allow a certain degree of eccentric screw placement and which prevent screw head penetration of the plate (,2,,6).

Blade plates are fixed angle plates. They have a sharply angled extension at the end that is placed into the metaphysis. Blade plates have a wide range of angles to accommodate different fixation needs (,Fig 22) (,1,6).

Reconstruction plates have deep notches between the holes and allow a considerable amount of bending (,Figs 20, ,23, ,24). The screw holes are oval to allow for dynamic compression. Reconstruction plates are used mainly for fixation of pelvic and acetabular fractures. They also can be used for fixation of distal humeral and clavicular fractures (,1,,2,,4,6).

Interfragmentary bone compression with a plate can be achieved by compression with a tension device, by compression with a DCP or low-contact DCP, by contouring (overbending) the plate, and by using additional screws through plate holes. An interfragmentary screw should be used whenever fracture fragments permit it. Placement of the interfragmentary screw through the plate is preferred over a freestanding placement (,1).

Bridge plates are used for fixation of complex diaphyseal fractures to minimize additional soft-tissue injury. A bridge plate is applied through minimal soft-tissue exposure. It is designed to span a critical fracture area and is fixed with screws to the bone fragments only near its two ends (,1).

More recently, new types of plates that are called internal fixation system have been introduced. The point contact fixator (PC-Fix) was initially designed for fixation of forearm bone fractures. It consists of a narrow plate with a specially designed undersurface with small points that come in contact with the bone surface. The plate is fixed to bone with unicortical self-tapping screws. If needed, the PC-Fix plate can be gently contoured to accommodate the shape of the bone. PC-Fix plates for fixation of fractures of the tibia and humerus are under development. The LISS (less invasive stabilization system) plate was designed for fracture fixation in the metaphyseal and diaphyseal regions, initially for the distal femur and later for the proximal tibia (,,,Fig 25). Its shape conforms to the anatomic contour of a specific area of bone, and therefore separate implants are available for the left and right sides. Additional contouring is not needed because the LISS plate does not need to touch the bone. The plate is fixed to the bone with locked unicortical screws placed by means of a minimally invasive submuscular approach. Before placement of a PC-Fix or LISS plate, the fracture must be adequately reduced. PC-Fix and LISS plates have several promising advantages over conventional plates, including better preservation of blood supply to bone and better resistance to infection. They provide a fixed-angle plate screw device that consists of two components for easy application in complex fractures and self-tapping cortical screws that are easily and rapidly applied to a reduced fracture. The additional advantage of a LISS plate is its insertion in a minimally invasive fashion (,21,24).

A variety of special anatomically shaped plates exists that are dedicated for fracture fixation in a specific location. Some of these are the condylar plate 95° for stabilization of proximal and distal femoral fractures, angled blade plate 120° for valgus osteotomy of the femur, condylar buttress plate for the distal femur, T-plate 4.5 for the proximal humerus and proximal tibia, lateral tibial head buttress plate, tibial head buttress plate (right and left), cobra head plate for arthrodesis of the hip, angled blade plate for varization of the femur, dynamic condylar screw for the proximal and distal femur (combination of side plate and a separate screw), oblique angled 3.5 T-plate for fixation of distal radius fractures, and spider plate for partial carpal arthrodesis (,Figs 26,,28) (,1,6).

The next step in the evolution of biologic plating is percutaneous plating, which results in less surgical trauma to tissues and further improvement in clinical results compared with current methods of plate insertion. This technique was developed in an effort to combine the advantages of intramedullary nailing with the more stable fracture fixation available with plating. In percutaneous plating, a smaller incision is used to place the plate and the screws are then placed percutaneously. Preliminary reports about the results of percutaneous plating are promising. However, these methods are technically challenging, and long-term results from prospective studies will be needed for definite assessment of their advantages and disadvantages (,1,,21).

From the radiologic standpoint, important considerations are the location of the plate, whether the plate symmetrically spans the fracture, and the degree of fracture reduction. The plate should not impinge on joint motion, and the plate and the screws should not violate the articular surface. Any malposition or migration of the plate, breakage of the plate or screws, or loosening should be reported (,2,,6). The major possible complication with conventional plating is potential compromise of cortical blood supply because of a large contact area between the plate and underlying cortex (,1).

Intramedullary Nails or Rods

Intramedullary nailing was introduced by Gerhard Kuntscher in 1940 and represented a revolution in the treatment of femoral shaft fractures. Since that time, the technique has evolved considerably (,1,6,,25,,26). Intramedullary nailing is the standard treatment for diaphyseal fractures of the femur and tibia (,,,Figs 29, ,30). Humeral shaft fractures are also being treated with antegrade and retrograde intramedullary nailing, with variable complication rates being reported (,Fig 31). Intramedullary nails or rods allow early weightbearing. The intramedullary location of the nails provides optimal biomechanical positioning to resist torsion and bending (,1,6,,25).

Most intramedullary nailing is done closed with minimal soft-tissue exposure, either in an antegrade or retrograde fashion depending on the fracture site. Both antegrade and retrograde nailing are used for femoral and humeral shaft fractures, and for tibial shaft fractures antegrade nailing is used. The entrance site for an antegrade femoral nail is created in the piriformis fossa; for the retrograde femoral nail, in the intercondylar region; and for the antegrade tibial nail, anteriorly just below the joint line. The nails are introduced over a guide wire, frequently after reaming with flexible reamers to enlarge the intramedullary canal. Because reaming causes temporary damage to the internal cortical blood supply, which is associated with increased infection rates, it is not recommended for the treatment of some open fractures. There is also an increased rate of pulmonary complications including pulmonary embolism with reaming; therefore, controversy persists between those who recommend reamed nailing and those who do not in severely traumatized patients. Intramedullary nailing is performed with intraoperative fluoroscopic guidance (,1,6,,25).

Numerous intramedullary nails or rods of different design are available (,Fig 32). Femoral nails are bowed anteriorly to accommodate the contour of the bone. A majority of nails are cannulated to allow their placement over a guide wire. Intramedullary nails provide excellent stability against bending forces, but they do not control rotation and compressive forces. For the control of rotational forces, proximal and distal interlocking screws are placed (usually in a lateral to medial fashion) through the nail or rod holes in the proximal and distal femur. Interlocking screws increase fixation stability and therefore led to an increased use of nailing in fracture fixation. Interlocking screws were introduced by Grosse and Kemp (,1). There could be one to two proximal and there are usually two distal interlocking screws in the femoral nails and three in the tibial nails. The proximal femoral screws can be placed either more commonly obliquely through the intertrochanteric region or perpendicular through the proximal femoral shaft. The distal interlocking screws are placed perpendicular to the distal femoral shaft. Interlocking screws also prevent collapse or shortening of the fracture (,1,6).

If the nail is locked both proximally and distally, it is “statically locked” because all planes of motion are controlled or static. The nail is “dynamically locked” if it is locked at one end only, which allows compression at the fracture site. Dynamization (which allows increased compression at the fracture site after the nail is unlocked at one end after removal of the interlocking screws) is rarely needed in the femur, and it may be recommended in the tibia for certain fracture patterns. A dynamization is usually performed 2–3 months after initial surgery when one or both proximal interlocking screws are removed. Because the unreamed nails are thinner, the use of interlocking screws is mandatory to prevent torsion (,1,,2,,6).

Reconstruction nails have been designed for the treatment of femoral shaft fractures with ipsilateral femoral neck, intertrochanteric, and subtrochanteric fractures. These nails have proximal locking holes oriented to accommodate screw placement into the femoral neck and head (,Fig 32) (,1,6).

Flexible intramedullary rods are of smaller diameter and greater flexibility to accommodate different long bone anatomy (Ender nail, Lottes nail, and Rush pin) (,Fig 33). These nails are solid and are associated with a lower prevalence of infection than the cannulated rods. Flexible rods are inserted through the metaphysis. They are frequently used for fixation of long bone diaphyseal fractures in skeletally immature patients to avoid placement through the growth plate and subsequent premature closure of the growth plate. Multiple flexible rods, which diverge in the metaphyseal regions, are placed through multiple insertion sites. These rods provide some axial and rotational stability. For small-diameter bones, sometimes a single flexible rod is used. The major disadvantage associated with flexible rods is the frequent need for additional external stabilization such as a plaster cast (,1,,2,,4,,6,,26).

Short intramedullary rods with transversely and obliquely oriented interlocking screws are used for fractures in the diametaphyseal region that extend into the adjacent joint (,Fig 34). The weakest points of these intramedullary rods are the distal interlocking screws (,1,,2,,4,6). In children with osteogenesis imperfecta, two-part telescoping rods are used to allow lengthening of the rod as the child grows (,2).

Potential complications with intramedullary rods are change in bone length, distraction of the fracture site, hardware fracture, hardware loosen-ing, and infection. Intramedullary rods and interlocking screws should not violate the joint surface. The contraindications for intramedullary nailing are local or systemic infection; femoral fractures in patients with multiple injuries; pulmonary trauma, for which temporary stabilization with an external fixation device is recommended; and metaphyseal fractures, for which fixation with interlocking screws may be insufficient to control malalignment (,1,,2,,5,,6).

Bone Grafts

Bone grafts are frequently used for the treatment of bone defects, which may be the result of initial trauma, infection, or avascularity. Orthopedic surgeons perform 500,000 bone-grafting procedures annually in the United States alone. A bone defect may be filled with bone graft immediately or after an interval during which the host site is prepared (,1,,27).

Autogenous cancellous, corticocancellous, or cortical bone grafts are used, either as free or vascularized grafts (,Fig 35). The most frequent donor site for cancellous bone grafting is the iliac bone. Although autogenous bone grafting is the standard and is superior to other alternatives, it has significant limitations including donor site morbidity, inadequate amount of graft tissue, and inability of the graft tissue to be fabricated into customized forms. Allografts (tissue grafts between donor and recipient of the same species but of disparate genotypes, most commonly from the donor bone bank) are also used (,Fig 36). The disadvantages associated with allografts include disease transmission, immunogenicity, loss of biologic and mechanical properties secondary to its processing, increased cost, and unavailability worldwide because of financial and cultural concerns (,1,,13,,27).

Considerable limitations associated with autografts and allografts have prompted increased interest in alternative bone graft substitutes. The development and use of bone graft substitutes is a burgeoning field, and review of all available products and indications is beyond the scope of this article. Indications for use of bone graft substitutes include fracture augmentation, vertebroplasty, augmentation of defects associated with benign bone lesions, fracture nonunion, and osteomyelitis. The main types of commercially available bone graft substitutes are demineralized allograft bone matrix, ceramics and ceramic composites, composite graft of collagen and mineral, coralline hydroxyapatite, calcium phosphate cement (,Fig 37), bioactive glass, and calcium sulfate (,Fig 38) (,13,,28,32). The preclinical and biomechanical studies with bioactive cements are promising, but further clinical studies are needed for adequate assessment of their usefulness (,13,,28).

For infected fracture sites as well as for treatment of bone infections, antibiotic beads are frequently used. The beads are typically composed of polymethylmethacrylate cement, and they are packed into the region of infection. The bead packing material provides mechanical support in the region of missing or weakened bone. Antibiotic spacers and antibiotic paste impregnated with cement are also used, mainly during resection of infected joint arthroplasty sites (,Fig 39). Promising results in treatment of osteomyelitis with antibiotic impregnated calcium sulfate pellets have been reported (,1,,13,,33).

Figure 1.  External traction device. Lateral radiograph of the knee shows a Kirschner wire inserted through the distal femoral metaphysis with an external metallic traction device.

Figure 2a.  Casts and splint. (a) Radiograph shows a plaster of paris cast that overlaps the wrist; no fracture is visible. (b) Radiograph of another patient shows a fiberglass cast that overlaps the wrist; a distal radial fracture is seen through the cast. (c) Radiograph of a different patient shows a plastic splint that overlaps the volar aspect of the wrist; no fracture is visible.

Figure 2b.  Casts and splint. (a) Radiograph shows a plaster of paris cast that overlaps the wrist; no fracture is visible. (b) Radiograph of another patient shows a fiberglass cast that overlaps the wrist; a distal radial fracture is seen through the cast. (c) Radiograph of a different patient shows a plastic splint that overlaps the volar aspect of the wrist; no fracture is visible.

Figure 2c.  Casts and splint. (a) Radiograph shows a plaster of paris cast that overlaps the wrist; no fracture is visible. (b) Radiograph of another patient shows a fiberglass cast that overlaps the wrist; a distal radial fracture is seen through the cast. (c) Radiograph of a different patient shows a plastic splint that overlaps the volar aspect of the wrist; no fracture is visible.

Figure 3a.  Standard uniplanar external fixator. Frontal (a) and lateral (b) radiographs of the wrist show a standard uniplanar external fixator. The device was placed to treat a comminuted distal radius fracture, with pins in the second metacarpal and radial shaft. An ulnar styloid fracture is also present.

Figure 3b.  Standard uniplanar external fixator. Frontal (a) and lateral (b) radiographs of the wrist show a standard uniplanar external fixator. The device was placed to treat a comminuted distal radius fracture, with pins in the second metacarpal and radial shaft. An ulnar styloid fracture is also present.

Figure 4.  Ring external fixator. Radiograph shows a ring external fixator (Ilizarov) that transfixes a healing proximal tibial fracture. A healing proximal fibular osteotomy is also seen.

Figure 5a.  Hybrid external fixator. Frontal (a) and lateral (b) radiographs of the left leg in a patient who sustained gunshot injury to the leg show a hybrid external fixator. The device was placed to treat severely comminuted open proximal tibial and fibular fractures.

Figure 5b.  Hybrid external fixator. Frontal (a) and lateral (b) radiographs of the left leg in a patient who sustained gunshot injury to the leg show a hybrid external fixator. The device was placed to treat severely comminuted open proximal tibial and fibular fractures.

Figure 6.  Greater trochanter clamp. Frontal radiograph shows the greater trochanter, which is attached to the proximal femur by a clamp, and a unipolar hip hemiarthroplasty. A subsequent periprosthetic fracture through the femoral midshaft was transfixed with a reconstruction plate.

Figure 7.  Fixation pins. Frontal radiograph of the wrist shows a comminuted intraarticular distal radius fracture transfixed with three Kirschner wires and a standard uniplanar external fixator with Steinman pins in the distal radius and in the second metacarpal bone.

Figure 8a.  Tension band wire. Frontal (a) and lateral (b) radiographs of the knee show a transverse patellar fracture that is transfixed with a tension band wire (combination of two cancellous screws and two wires).

Figure 8b.  Tension band wire. Frontal (a) and lateral (b) radiographs of the knee show a transverse patellar fracture that is transfixed with a tension band wire (combination of two cancellous screws and two wires).

Figure 9.  Cerclage wires used in revision noncemented total hip arthroplasty. A proximal femoral shaft osteotomy was performed for ease of removal of the femoral component. Frontal radiograph of the hip shows three cerclage wires placed over the proximal femoral shaft for additional stabilization of the osteotomy site. Multiple drains are overlying the soft tissues.

Figure 10.  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).

Figure 11.  Diagram illustrates screw “anatomy.”

Figure 12a.  Interfragmentary screw. Mortise (a) and lateral (b) radiographs of the ankle show a low-contact DCP (note small indentations on the undersurface of the plate in the mortise projection) and five cortical screws that transfix a distal fibular shaft fracture. The third screw placed through the plate is obliquely oriented crossing the fracture site (interfragmentary screw). A fully threaded syndesmotic screw is also present.

Figure 12b.  Interfragmentary screw. Mortise (a) and lateral (b) radiographs of the ankle show a low-contact DCP (note small indentations on the undersurface of the plate in the mortise projection) and five cortical screws that transfix a distal fibular shaft fracture. The third screw placed through the plate is obliquely oriented crossing the fracture site (interfragmentary screw). A fully threaded syndesmotic screw is also present.

Figure 13.  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.

Figure 14.  Cannulated screws. Frontal radiograph of the hip shows three cannulated cancellous screws that transfix a subcapital proximal femoral fracture.

Figure 15.  Dynamic compression screw. Frontal radiograph of the hip shows a dynamic compression screw device that transfixes the intertrochanteric fracture.

Figure 16.  Herbert screw. Frontal radiograph of the foot shows a Herbert screw transfixing the proximal fifth metatarsal (Jones) fracture.

Figure 17.  Anchor screws. Frontal radiograph of the wrist shows two suture anchors (Mitek Worldwide, Norwood, Mass) in the base of the proximal phalanx of the thumb in a patient with surgical fixation of an ulnar collateral ligament injury (gamekeeper thumb).

Figure 18a.  Interference screws. Frontal (a) and lateral (b) radiographs of the knee in a patient treated for prior knee dislocation show interference screws in the lateral femoral condyle and proximal medial tibial metaphysis related to ACL reconstruction. Bone irregularity in the posterior tibial plateau in the lateral projection is related to posterior cruciate ligament reconstruction. Multiple suture anchors are present in the distal femur and proximal tibia, consistent with medial collateral ligament and capsular repair. A Hoffman uniplanar external fixator is also present.

Figure 18b.  Interference screws. Frontal (a) and lateral (b) radiographs of the knee in a patient treated for prior knee dislocation show interference screws in the lateral femoral condyle and proximal medial tibial metaphysis related to ACL reconstruction. Bone irregularity in the posterior tibial plateau in the lateral projection is related to posterior cruciate ligament reconstruction. Multiple suture anchors are present in the distal femur and proximal tibia, consistent with medial collateral ligament and capsular repair. A Hoffman uniplanar external fixator is also present.

Figure 19a.  ACL reconstruction with bioabsorbable interference screws. Frontal (a) and lateral (b) radiographs of the knee in a patient after ACL reconstruction with bioabsorbable screws. Femoral and tibial tunnels with proper orientation are seen in both projections.

Figure 19b.  ACL reconstruction with bioabsorbable interference screws. Frontal (a) and lateral (b) radiographs of the knee in a patient after ACL reconstruction with bioabsorbable screws. Femoral and tibial tunnels with proper orientation are seen in both projections.

Figure 20.  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).

Figure 21.  Low-contact DCP. Oblique radiograph of the wrist shows a low-contact DCP used for wrist arthrodesis.

Figure 22.  Blade plate that transfixes the humerus in a patient with a pathologic fracture from renal cell carcinoma metastasis. Frontal radiograph shows multiple metallic embolization coils and polymethylmethacrylate cement at the proximal humeral metaphyseal fracture site. A blade plate with multiple cortical screws and an additional low-contact DCP with screws that was placed intramedullary transfix the fracture site. Peripherally inserted vascular catheter overlies the medial upper arm.

Figure 23.  Reconstruction plate in a patient with ipsilateral right sacral and pubic rami fractures. Frontal radiograph of the pelvis shows a reconstruction plate and multiple cortical screws that transfix the symphysis pubis, right superior pubic ramus, and anterior column of the right acetabulum. A fully threaded cannulated screw with a washer transfixes the right sacroiliac joint.

Figure 24.  Reconstruction plate in the elbow. Frontal radiograph shows a small reconstruction plate and multiple cortical screws that transfix the radial head and neck fracture. A suture anchor is present in the lateral epicondyle related to capsular/ligamentous repair.

Figure 25a.  LISS plate in a patient with a periprosthetic distal femoral fracture. Frontal (a) and lateral (b) radiographs of the knee show a periprosthetic distal femoral fracture that is transfixed with a LISS plate.

Figure 25b.  LISS plate in a patient with a periprosthetic distal femoral fracture. Frontal (a) and lateral (b) radiographs of the knee show a periprosthetic distal femoral fracture that is transfixed with a LISS plate.

Figure 26.  Anatomically shaped plate. Frontal radiograph of the knee shows a specially designed short plate that transfixes a high proximal tibial osteotomy site. The knee is in a hinged brace. A drain is seen overlying the lateral soft tissues.

Figure 27.  Oblique radiograph of the wrist in a patient with a nonunited scaphoid fracture shows a spider plate used for partial carpal fusion. Two suture anchors are seen in the proximal scaphoid.

Figure 28.  Frontal radiograph of the wrist shows a 3.5 T-plate that transfixes a distal radial healed fracture. A cannulated screw and a threaded washer transfix a healed scaphoid fracture.

Figure 29a.  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. (b) Frontal radiograph of the femur in a different patient shows a distal femoral shaft fracture that is transfixed with a retrograde intramedullary nail with one proximal and two distal interlocking screws.

Figure 29b.  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. (b) Frontal radiograph of the femur in a different patient shows a distal femoral shaft fracture that is transfixed with a retrograde intramedullary nail with one proximal and two distal interlocking screws.

Figure 30.  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.

Figure 31.  Frontal radiograph of the humerus shows an antegrade intramedullary nail with one proximal and three distal screws (poorly visualized on this single projection) that transfix a pathologic distal humeral shaft fracture from renal cell carcinoma metastasis. Multiple metallic embolization coils and polymethylmethacrylate cement are present at the fracture site.

Figure 32.  Photograph shows a variety of nails used in internal fixation: antegrade femoral reconstruction nail (A), retrograde femoral nail (B), and dynamic compression hip screw device (C).

Figure 33.  Flexible intramedullary rods. Frontal radiograph of the femur shows two flexible intramedullary nails (Ender) that transfix a proximal femoral shaft fracture.

Figure 34.  Short intramedullary rod. Frontal radiograph of the hip shows a short antegrade intramedullary femoral rod with an interlocking dynamic compression screw device that extends into the femoral head and transfixes an intertrochanteric fracture.

Figure 35.  Autogenous bone grafts. Oblique radiograph of the knee shows two autogenous osteochondral grafts (arrows) at the articular site of the patella. Donor sites (arrowheads) are seen in the medial femoral condyle. Two cortical screws transfix the tibial tubercle osteotomy site.

Figure 36.  Allograft. Lateral radiograph of the knee shows a distal femoral cadaveric allograft approximated to the native femoral stump by a retrograde intramedullary nail. Two interlocking cannulated screws are placed through the distal nail. Two interference screws and two staples in the proximal tibia, and a single staple in the posterior allograft metaphysis, are all related to cruciate ligament and capsular reattachment.

Figure 37.  Calcium phosphate cement as a bone graft substitute. Frontal radiograph reveals calcium phosphate (SRS cement; Norian, Cupertino, Calif), which was used to augment the site of a previous enchondroma complicated by a pathologic fracture in the base of the proximal phalanx of the right fourth digit.

Figure 38.  Calcium sulfate cement as a bone graft substitute. Frontal radiograph of the forefoot reveals calcium sulfate pellets (OsteoSet; Wright Medical Technology, Arlington, Tenn), which were used to pack a previous aneurysmal bone cyst in the second metatarsal bone. A Kirschner wire transfixes the first and second metatarsals. A plaster cast is applied.

Figure 39.  Antibiotic beads. Radiograph of the distal tibia and fibula shows antibiotic beads at a previously infected resected distal tibial site. Screw tracks are seen in the distal fibula from removed fixation hardware.

Abbreviations: ACL = anterior cruciate ligament, ASIF = Association for the Study of Internal Fixation, DCP = dynamic compression plate, LISS = less invasive stabilization system, PC-Fix = point contact fixator

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Article History

Published in print: Nov 2003